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Health Maintenance OrganizationsHealth Maintenance Organizations (HMOs) aremanaged care plans in which the healthcareprovider is also the insurer: Kaiser and Cignaare two examples. This is typically the mostlimited type of managed care plan, regardingyour choice of provider. Care is monitored by aprimary care doctor, commonly known as agatekeeper. This individual is responsible for allreferrals, treatment plans, sites of service,treatment and review standards, and has afinancial incentive to provide medicallyappropriate care in a most cost-effectivemanner.There are different operating plans of HMOs.The most common are: staff-model, groupmodel and network-model. A staff-modelHMO consists of a group of doctors who areeither salaried employees of a group practicethat is an important part of the HMO plan, orsalaried employees of the HMO. Healthcareservices in staff plans are delivered at HMOowned health centers. There are two kinds ofgroup-model HMOs: a) the closed-panel plan,in which medical services are delivered in theHMO-owned health center or satellite clinic bydoctors who belong to a legally separatemedical group that only serves the HMO, andb) the plan in which the group of doctorsdelivers medical care. A network-model HMOis an organizational form in which the HMOcontracts with a network of medical groups toprovide healthcare services.Q19. What are the advantages of thistype of plan?A19. Typically these plans are comprehensive,providing all of the services (andpotentially more) that are offered underindemnity plans, or self-funded plans,while being less costly. You areresponsible for a premium (there is5usually no deductible), and a minimalco-payment per office visit. (The copayment structure typically changes forhospital, ancillary and other services.)These plans usually don't havepreexisting condition waiting periods.Q20. What if I choose to receive careoutside of the plan?A20. Usually, care you receive outside of theplan is at your own expense. However,there are situations in which careoutside of the plan may be coveredwith a referral from your primary caredoctor. For example, care required froma specialist that is not available withinthe plan, is generally covered with areferral from your primary care doctor.Also, some HMOs now offer a Point ofService (POS) component. Using thePOS option, you may select doctors andother healthcare providers who areoutside of the plan. However, using thePOS option may change yourdeductible and co-payment obligation.Preferred Provider OrganizationsAs compared to an HMO, a Preferred ProviderOrganization (PPO) is a group of doctors,hospitals, and other practitioners thatcontracts with a payor to provide services at adiscounted rate to preferred providers. Benefitshave already been agreed upon with thehealth plan; therefore, the patient is usuallynot responsible for the amount the providermay bill in excess of the health plan's usualand customary charge.Q21. How does a PPO compare with atraditional indemnity plan, selffunded plan, Taft-Hartley plan oran HMO?

A21.Similar to a traditional indemnity plan,a PPO will usually allow you to see anetwork provider without a referralfrom your primary care doctor. Also likean HMO, your out-of-pocket costs maybe lower, benefiting from thecontractual relationship between yourprovider and the plan. A PPO provides alarger selection of healthcare providers,better out-of-network benefits, and isless restrictive with accessing specialists.Self-funded plans and Taft-Hartley plansmay also be part of a PPO. TheSummary Plan Description wouldspecify the financial differencesbetween using the PPO networkproviders and the non-PPO providers.Q22. Will my costs be different if I see aprovider who is not a member ofthe PPO?A22.Yes. If your provider is a participatingprovider of the PPO, then you will beable to enjoy the special contract rates,which may result in reducedco-payments to you. If your provider isnot participating in the PPO plan, youmay still receive care, however, yourout-of-pocket costs may be higher.For example, let's say your provider'snormal charge is 100. As aparticipating provider, the contractedfee may be 60. The plan pays 80% ofthe contracted rate (which is 48 in thisexample) and you are responsible for20% (in this example, 12). If yourprovider is non-participating, the planwill still only pay 48, but you will beresponsible not only for the 20%coinsurance ( 12), but also for thedifference between your provider'scharge of 100 and the contracted rateof 60. As a result, for using a non-participating provider, your out-ofpocket expense will be 52 ratherthan 12.Participating Non-ParticipatingProviderProviderProvider'sCharge: 100 100Insurance'scontracted rate: 60 6080% paymentby insurance: 48 48Patientcoinsuranceresponsibility: 12 52( 60 - 48)( 100 - 48)Public (Government)Health PlansSupplemental Security IncomeSupplemental Security Income, (SSI), is aprogram run by the Social SecurityAdministration that provides monthlypayments to the elderly, the blind, and peoplewith disabilities who have modest income. Toreceive SSI checks, you must live in the U.S.and be a U.S. citizen or national. (Certainnoncitizens may also be eligible.) Thesemonthly payments generally represent 552for one person, and 829 for a couple,however, they can vary based upon yourincome and what state you live in. Indetermining your income, the governmentreviews your cash, bank accounts, stocks andbonds, earnings, Social Security checks,pensions, and non-cash items you receive,such as food, clothing or shelter. There areseparate rules for working and non-workingapplicants.Contact your nearest Social Security office orcall Social Security's toll-free number,1-800-772-1213, or log on to www.ssa.gov toCaremark Customer Assistance Hotline 1-800-331-71716

learn more about this program. You may alsocontact the Caremark Customer AssistanceHotline at 1-800-331-7171.Social Security Disability IncomeSocial Security Disability Income (SSDI), is aprogram run by the Social SecurityAdministration that provides monthlypayments to individuals who have a severeimpairment and are unable to perform anygainful work activity (not just the job you wereperforming at the time the disability began).Q23. When do I become eligible forbenefits?A23. If you have paid social security taxesover a sufficiently long period to be"fully insured," and contributed to theprogram recently enough to have"disability insured status," you areeligible for benefits after you have beendisabled for five months, and if thedisability is expected to last at least 12months.Q24. How are the payments calculated?A24. Your payments will be based on yoursalary and the number of years youhave been covered under SocialSecurity.Q25. How does receipt of SSDI enableme to receive Medicare benefits?A25. After 24 months of SSDI benefits, youqualify for Medicare.Q26. Is there a time limit on SSDIbenefits?A26. No. You will continue to receive adisability benefit as long as yourcondition keeps you from working.However, your case will be reviewed7from time to time to determinewhether there has been improvementin your condition, and whether you arestill eligible for benefits. If you are stilleligible when you reach 65, yourdisability benefit will automaticallyconvert to retirement benefits.Q27. How can I learn more about thisprogram?A27. Contact your nearest Social Securityoffice or call Social Security's toll-freenumber, 1-800-772-1213, or log on towww.ssa.gov to learn more about thisprogram. You may also contact theCaremark Customer Assistance Hotlineat 1-800-331-7171.MedicareMedicare is a federally sponsored health planfor people 65 years of age and older, certainyounger people with disabilities (see SSDIdiscussion), and people with end-stage renaldisease. Qualified individuals now have theirchoice of the traditional Medicare program orMedicare Choice.Q28. What is traditional Medicare?A28. The traditional Medicare plan is thetraditional pay-per-visit arrangementthat allows you to be treated by anydoctor, hospital, or other healthcareprovider that participates in theMedicare program. The traditionalMedicare Plan has Part A (HospitalServices) and Part B (Major MedicalServices).Q29. What is Part A and what are mycosts?A29. Part A helps pay for care provided inhospitals, skilled nursing facilities(SNFs), hospice, and home health. If

you are eligible, you will be premiumfree, because you or your spouse paidMedicare taxes while you wereworking. If you don't qualify forpremium-free Part A, you may be ableto buy it. After payment of adeductible, you will be responsible forthe coinsurance, which will varydepending upon the care provided. Forexample, for hospitals and skillednursing facilities the coinsurance iscalculated for each benefit period (theperiod of time from admittance to 60consecutive days past the last hospitalin-patient or SNF care day) based uponyour length of stay.supplies, your coinsurance will be 20%of Medicare's approved amountwithout any out-of-pocket limitation.Q31. What are Medicare Choice Plans?A31. Recognizing the limitations of thetraditional Medicare Plan, Medicare Choice Plans provide you with a widerarray of health plan options. If youhave Medicare Parts A and B, do nothave end-stage renal disease, and livein the service area of a health plan,your options include:n Traditional Medicare Plan with asupplemental plann Managed Caren Private Fee-for-Service Plann Medicare Medical Savings AccountQ30. What is Part B and what are mycosts?A30. Part B helps pay for doctors, out-patient hospital care, and other medicalservices, such as physical andoccupational therapists, x-rays,preventive services, and limited outpatient drugs (including blood clottingfactor) when administered inconjunction with covered Part Bservices. Effective July 18, 1994, selfadministered blood clotting factors andnecessary items furnished to hemophiliapatients competent to use such factorsto control bleeding without medical orother supervision are covered andreimbursed under Part B. You areautomatically eligible for Part B if youare eligible for premium-free Part A.You are also eligible if you are a U.S.citizen or permanent resident aged 65or older. You will be responsible for amonthly premium, an annualdeductible, and coinsurance, which willvary depending upon the serviceprovided. For example, for doctors,medical and surgical services andPlan (MSA)Q32. What is the benefit of thetraditional Medicare Plan with asupplemental plan?A32.Purchase of one of the 10 standardsupplemental insurance policies mayprovide additional benefits not coveredunder the traditional Medicare Plan(e.g., prescription drugs), and help payMedicare's coinsurance amounts anddeductibles. There are two types ofMedicare supplemental insurancepolicies: Medigap and Medicare Select.Medigap allows you to go to anydoctor or hospital that acceptsMedicare. Medicare Select requires youto use plan hospitals, and in somecases, plan doctors.Q33. What is a Managed Care Plan, andCaremark Customer Assistance Hotline 1-800-331-7171how does it compare with thetraditional Medicare Plan?8

A33. A Managed Care Plan involves a groupof doctors, hospitals, and otherhealthcare professionals who inexchange for a fixed amount of moneyor other negotiated reimbursementfrom Medicare, agree to provide care toMedicare beneficiaries. Managed CarePlans include health maintenance plans(HMOs), HMOs with a Point of Service(POS) option and Preferred ProviderOrganizations (PPOs). A Managed CarePlan, may, or may not, be right for you,depending upon how you value choiceof provider, benefits, need forspecialists and cost. In comparing theManaged Care Plan to the traditionalMedicare Plan, while your choice ofprovider may be more restricted, yourcoverage is usually better and yourcosts are usually less.For example, HMOs usually require youto use doctors and hospitals that aremembers of the plan, while PPOs andHMOs with POS options may allow youto use doctors and hospitals "outside"of the plan (although usually at greatercost). Managed Care Plans must offeryou at least the same covered servicesavailable under the traditional MedicarePlan; however, they typically offergreater benefits including coverage forout-patient drugs, vision or dental care,hearing aids, etc. While all plans(traditional and Managed Care) requireyou to pay the Part B premium,Managed Care Plans are generally lessexpensive, even when a co-paymentper visit or per service is required.Q34. How does the Private Fee-forService Plan operate?A34. Under this program you choose aprivate insurance plan that accepts9Medicare beneficiaries. You may go toany doctor or hospital you choose. Theinsurance plan, rather than theMedicare program, determines thereimbursement amount and pays theprovider. You are still responsible forthe Medicare Part B premium, as wellas any monthly premium the plancharges, and an amount per visit orservice. In addition, if the doctor billsmore than the plan pays, you areresponsible for this difference.Q35. How do I enroll/disenroll in one ofthe Medicare Plans?A35. If you are not yet 65 and alreadygetting Social Security or RailroadRetirement benefits, you are enrolledautomatically in both Parts A and B,and your Medicare card is mailed toyou about 3 months before your 65thbirthday. If you are disabled, you will beautomatically enrolled in both Parts Aand B beginning in your 25th month ofdisability, and your Medicare card willbe mailed to you about 3 monthsbefore you are entitled to Medicare.Your initial enrollment period starts 3months before you turn 65 and lastsfor 7 months. If you chose not to takePart B when you were first eligible, youcan sign up during two enrollmentperiods: general enrollment period(January 1 through March 31 of eachyear for coverage that begins on July 1of that year); special enrollment period(available to individuals who are/werepreviously covered under a grouphealth plan).You may enroll in a Medicare ManagedCare Plan or Private Fee-for-Service Planat any time, simply by contacting theplan and requesting an enrollment

form. The plan cannot refuse to enrollyou during your open enrollmentperiod (the first six months after youturn 65 and are enrolled in MedicarePart B). You may disenroll at any time,for any reason, by contacting the planor the Social Security Administration.Your disenrollment becomes effectiveas early as the first of the month afteryour request is received.You can only enroll in a MedicareMedical Savings Account (MSA) planduring the 3-month period before youare entitled to Part A and Part B, orduring November of each year. Youmust set up a Medicare MSA at a bankor savings institution. You can leave theMedicare MSA Plan by filing a requestfor disenrollment in November. Yourdisenrollment becomes effectiveDecember 31.As of January 1, 2002, disenrollmentopportunities have become limited.Q36. What if I can't afford the costsassociated with Medicare?A36. If you have Medicare Part A and yourQ37. How can I learn more aboutMedicare?A37. Contact your local Social Security officeor Medicare carrier to learn more aboutthis program. Additional information isavailable online at www.medicare.gov.You may also contact the CaremarkCustomer Assistance Hotline at1-800-331-7171.TRICARETRICARE is a regionally managed healthcareprogram for active duty and retired membersof the uniformed services, their families, andsurvivors.Q38. Are different plans available underTRICARE?A38. Yes. There is TRICARE Prime (HMO),TRICARE Extra (PPO), TRICARE Standardand TRICARE for Life.Q39. What is TRICARE Prime?A39. TRICARE Prime is the managed carebank accounts, stocks, bonds, or otherresources do not exceed 4,000 (for anindividual), or 6,000 (for a couple),you may qualify for assistance as aQualified Medicare Beneficiary (QMB),Specified Low-Income MedicareBeneficiary (SLMB) or QualifyingIndividual (QI). The QMB program paysMedicare's premiums, deductibles, andcoinsurance for entitled older anddisabled people who are qualified forMedicare Part A. If your income is toohigh to qualify for QMB, you may beable to get help under the SLMB or QIprograms. Both SLMB and QI pay yourMedicare Part B premium, but do nothelp with Part A.Caremark Customer Assistance Hotline 1-800-331-7171option. If implemented in your area,you may enroll in this plan at any time;however, there is a one-yearcommitment. If you are on active duty,you will be enrolled in this planautomatically, and assigned a PrimaryCare Manager. Your eligible familymembers may choose to also enroll inthis plan, or any of the other plansoffered, except TRICARE for LIFE. UnderTRICARE Prime, there is no annualdeductible, no enrollment fee, and noco-payments for authorized medicalvisits and prescriptions except forretirees under the age of 65. Retireesunder the age of 65 have an annualenrollment fee of 230 per individualor 460 per family. Enrollees in the10

TRICARE Prime plan have access tomedical treatment facilities andTRICARE network providers.Q40. What is TRICARE Standard?A40. TRICARE Stan

of insurance, the employer may pay all or part of the premiums. Individual insurance policies are purchased from an insurance company by a person who pays the premium directly to the insurance company. Several types of employer group health coverage are available: traditional indemnity plans, self-funded plans or Taft-Hartley plans. When .