Member Help Team

Here are some frequently asked questions from members just like you about our Medicare Advantage Plans!

What makes Independence different?
For nearly 80 years, Independence has provided quality coverage for our neighbors in Philadelphia and its surrounding counties. We are committed to our communities and Medicare beneficiaries.

All Medicare Advantage plans from Independence represent the best choices in health care coverage we have to offer. All of our plans include:

• Comprehensive medical coverage with virtually no paperwork;
• Routine medical exams, screenings, and preventive care;
• Access to one of the largest networks in Southeastern Pennsylvania;
• Access to health resources, wellness programs and a fitness membership;
• Our Member Help Team — dedicated, locally-based service representatives committed to providing you the answers you need.

What’s the difference between Keystone 65 Select Rx HMO and Keystone 65 Focus Rx HMO?
Keystone 65 Focus Rx HMO is our new Medicare Advantage with Prescription Drug (MA-PD) plan. The premium for Keystone 65 Focus Rx is $0 in Philadelphia and Bucks counties and $25 in Chester, Delaware and Montgomery counties. Keystone 65 Select Rx members will be responsible for a $36 premium in Philadelphia and Bucks counties, and $75 Chester, Delaware and Montgomery counties.

The Keystone 65 Focus Rx plan features a defined network of doctors and hospitals focused around our local communities. It is important to make sure your providers are in the plan network before joining this plan. Keystone 65 Select Rx features a larger network, with all hospitals in the five-county area participating.

Keystone 65 Focus Rx HMO is a defined formulary plan that provides access to the most utilized generic drugs, but fewer brand name drugs; this is done to keep your premium costs lower on this plan. This formulary has been approved by the Centers for Medicare & Medicaid Services. It is important to check the formulary to ensure your drugs are covered before selecting this plan. The Keystone 65 Select Rx plan has a larger formulary.

Members of Keystone 65 Focus Rx and Keystone 65 Select Rx are eligible to enroll in the Choice Program. The Choice Program provides coverage for routine vision, hearing and dental visits. The monthly premium for the Choice Program is $6 in addition to your base monthly premium.

For a comparison chart of different copayments and coinsurance between the two plans, see the Summary of Benefits.

The right plan for you depends on your current health profile and expected health needs this year.

Our representatives can provide you with the information you need to decide which of our HMO plans is right for you.

Why are my plan premiums increasing?
The federal government contracts with private insurers like Independence because we can deliver health care services in a cost-efficient way. We are also able to provide additional benefits like the SilverSneakers fitness program. Through our relationship with the federal government, Independence is reimbursed for the services we deliver to members. Independence works hard to keep premiums as low as possible for our members. In some cases, due to increasing medical costs, the federal reimbursement does not completely cover the cost of the coverage that Independence provides. When this happens, increases to premiums are necessary so that we may continue to provide you quality coverage for your health care needs.

Are there any changes to my drug coverage in 2016?
The list of drugs covered by your plan is renewed each benefit year. In 2016, all individual Independence plans will have 5-Tier Closed formulary. This means that there will be five cost-sharing tiers for covered drugs. Drugs that are not on the formulary, referred to as “Non-formulary”, are not covered by your plan. The copayment or coinsurance for each of the tiers for covered drugs depends on your plan - check your Evidence of Coverage for cost-sharing amounts. Covered drugs fall into the following categories:

• Tier 1: preferred generic drugs
• Tier 2: generic drugs
• Tier 3: preferred brand-name drugs
• Tier 4: non-preferred brand-name drugs
• Tier 5: specialty drugs

You should check your Formulary each year to see if a drug has moved to a new cost-sharing tier or is no longer covered. You will receive your Formulary in late September as part of the Annual Notice of Changes packet you receive from the plan. You can also search the formulary online. If you need a new Formulary sent to you, call the Member Help Team to order one.

In addition to different cost-sharing, all of our plans have a different deductible structure:

	Tier 1	Tier 2	Tier 3	Tier 4	Tier 5
Keystone 65 Focus Rx	No deductible	No deductible	No deductible	No deductible	No deductible
Keystone 65 Select Rx	No deductible	No deductible	Deductible applies	Deductible applies	Deductible applies
Keystone 65 Preferred Rx	No deductible	No deductible	No deductible	No deductible	No deductible
Personal Choice 65 Rx	No deductible	No deductible	Deductible applies	Deductible applies	Deductible applies

See your Evidence of Coverage for deductible amounts as well as information about coverage in the Coverage Gap Stage.

How can I save on prescription drugs?
We encourage you to have proactive conversations with your provider about generic drug options whenever possible. Generic alternatives are less expensive and are not subject to coverage deductibles. In addition, there are programs such as PACE that offer Medicare beneficiaries extra help with their prescription drug needs. These programs are subject to income restrictions. You can call our Member Help Team or PACE at 1-800-225-7223 (TTY/TDD: 711), 8 a.m. to 8 p.m., seven days a week, for more information. Please note that on weekends and holidays from February 15 through September 30, your call may be sent to voicemail.

If you get extra help from Medicare in paying for your Medicare prescription drug plan costs, your monthly plan premium will be lower than if you did not get that extra help. The amount of extra help you get will determine your total monthly plan premium as a member of our plan. For more information, please click here.

Does the Affordable Care Act (ACA) impact my coverage?
The biggest impact of the ACA to Medicare coverage is that it works to reduces prescription drug prices and closes the coverage gap, also known as the "donut hole". Medicare beneficiaries who reach the Coverage Gap Stage automatically receive a discount on prescription drugs. Each year, beneficiaries pay a reduced cost for brand-name and generic drugs while in the Coverage Gap Stage.

In 2016, Medicare beneficiaries in the donut hole receive a 45% discount on brand-name drugs and a 58% discount on generic drugs.

I’ve heard in the news, that the new Affordable Care Act (ACA) tax also impacts Medicare Advantage premium? Is that true?
Yes. Starting in 2014, the ACA imposes a tax on health insurance providers based on net premiums in the fully-insured market. The aggregate tax in 2014 is $8 billion. It climbs to $14.3 billion by 2018, and after that grows by premium inflation. Independent experts estimate that the health insurance tax will increase Medicare Advantage premiums by at least $16 to $20 per member, per month. That figure increases to between $32 and $42 by 2023. The average expected cost increase over 10 years is $3,590. Health insurance plans will be left to close that gap in the premium.

Are Medicare Advantage and Medicare supplement Plans the same?
No. Medicare Advantage Plans — sometimes referred to as Medicare Part C or MA Plans — replace Original Medicare. Medicare Advantage plans are HMO & PPO plans that are contracted with CMS to administer the Medicare benefits.

If I chose a Medical-Only option, can I join a different Medicare Part D drug plan?
If you are considering an HMO or PPO Medicare Advantage plan, and you want drug coverage, you must get it through the plan. You cannot join a stand-alone prescription drug plan (PDP) if you are enrolled in an HMO or PPO Medicare Advantage plan. If you are considering a PFFS (private fee-for-service) plan, you may enroll in a separate PDP. Please note that Independence does not offer a PFFS at this time.

If you are already in a stand-alone drug plan and you enroll in a Medicare Advantage plan, you will be automatically disenrolled from your stand-alone drug plan.

Why is it important to choose a primary care physician (PCP) when I enroll?
In an HMO plan (like a Keystone 65 HMO plan), your primary care physician (PCP) plays an important role in managing your health care. Your PCP is responsible for providing and coordinating care, referring you to specialists, or authorizing additional treatment. You select your PCP from our large networks to coordinate your care. Coordination of care lessens the likelihood that your medications and treatments will conflict. You may choose from more than 2,700 PCPs in the Keystone 65 networks.

As a member of a PPO plan (like Personal Choice 65 PPO) you are free to use the doctors and specialists you want in and out of the network. You do not need a referral from your PCP. We do recommend that you confirm that services are covered and medically necessary before seeking them. If you receive care that is not medically necessary outside of the network, you may be responsible for the charges.

If I choose a plan with Part D prescription drug (Rx) coverage how do I know if the medications I take are covered?
You should check your Formulary each year to see if a drug has moved to a new cost-sharing tier or is no longer covered. You will receive your Formulary in late September as part of the Annual Notice of Changes packet you receive from the plan. You can also search the formulary online. If you need a new Formulary sent to you, call the Member Help Team to order one.

What if I need medical care while outside the service area?
All Independence Medicare Advantage plans offer worldwide emergency coverage. This means that you are covered if you are out of the area and need emergency care, urgent care, or renal dialysis.

As an HMO plan member, if you go to a provider outside of your plan’s network for other care, you will have to pay for the services you receive.

If you are a member of a PPO plan, you have the option of seeing providers outside of the Personal Choice 65 network. Please keep in mind that if you use services outside the network, your cost-sharing may be higher than if you choose a provider in the network. We recommend that you check with the plan or your provider regarding out-of-network services before receiving them.

What resources do you have for managing health conditions like asthma?
If you have asthma, diabetes, or another chronic condition, you can get one-on-one support to manage your health through the Connections^SM Health Management Program. You’ll have access to a Health Coach any time of day or night, seven days a week at 1-800-ASK-BLUE (press 1, then press 2) or 1-888-525-4481 for the speech- and hearing-impaired.

Do I have to file claims?
Usually not, there is virtually no paperwork. With our automatic claims filing, you don’t need to worry about paperwork unless you use services outside of your plan’s network. Even then the paperwork is minimal. In most cases, you simply present your insurance ID card when you receive medical services.

What if I have Keystone Health Plan East coverage through my employer?
If you have coverage through your former (or current) employer, Health and Welfare Fund, or an association group, your benefits may vary. Call the Member Help Team for more information.

What is the coverage gap (donut hole) phase of coverage and what are the costs?
Most Medicare Part D plans have a coverage gap. The Coverage Gap Stage begins after the payments you (or others on your behalf) and the plan have made reach the Initial Coverage Limit ($3,310 in 2016). Once you reach this amount, your cost-sharing for Part D drugs may increase. Please note that not everyone will have increased cost-sharing in the coverage gap. People with Medicare who get Extra Help paying Part D costs will not have increased cost-sharing in the coverage gap for covered Part D drugs.

When you are in the Coverage Gap Stage, the Medicare Coverage Gap Discount Program provides manufacturer discounts on brand-name drugs. You also receive some coverage for generic drugs. In 2016, Medicare beneficiaries in the donut hole pay 45% for brand-name drugs and 58% for generic drugs.

For brand-name drugs, both the amount you pay and the amount discounted by the manufacturer count toward your out-of-pocket costs as if you had paid them and move you through the coverage gap. For generic drugs, the amount paid by the plan (42%) does not count toward your out-of-pocket costs. Only the amount you pay counts and moves you through the coverage gap.

You continue paying the discounted price for brand-name drugs and no more than 58% of the costs of generic drugs until your yearly out-of-pocket payments reach a maximum amount that Medicare has set. In 2016, that amount is $4,850.

Medicare has rules about what counts and what does not count as your out-of-pocket costs. When you reach an out-of-pocket limit of $4,850, you leave the Coverage Gap Stage and move on to the Catastrophic Coverage Stage. Check your Evidence of Coverage for more information on out-of-pocket costs.

What payments count towards your True out-of-pocket costs, or TrOOP?
Your yearly TrOOP, which include your deductible (if applicable), coinsurance, and copayments paid for covered Part D drugs, as well as 95% of the cost of brand-name drugs paid for during the coverage gap count towards your TrOOP. Your drug plan premium and non-covered drugs do not count towards your TrOOP.