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Blue Cross Medicare Advantage Value (HMO) offered byGHS Insurance Company (GHS)Annual Notice of Changes for 2018You are currently enrolled as a member of Allegian Advantage (HMO). Next year, there will besome changes to the plan’s costs and benefits. This booklet tells about the changes. You have from October 15 until December 7 to make changes to your Medicarecoverage for next year.What to do now1. ASK: Which changes apply to you Check the changes to our benefits and costs to see if they affect you. It’s important to review your coverage now to make sure it will meet your needs nextyear. Do the changes affect the services you use? Look in Sections 2.1 and 2.5 for information about benefit and cost changes for our plan. Check the changes in the booklet to our prescription drug coverage to see if theyaffect you. Will your drugs be covered? Are your drugs in a different tier, with different cost-sharing? Do any of your drugs have new restrictions, such as needing approval from us before youfill your prescription? Can you keep using the same pharmacies? Are there changes to the cost of using thispharmacy? Review the 2018 Drug List and look in Section 2.6 for information about changes to ourdrug coverage. Check to see if your doctors and other providers will be in our network next year. Are your doctors in our network? What about the hospitals or other providers you use? Look in Section 2.3 for information about our Provider Directory.Y0096 BEN TX HMOValue 2018 AcceptedForm CMS 10260-ANOC/EOC(Approved 05/2017)A8554/001OMB Approval 0938-1051 (Expires: May 31, 2020)
Think about your overall health care costs. How much will you spend out-of-pocket for the services and prescription drugs you useregularly? How much will you spend on your premium and deductibles? How do your total plan costs compare to other Medicare coverage options? Think about whether you are happy with our plan.2. COMPARE: Learn about other plan choices Check coverage and costs of plans in your area. Use the personalized search feature on the Medicare Plan Finder athttps://www.medicare.gov website. Click “Find health & drug plans.” Review the list in the back of your Medicare & You handbook. Look in Section 4.2 to learn more about your choices. Once you narrow your choice to a preferred plan, confirm your costs and coverage onthe plan’s website.3. CHOOSE: Decide whether you want to change your plan If you want to keep Blue Cross Medicare Advantage Value (HMO), you don’t need to doanything. You will stay in Blue Cross Medicare Advantage Value (HMO). To change to a different plan that may better meet your needs, you can switch plansbetween October 15 and December 7.4. ENROLL: To change plans, join a plan between October 15 and December 7, 2017 If you don’t join by December 7, 2017, you will stay in Blue Cross Medicare AdvantageValue (HMO). If you join by December 7, 2017, your new coverage will start on January 1, 2018.
Additional Resources This document is available for free in other languages. ATTENTION: If you speak English, language assistance services, free of charge, areavailable to you. Please contact our Customer Service number at 1-877-774-8592 foradditional information. (TTY users should call 711.) Hours are 8:00 a.m. – 8:00 p.m.,local time, 7 days a week. If you are calling from February 15 through September 30,alternate technologies (for example, voicemail) will be used on weekends and holidays. ATENCIÓN: si habla Español, tiene a su disposición servicios gratuitos de asistencialingüística. Llame al 1-877-774-8592 (TTY: 711). Nuestro horario es de 8:00 a.m. a 8:00p.m., hora local, los 7 días de la semana. Si usted llama del 15 de febrero al 30 deseptiembre, durante los fines de semana y feriados, se usarán tecnologías alternas (porejemplo, correo de voz). Please contact Blue Cross Medicare Advantage Value (HMO) if you need thisinformation in another language or format (Spanish, Braille, large print or audio tapes). Coverage under this Plan qualifies as minimum essential coverage (MEC) andsatisfies the Patient Protection and Affordable Care Act’s (ACA) individual sharedresponsibility requirement. Please visit the Internal Revenue Service (IRS) website als-and-Families for more information.About Blue Cross Medicare Advantage Value (HMO) Blue Cross Medicare Advantage HMO and HMO-POS plans are provided by GHSInsurance Company (GHS), an Independent Licensee of the Blue Cross and Blue ShieldAssociation. GHS is a Medicare Advantage organization with a Medicare contract.Enrollment in GHS plans depends on contract renewal. When this booklet says “we,” “us,” or “our,” it means GHS Insurance Company (GHS).When it says “plan” or “our plan,” it means Blue Cross Medicare Advantage Value(HMO).
Blue Cross Medicare Advantage Value (HMO) Annual Notice of Changes for 20181Summary of Important Costs for 2018The table below compares the 2017 costs and 2018 costs for Blue Cross Medicare AdvantageValue (HMO) in several important areas. Please note this is only a summary of changes. It isimportant to read the rest of this Annual Notice of Changes and review the enclosed Evidenceof Coverage to see if other benefit or cost changes affect you.Cost2017 (this year)2018 (next year) 0.00 0.00Maximum out-ofpocket amountThis is the most youwill payout-of-pocket for yourcoveredPart A and Part Bservices.(See Section 2.2 fordetails.) 4,000 4,000Doctor office visitsPrimary care visits: 0 pervisitPrimary care visits: 0 copay pervisitMonthly planpremium** Your premium maybe higher or lower thanthis amount. SeeSection 2.1 for details.Specialist visits: 40 per visit Specialist visits: 40 copay pervisit
Blue Cross Medicare Advantage Value (HMO)CostInpatient hospitalstaysIncludes inpatientacute, inpatientrehabilitation, longterm care hospitals andother types of inpatienthospital services.Inpatient hospital carestarts the day you areformally admitted tothe hospital with adoctor’s order. The daybefore you aredischarged is your lastinpatient day. Annual Notice of Changes for 20182017 (this year) 200 copay per day for days1-62018 (next year) 200 copay per day for days 1-6; 0 copay per day for days 7-90 0 copay per day for days 790 0 copay per day for days 91 andbeyond2
Blue Cross Medicare Advantage Value (HMO)Cost Annual Notice of Changes for 20182017 (this year)2018 (next year)Part D prescriptiondrug coverageDeductible: 0Deductible: 0(See Section 2.6 fordetails.)Copayment/Coinsuranceduring the Initial CoverageStage:Copayment/Coinsurance duringthe Initial Coverage Stage: Drug Tier 1-PreferredGeneric:Standard cost-sharing: 2 copayDrug Tier 2-Generic:Standard cost-sharing: 15 copayDrug Tier 3-PreferredBrand:Standard cost-sharing: 45 copayDrug Tier 4-NonPreferred Brand:Standard cost-sharing: 95 copayDrug Tier 5-Specialty:Standard cost-sharing:33% coinsurance Drug Tier 1-PreferredGeneric:Standard cost-sharing: 5copayPreferred cost-sharing: 0copayDrug Tier 2-Generic:Standard cost-sharing: 19 copayPreferred cost sharing: 8copayDrug Tier 3-PreferredBrand:Standard cost-sharing: 47 copayPreferred cost-sharing: 39copay Drug Tier 4-Non-PreferredBrand:Standard cost-sharing: 100 copayPreferred cost-sharing: 95 copayDrug Tier 5-Specialty:Standard cost-sharing:33% of the total costPreferred cost sharing:33% of the total cost3
Blue Cross Medicare Advantage Value (HMO) Annual Notice of Changes for 20184Annual Notice of Changes for 2018Table of ContentsSummary of Important Costs for 2018 . 1SECTION 1We Are Changing the Plan's Name . Error! Bookmark not defined.SECTION 2Changes to Benefits and Costs for Next Year . 5Section 2.1 – Changes to the Monthly Premium . 5Section 2.2 – Changes to Your Maximum Out-of-Pocket Amount . 6Section 2.3 – Changes to the Provider Network . 6Section 2.4 – Changes to the Pharmacy Network . 7Section 2.5 – Changes to Benefits and Costs for Medical Services . 7Section 2.6 – Changes to Part D Prescription Drug Coverage . 14SECTION 3Other Changes . 18SECTION 4Deciding Which Plan to Choose. 20Section 4.1 – If you want to stay in Blue Cross Medicare Advantage Value (HMO) . 20Section 4.2 – If you want to change plans . 20SECTION 5Deadline for Changing Plans . 21SECTION 6Programs That Offer Free Counseling about Medicare . 21SECTION 7Programs That Help Pay for Prescription Drugs . 21SECTION 8Questions? . 22Section 8.1 – Getting Help from Blue Cross Medicare Advantage Value (HMO) . 22Section 8.2 – Getting Help from Medicare . 23
Blue Cross Medicare Advantage Value (HMO) Annual Notice of Changes for 20185SECTION 1 We Are Changing the Plan’s NameOn January 1, 2018, our plan name will change from Allegian Advantage (HMO) to Blue CrossMedicare Advantage Value (HMO).Because we are changing the name of the plan, you will receive new member identification cardsby mail by October 1, 2017. Please make sure you use the new Blue Cross Medicare Advantagecard starting on January 1, 2018. In addition, please review your new Evidence of Coverage,provider directory, formulary, pharmacy directory as well as the Annual Notice of Change forinformation on new and changes in services effective January 1, 2018.If you have any questions regarding your benefits or if you do not receive your member ID cards,Evidence of Coverage or any other member information, please contact our Customer Servicearea at 1-877-774-8592. (TTY/TDD users call 711) Hours are 8:00 a.m. – 8:00 p.m., local time,7 days a week. If you are calling from February 15 through September 30, alternate technologies(for example, voicemail) will be used on weekends and holidays. You can also visit our websiteat www.getbluetx.com/mapd.SECTION 2 Changes to Benefits and Costs for Next YearSection 2.1 – Changes to the Monthly PremiumCostMonthly premium(You must also continue to pay yourMedicare Part B premium.)2017 (this year)2018 (next year) 0.00 0.00 Your monthly plan premium will be more if you are required to pay a lifetime Part D lateenrollment penalty for going without other drug coverage that is at least as good asMedicare drug coverage (also referred to as “creditable coverage”0 for 63 days or more ifyou enroll in Medicare prescription drug coverage in the future. If you have a higher income, you may have to pay an additional amount each monthdirectly to the government for your Medicare Prescription drug coverage.
Blue Cross Medicare Advantage Value (HMO) Annual Notice of Changes for 2018Your monthly premium will be less if you are receiving “Extra Help” with yourprescription drug costs.Section 2.2 – Changes to Your Maximum Out-of-Pocket AmountTo protect you, Medicare requires all health plans to limit how much you pay “out-of-pocket”during the year. This limit is called the “maximum out-of-pocket amount.” Once you reach thisamount, you generally pay nothing for covered services for the rest of the year.CostMaximum out-ofpocket amountYour costs forcovered medicalservices (such ascopays) count towardyour maximum outof-pocket amount.Your plan premiumand your costs forprescription drugs donot count towardyour maximum outof-pocket amount.2017 (this year)2018 (next year) 4,000 4,000Once you have paid 4,000 out-ofpocket for covered services, youwill pay nothing for your coveredservices for the rest of the calendaryear.Section 2.3 – Changes to the Provider NetworkThere are changes to our network of providers for next year. An updated Provider Directory islocated on our website at www.getbluetx.com/mapd. You may also call Customer Service forupdated provider information or to ask us to mail you a Provider Directory. Please review the2018 Provider Directory to see if your providers (primary care provider, specialists,hospitals, etc.) are in our network.It is important that you know that we may make changes to the hospitals, doctors and specialists(providers) that are part of your plan during the year. There are a number of reasons why yourprovider might leave your plan, but if your doctor or specialist does leave your plan you havecertain rights and protections summarized below:6
Blue Cross Medicare Advantage Value (HMO) Annual Notice of Changes for 20187 Even though our network of providers may change during the year, Medicare requiresthat we furnish you with uninterrupted access to qualified doctors and specialists. We will make a good faith effort to provide you with at least 30 days’ notice that yourprovider is leaving our plan so that you have time to select a new provider. We will assist you in selecting a new qualified provider to continue managing your healthcare needs. If you are undergoing medical treatment you have the right to request, and we will workwith you to ensure, that the medically necessary treatment you are receiving is notinterrupted. If you believe we have not furnished you with a qualified provider to replace yourprevious provider or that your care is not being appropriately managed, you have theright to file an appeal of our decision. If you find out your doctor or specialist is leaving your plan, please contact us so we canassist you in finding a new provider and managing your care.Section 2.4 – Changes to the Pharmacy NetworkAmounts you pay for your prescription drugs may depend on which pharmacy you use. Medicaredrug plans have a network of pharmacies. In most cases, your prescriptions are covered only ifthey are filled at one of our network pharmacies. Our network includes pharmacies withpreferred cost-sharing, which may offer you lower cost-sharing than the standard cost-sharingoffered by other network pharmacies for some drugs.There are changes to our network of pharmacies for next year. An updated Pharmacy Directoryis located on our website at www.getbluetx.com/mapd/pharmacies. You may also call CustomerService for updated provider information or to ask us to mail you a Pharmacy Directory. Pleasereview the 2018 Pharmacy Directory to see which pharmacies are in our network.Section 2.5 – Changes to Benefits and Costs for Medical ServicesWe are changing our coverage for certain medical services next year. The information belowdescribes these changes. For details about the coverage and costs for these services, see Chapter 4,Medical Benefits Chart (what is covered and what you pay), in your 2018 Evidence of Coverage.
Blue Cross Medicare Advantage Value (HMO)Cost/H8554/001 Annual Notice of Changes for 20182017 (this year)82018 (next year)Ambulatory surgicalservicesIn-network 150 copay for Medicarecovered ambulatory surgicalservicesIn-network 75 copay for Medicare-coveredambulatory surgical servicesAnnual PhysicalExamIn-networkNot-coveredIn-network 0 copay for Medicare-coveredservicesCardiac RehabservicesIn-network 20 copay per session forMedicare-covered Cardiacrehab and Intensive Cardiacrehab servicesIn-network 30 copay for Medicare-coveredCardiac rehab servicesDental servicesIn-networkPreventive dental benefits: One oral exam everyyear One cleaning every yearIn-networkPreventive dental benefits: 2 oral exams per year 2 cleanings per yearDiabetes Selfmanagement training,supplies and servicesIn-network0% cost sharing is limited toFreestyle and Accu-Chek. Ifother diabetic testing suppliesare required, you, your provideror an authorized representativecan request a coveragedeterminationIn-network0% cost sharing is limited toAscensia Diabetes Care testingsupplies (Contour, Contour Next,and Breeze products), including themeter, test strips and lancets. Ifother diabetic testing supplies arerequired, you, your provider or anauthorized representative canrequest a coverage determination;however, you will pay a 20% coinsurance for these other products.20% cost sharing for all otherdiabetic supplies in this category. 0 copay for Diabetictherapeutic shoes or inserts20% of the total cost for Medicarecovered diabetic shoes and inserts 30 copay for Medicare-coveredIntensive Cardiac rehab services
Blue Cross Medicare Advantage Value (HMO)Cost/H8554/001 Annual Notice of Changes for 20182017 (this year)92018 (next year)Emergency services 75 copay 80 copayEmergency serviceswaiverCopay is waived if you areadmitted to the hospital within24 hours for the samecondition.Copay is waived if you areadmitted to the hospital within 3days for the same condition.Eye Exams and EyeWearIn-network 25 copay for Medicarecovered eye exams to diagnoseand treat diseases andconditions of the eye (includingyearly glaucoma screening)In-network 0 copay for Medicare-covered eyeexam; 0 copay for one visionspecialist examHearing exams andservicesIn-network 25 copay for Medicarecovered diagnostic hearingexams to diagnose and treathearing and balance issuesIn-network 35 copay for Medicare-coveredhearing exam 25 copay for one routinehearing exam every year 5 copay for routine hearing exam Up to 1 routine hearingexam every yearHealth and wellnesseducation programsSilver & Fit Exercise andHealthy Aging ProgramSilverSneakers Wellness Program(see Chapter 4, Medical Benefitschart for more information)Other Health CareProfessional services(i.e. nursepractitioner,physician assistant)In-network 0 copayIn-network 0 for services performed with aPCP, 40 for services performedwith a Specialist
Blue Cross Medicare Advantage Value (HMO)Cost/H8554/001Outpatient MentalHealth Specialtyservices Annual Notice of Changes for 20182017 (this year)In-network 25 copay for Medicarecovered individual or groupoutpatient mental health therapyservices102018 (next year)In-network 35 copay for Medicare-coveredindividual services 35 copay for Medicare-coveredgroup services
Blue Cross Medicare Advantage Value (HMO)Cost/H8554/001Outpatient Diagnosticprocedures/tests/labservices; therapeuticradiology servicesOutpatient Hospitalservices Annual Notice of Changes for 2018112017 (this year)2018 (next year)In-network 0 copay for Medicare-coveredlab services and Medicarecovered diagnostic proceduresand testIn-network 0 to 100 copay; 0 copay for theDiagnostic Bone MassMeasurement, DiagnosticColonoscopy and DiagnosticMammography test performed onthe same date of service as thecorresponding preventive test andall other services at 100 copaymaximum cost sharing. 0 to 50copay; 0 PCP, 0 SPC, 0 FreeStand lab, 50 Outpatient Hospitallabs for Medicare-coveredoutpatient lab services 25 to 150 copay foroutpatient diagnostic services. 25 copay for generaloutpatient diagnostic services. 150 copay for complexoutpatient diagnostic services 225 to 300 copay; 225 copay Free Stand Rad, 300Outpatient Hospitalfor Medicare-covered diagnosticradiology services 60 copay for Medicarecovered therapeutic radiologyservices20% of the total cost for Medicarecovered therapeutic radiologyservices 0 copay for Medicare-coveredx-rays 0 to 100 copay; 0 PCP, 0 PSC, 0 Free Stand Rad, 100 OutpatientHospital for Medicare-covered xray servicesIn-network 225 copay for Medicarecovered outpatient hospitalvisitsIn-network 0 copay to 225 copay ( 0 copayfor observation, 225 for otherOutpatient Hospital services.)
Blue Cross Medicare Advantage Value (HMO)Cos
GHS Insurance Company (GHS) Annual Notice of Changes for 2018 You are currently enrolled as a member of Allegian Advantage (HMO). Next year, there will be some changes to the plan’s costs and benefits. This booklet tells about the changes. You have from October 15 until December 7
