Medicare Advantage Plan Highlights

What’s New?

What exactly are MA plans?

Medicare offers you different ways to get your Medicare benefits when you reach age 65, or become covered under Medicare before age 65. One option is called Original Medicare, and is the traditional form that underlies your retiree health coverage from the city.

Another option is called a Medicare Advantage plan where Medicare contracts with private companies to provide the benefits instead of Medicare. The city has selected Aetna, TexanPlus and Texas HealthSpring to provide this service.

These city-sponsored MA plans are two HMO-type plans, and one private-fee-for-service plan similar to the PPO. In the HMO plans, you must choose a PCP to coordinate your care, and use network providers. In the private-fee-for-service plan, almost every doctor and hospital in the US can participate directly. You seek care from any doctor who agrees to Aetna’s terms of participation. There is no network. When you enroll in an MA plan, Medicare pays a monthly amount to Aetna, TexanPlus, and Texas HealthSpring to provide your Medicare benefits. That means that these MA plans cover everything Medicare covers, and more. Medicare writes most of the rules that the vendor and the retiree must follow.

Three Good options for saving money

You have the choice of three Medicare Advantage plans for 2008. Those of you who live in the Houston area told us how happy you are saving money on monthly health premiums and copayments; so, we found a way to provide great cost savings and top-notch benefits for those folks living outside of Texas. Effective this past January 2007, the City began offering the Aetna Private-Fee-for-Service Plan, and already, almost 350 of you have decided to try it out. City retirees and their eligible dependents can choose from a total of five health-benefits plans.

What’s the difference in these three city-sponsored Medicare Advantage plans?

• Texas HealthSpring offers HMO-type benefits to Medicare-covered retirees, primarily in the southeast/east Texas area. The network includes Kelsey Seybold, Sadler Clinic and Renaissance doctors from which to select a PCP.
• TexanPlus offers HMO–type benefits to Medicare-covered retirees in the southeast Texas area. The network includes Kelsey Seybold and Heritage doctors from which to select a PCP.
• Aetna Private-Fee-for-Service offers copayment benefits for most services in all 50 United States. Any doctor and hospital that accepts Medicare assignment can participate. You seek care from any doctor who agrees to Aetna’s terms of participation.

Carefully study the material in this guide. It explains who is eligible and your enrollment options. Take the time to learn about each plan. We think you’ll find an MA plan worth trying. You can’t lose in this game!

Medicare Advantage plans – good strategy
to win against rising health care costs

What are the benefits of considering one of these plans? If you are already covered by Medicare, these plans are just a different way to have Medicare coverage. MA plans offer familiar benefits for lower cost than a traditional health plan.

Aetna, TexanPlus and Texas HealthSpring are managed locally. Medicare believes that contracting with quality health plans helps better manage retiree health benefits. So Medicare pays MA plans for maintaining closer contact with the retirees – something Medicare cannot do for 50 million retirees in America. That is why MA plans cost less than traditional health plans.

Here’s what this means to city of Houston retirees.

• Your contribution for health coverage in an MA plan for one retiree is only $8 to $54 per month. Compare that to the $131cost per month to enroll in the HMO, and $400 in the PPO.
• Copayments are 25 - 70 percent lower for a visit to the PCP and specialist.
• Most other copayments are lower.
• The plan design is still familiar to you.
• You can get better than the equivalent of the Medicare Part D drug benefit from these plans.
• There is no Medicare Part D premium.
• You can join an MA plan now, and your dependents can remain in the HMO or PPO.
• You can enroll in a city-sponsored MA plan on the first day of any month in 2008. If the MA plans do not meet your needs, you can re-enroll in the HMO or PPO within 90 days of your enrollment in the MA plan, or on May 1, 2008.
  

What are your options during open enrollment?

• Enroll in one of the three MA Plans for yourself only.
• Enroll in one of the three MA Plans for yourself and your Medicare-covered dependents.
• Enroll in an MA Plan for a Medicare-covered family member and leave another Medicare or non-Medicare covered family member in the HMO or PPO plan.
• Return to the HMO or PPO within 90 days of MA plan enrollment if you are not satisfied.
• After 90 days, your next opportunity to return to the HMO or PPO will be on May 1, 2008.
• Do nothing and remain in the plan you are in now.

Who is eligible?

Probably you. Here are the FIVE things you need to qualify:

• Be a city retiree, dependent or survivor currently covered under a city medical plan.
• Live in a plan’s service area, if you enroll in an MA HMO; Aetna’s service area is all 50 states.
• Pay the required premium to the city.
• Be a card-carrying member of Medicare enrolled for coverage in both Part A, hospital insurance, and Part B, medical insurance.
• Not have end-stage renal disease, except for Aetna Private-Fee-for-Service plan.

There are no waiting periods and you cannot be turned down for coverage for a pre-existing health condition.

Important dates
If you meet eligibility requirements, you may join during open enrollment.

1. Forms are due to the city by Dec. 31, 2007, for coverage to begin Jan. 1, 2008.
2. Forms received after Dec. 31, 2007, will become effective on the first day of the following month.
3. To immediately pay the lower premium, the benefits division must receive your application by the third of the month prior to the month in which you want coverage to start. If you want to pay the lower premium on Jan. 1, the benefits division should receive your form by Dec. 3. If we don’t, you will receive a refund for the higher premium for Jan. 1.

MA plan highlights

You now have the choice of three MA plans that will all cost you less that $55 per member per month. TexanPlus and Texas HealthSpring offer benefits very similar to those provided by HMO Blue Texas. The Aetna PFFS plan provides benefits that require more thought on your part before making an appointment, but will still provide great savings – especially if you live outside of the service areas. Below is a brief summary of each plan, but be sure to see the Comparison Chart for more details.

Aetna Private-Fee-for-Service-Plan
Since January 2007, 100 employers are offering the Aetna PFFS plan to their eligible retirees and dependents, and 55,000 members have enrolled in the plan. Almost 350 of those members are from the City of Houston. See the box, “How can my doctor or hospital participate in the Aetna PFFS plan?” if you’d like to ensure that your doctors are participating, so you can enroll.

• Approximately 96% of doctors in the US can become part of the Aetna PFFS plan — they must accept Medicare assignment and agree to Aetna’s terms and conditions.
• You do not need a PCP, but it is recommended that you have one. No referrals are needed for specialists. Physicians are required to agree to Aetna’s terms and conditions.
• Precertification for certain services is recommended, but not required.
• Medicare Part B drugs are covered at 100 percent.
• Worldwide emergency care.
• One routine hearing exam free per year; $500 reimbursement on hearing aids every 36 months.
• One routine eye exam free per year. Discounts on frames and lenses.
  

TexanPlus
TexanPlus was introduced to retirees in 2005 as a great savings opportunity for those who live in specific service areas. Below are TexanPlus highlights:

• TexanPlus includes an established network of physicians in 10 counties of the greater Houston area, including Kelsey Seybold and Heritage doctors.
• You must have a Primary Care Physician (PCP), and your PCP must refer you to network specialists.
• Medicare Part B drugs are covered with a 20% coinsurance, to a maximum of $2000. After you have paid $2000, TexanPlus will pay for Part B drugs at 100%.
• Extra benefits include discounts on fitness memberships, hearing exams, dental services, eye exams and lenses.
• One-time $500 reimbursement on a hearing aid.

Texas HealthSpring
TexanPlus was introduced to retirees in 2005 as a great savings opportunity for those who live in specific service areas. See pages 11 - 15 for tools to help you decide if this plan is right for you. Below are TexanPlus highlights:

• TexanPlus includes established physician networks, including Kelsey Seybold, Heritage, Memorial , Katy and CyFair doctors, in 14 Texas counties.
• You must have a Primary Care Physician (PCP), and your PCP must refer you to network specialists.
• Medicare Part B drugs are covered with a 20 percent coinsurance, to a maximum of $1500. After you have paid $1,500, TexanPlus will pay for Part B drugs at 100 percent.
• Extra benefits include discounts on fitness memberships, hearing exams, dental services, eye exams and lenses.
• One-time $500 reimbursement on a hearing aid.

Savings? Okay, show me the money.
Savings come in the form of lower monthly contributions and lower time-of-service payments. Since May 1, 2005, almost 2,000 participating retirees and dependents have saved more than $2.7 million in contributions. That doesn’t count what they’ve saved in copayments. Here’s how the savings stack up:

• If you enroll in one of the MA plans, you could save 59 - 94 percent over what you would pay for HMO coverage and 86 – 98 percent over what you would pay for PPO coverage.
• Lower out-of-pocket costs on many services including:
  • 25 - 70 percent on doctor visits
  • $200 - $500 on hospital admissions
  • $100 on emergency room visits
  • 5 - 10 percent on durable medical equipment, like wheel chairs and walkers
  • 100 percent coverage for home health visits
  • Free rides to the doctor if you enroll in Texas HealthSpring: up to 15 round trips to doctors, hospitals, pharmacies

How can these benefits costs less than what I’ve been paying?

• Medicare has delegated most of the responsibility for providing benefits for 50 million beneficiaries to managed care companies, which means you can receive more personalized service, and they can better manage the unique medical needs of the senior population.
  
• Managed care companies can coordinate your care better than Medicare alone, and can perform better analysis on prescription interaction.
  
• The federal government is still responsible for making sure each Medicare beneficiary gets full Medicare benefits. With MA plans, employers can increase the benefit, and provide benefits that are better than Medicare alone.

Plan features for medical plans

The following MA plan features are effective Jan. 1, 2008. The emergency room copayment for Aetna has changed from $35 to $50. All other plans remain the same. Below is a brief summary of each plan, but be sure to see the Comparison Chart for more detail. Refer to the evidence of coverage for Aetna, TexanPlus or Texas HealthSpring, or to the HMO/PPO medical plan summary document for covered benefits and exclusions. All prescription plans include a mandatory generic policy, which means that if your doctor prescribes a generic drug but you purchase the brand-name equivalent, you will pay more for your medicine. Your copayment will be the difference in cost between the brand and generic drug, plus the generic copayment.

*NOTE: TexanPlus has discontinued the mail order option; however, you can fill a 90-day prescription for a 2-months copay at your local network pharmacy.

* Prior authorization required

A message from the MA plans

Aetna PFFS
Aetna is proud and excited to tell you about our newest Medicare Advantage plan that began Jan. 1 2007 – the Aetna Medicare Open Private-Fee-for-Service plan which is offered in all 50 States. As of October 2007, Aetna has over 100 plan sponsors with over 55,000 members on the Aetna Medicare Open private-fee-for-service plan.It’s great for retirees who do not live inside a contracted network service area or for those who simply want to be able to make their own provider choices. With the Aetna PFFS, you can go to any doctor who is Medicare eligible and accepts Aetna’s terms and conditions, and you don’t need referrals from a PCP to see a specialist. There are no deductibles in this plan, low copayments, and there isn’t even a hospital copayment. To make sure we are there when you need us, our Member Services Department is open 7 days a week, including holidays, 365 days a year from 8 a.m. – 8 p.m. in all time zones. To order your enrollment kit please call us at (800) 307-4830.

TexanPlus
TexanPlus has been offered to City retirees and their dependents since May 2005, and right now we are proud to say that more than 850 folks have selected TexanPlus to provide coverage for their health care needs.

Why choose TexanPlus? First of all, we work in partnership with our doctors, who have been serving Medicare-eligible members since 2001. Our physician groups include Kelsey-Seybold, Memorial Clinical Associates, and the Heritage Physicians Network. We also have a comprehensive hospital network that includes the Methodist Healthcare System, Memorial Hermann Healthcare System and St. Luke’s Episcopal Hospital (for Kelsey members).

Best of all, we offer easy access to primary care doctors, specialists and hospitals for very low copayments. Your prescription drug coverage (Part D) has no additional premium and no deductible. TexanPlus also offers value-added services, like discounts for dental, vision and hearing needs. Our Eldercare plan can assist you and your family in dealing with long-term health care decisions.

We have designed our program with you in mind, and we believe that TexanPlus may be the right choice for you!

Texas HealthSpring
We are pleased to share with you the exciting benefits that you will receive as a member of Texas HealthSpring. We have earned a reputation for top-of-the-line, local customer service, which is based on the Personal Assistance Liaison program. Every member is assigned their own PAL to assist them in better understanding plan benefits, resolve any issues, and serve as a direct contact to Texas HealthSpring. We can assure you that the Texas HealthSpring personalized customer service approach sets us apart from other plans in our service area.

With Texas HealthSpring, you will find the most extensive provider network, with more than 2000 physicians from which to choose, including Kelsey-Seybold Clinic and Sadler Clinic. There are also over 40 hospitals in our network, including the Memorial Hermann Healthcare System, Methodist Hospitals, and Woman’s Hospital of Texas. You can count on Texas HealthSpring when you need a ride to your physician’s office or hospital. Our transportation benefit offers up to 30 trips (15 round trips) per year at no additional charge. Texas HealthSpring members can get physically fit, meet new friends, and participate in fun events by becoming active with the free Silver Sneakers Fitness Program which gives you access to more than 30 local fitness centers.

We know you will enjoy being a member of Texas HealthSpring and look forward to sharing these and other exciting benefits with you in the future!

Schedule of enrollment meetings
Learn more about these money-saving MA plans
at one of the meetings below:

E. B. Cape Center
4501 Leeland
Houston, TX 77023