L I F E , H E A LT H & W E L L N E S S
A PUBLICATION OF
FA L L 2 01 4
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The coverage and the costs were just
so much better with Network Health. Network Health Medicare member, Jane Barnetzke
inside LIFE
Who Needs a Flu Shot?
HEALTH Foods to Boost Your Mood
WELLNESS Choosing Your 2015 Plan
Exclusive Reduced Rate for Network Health Medicare Advantage Members
Mamma Mia!
Sunday, March 1, 2015, at 1 p.m. Tickets $40. To claim this offer, register by October 19. Log on to www.foxcitiespac.com/onlineoffers and type Medicare in the password field. Then, purchase your ticket by following the simple instructions that appear. This offer is only valid for Network Health Medicare Members and their families. Not valid on previously purchased tickets. Valid while supplies last.
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life 3 Choosing Your 2015 Plan 3 Who Needs a Flu Shot? 4 Five Easy Steps to Better Bone Health
health
08
FEATURE 8 Peace of Mind Assurance Jane Barnetzke has a unique perspective on health care
10 Extra Help for Members who Need Joint Replacement
wellness
5 Finding the Right Care Emergency vs. Urgent Care
11 Help Stop Antibiotic Resistance
5 Need Care After Hours?
12 Ensuring the Service You Deserve
6 Know Your Numbers 6 Staying Fit in Stevens Point
13 Stress Free Guide to the Annual Enrollment Period
7 Foods to Boost Your Mood
BACK COVER Meet Dawn Mason
Y0108_157_091514 Accepted 09222014 EDITORIAL STAFF President Chief Administrative Officer Publications Coordinator Graphic Designer
Sheila Jenkins Penny Ransom Cassie Ashman Debra Sutton
EDITORIAL BOARD Marcia Broeren, Joan Merwin, Angie Keenan, Jeanne Skinner, Melanie Draheim, Dawn Rady, Deborah Anderson, Renee Corral, Barb Gore, Chuck Rynearson, Teri Kopeke, Shari Fowler
Concierge is published quarterly by Network Health. The health information contained in Concierge is meant to supplement, not replace, the advice of health care professionals. Š 2014 Network Health Insurance Corporation. No portion of this newsletter may be reproduced without written permission from Network Health Insurance Corporation. Network Health Medicare Advantage Plans are MSA and PPO plans with a Medicare contract. NetworkCares is a Coordinated Care Plan with a Medicare contract and a contract with the Forward Health Wisconsin Medicaid Program. Enrollment in Network Health Medicare Advantage plans depends on contract renewal.
TELL US WHAT YOU THINK Thank you for your comments about Concierge. Please continue to email your feedback to concierge@networkhealth.com. YOU CAN ALSO WRITE TO US Network Health, Attention: Cassie Ashman, 1570 Midway Pl., Menasha, WI 54952 2 | C oncierge
NetworkHealthMedicare.com
life 98
%
of Medicare members who join Network Health, stay.* That tells you something.
*Based on the percentage of Network Health Medicare Advantage (PPO) members who stayed in the plan for 2014, for coverage starting January 1, 2014.
Choosing Your 2015 Plan T
he 2015 Annual Enrollment Period for Medicare runs October 15 December 7. During this time, you can make changes to your Medicare health care coverage, and we’re here to help so you can be sure you’re in the right plan for 2015. In this special edition of Concierge, you’ll find a simple guide to our plans on pages 13 - 19. Follow the steps in the guide, and read all your plan materials carefully. Give us a call and we can walk you through any questions you might have and make sure you’re getting the right coverage for the right price. If you’d like to change your plan, your health care concierge can help. To stay in the same plan, you don’t have to do anything. You’re automatically re-enrolled and changes to your plan will start January 1, 2015.
Stress free guide to the Annual Enrollment Period
2015
Follow the simple steps in this guide to make sure you’re in the right plan for 2015. NetworkHealth
Medicare.com
Who Needs a Flu Shot?
C onC ierg e | 13
A
ccording to the Centers for Disease Control and Prevention (CDC), anyone over six months old should get a flu vaccine. This injection is usually given in the arm and contains an inactive vaccine made of a killed flu virus. Since the virus in the vaccine isn’t live, the shot enables your body to build up antibodies without actually giving you the flu. For Medicare Advantage members, a flu shot is covered at no cost to you. If you attend a member appreciation event in October, you can get your 3-strain flu shot at the same time you learn about changes to your plan. See events and reserve your seat at onlineregistrationcenter.com/movieflu/ or call 855-522-7785. If you get your flu vaccine during a doctor appointment, remember that discussing anything else with your doctor other than the flu vaccine can result in an office visit charge, which may mean you’ll need to pay a copayment. WHAT’S THAT?
3-strain
This is the most common flu vaccine in the United States. It’s designed to protect against three types of flu. NetworkHealthMedicare.com
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life
Learn more about falls prevention and attend a Stepping On workshop. Helpful instructors can teach you proven techniques to reduce your risk of falling. Call Sue Srnka at 920-720-1655, Monday - Friday, 8 a.m.- 5 p.m., to find classes in your area.
FIVE EASY STEPS to Better Bone Health Slips, falls and fractures don’t have to keep you from doing things you enjoy. Unfortunately, every year millions of older Americans suffer from painful injuries due to falls. And for people with osteoporosis, these falls can cause serious damage. Take action and learn simple steps to prevent injuries. By following the tips below, you’ll reduce your risk for falls and bone fractures.
1. Get and stay active. Stretching and flexibility
can help you avoid injury. You can improve your muscle strength and reaction time by exercising and being active, which decreases your risk of falling. Doctors often recommend weight bearing, low-impact exercises like walking to help keep bones strong.
2. Talk to your doctor. Osteoporosis is a common
disease that weakens the bones, and it can often be prevented. As you age, it is important to take steps to limit bone thinning, which increases your risk for fractures. Ask your doctor about how exercise and diet affect bone health. You may also want to find out if he or she recommends taking calcium and vitamin D dietary supplements. And, talk to your doctor if a medication is making you dizzy or lightheaded. Side effects from prescription drugs are often the culprit behind serious falls. If you’ve recently fallen, make sure to discuss it. Your doctor may need to evaluate your strength and balance.
of your test and ask your doctor about follow-up care. He or she may prescribe a medication to preserve your bone density or recommend another BMD test in the future. If you experience a fracture and you’re a woman over age 66, it’s important to talk to your doctor about a BMD test or start a medication for osteoporosis within six months. Your doctor can prescribe the best medication for building bone density and you can take it safely under his or her supervision. Working with your doctor to develop a personal treatment plan is the best way to prevent future injuries.
4. Take precautions. When it’s wet or icy outside, slow down and take small steps. Be careful getting in and out of your car and make sure paths and walkways are clear.
5. Avoid alcohol and tobacco. Drinking two
or more alcoholic drinks per day can interfere with your 3. Get a bone mineral density (BMD) test. body’s ability to absorb calcium. Research has shown a Make sure to get a BMD test, especially if you’ve broken direct relationship between tobacco use and decreased a bone and/or if you’re a woman over 65. This quick and bone density. To keep your bones strong and healthy, it’s painless test will measure how strong (or dense) your bones important to limit alcohol and stay away from all forms are and determine if you have osteoporosis. Keep a record of tobacco. 4 | C oncierge
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health
Finding the Right Care Emergency vs. Urgent I
f you get hurt or become very ill, panic and confusion can make it difficult to know what to do. If you feel it’s an emergency, it’s important to get to the nearest emergency room or call 911. But, sometimes you might not be sure if it’s an emergency. If it’s not, many times your primary doctor or a walk-in clinic can help. Here are the answers to two of the most common questions we get about knowing what type of care you need.
What’s the difference between emergency care and urgent care? Emergency care and urgent care are not the same. An emergency is an illness, injury, symptom or condition so serious that a reasonable person would seek care immediately to avoid serious harm. Urgent care is for an unexpected injury or illness that is not life threatening, but still needs attention quickly so you don’t develop a serious problem. You typically receive emergency care at the emergency room. You may get urgent care at your primary doctor’s office, a walk-in clinic or an urgent care facility.
Care
What if I’m not sure if it’s an emergency? Planning ahead for what to do in an emergency can help you make the right decision quickly in an actual emergency situation. If you’re not sure whether you should go to the emergency room, call your doctor. Several health systems also have 24-hour hotlines you can call to speak to a nurse or health professional for advice. Ask your doctor for this number. Here are some of those local hotlines. - Affinity NurseDirect at 800-362-9900 - Bellin Health On-Call 888-758-7373 - Prevea On-Call 888-277-3832 - ThedaCare On-Call 800-236-2236 Don’t forget to ask questions Anytime you visit the emergency room, a walk-in clinic or see your doctor, don’t be afraid to ask questions. This is the best thing you can do to ensure your safety. If something doesn’t seem right or make sense, ask about it. Remember, there’s no such thing as a dumb question, especially when it comes to your health.
Need Care After Hours?
Health care needs can come up any time of day or night, so it’s important that you have access to after-hours, urgent, routine and preventive care. At Network Health, we want to make sure you have appropriate access at the appropriate time for your medical and behavioral health needs, during and after office hours. We also want to make sure our providers meet your needs in a timely manner. Network Health requires primary care physicians to provide access to health care services without excessive scheduling delays, and we share standards for timeliness of appointments and office waits throughout our provider network. If you don’t feel your needs for urgent, routine or preventive care are met in a timely manner, call your health care concierge for help. NetworkHealthMedicare.com
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Are you a NetworkCares member?
Call 855-653-4363 (TTY 800-947-3529) when you have questions about your plan. It’s our new, toll-free number that allows you to reach a NetworkCares concierge directly. We’re available Monday through Friday, 8 a.m. to 8 p.m.
health
KNOW YOUR NUMBERS BLOOD PRESSURE
High blood pressure
Prehypertension
Near or above goal
121-139/81-89
120/80 or below
S A Y W H A T120?
140 160 180
100
140/90
TRIGLYCERIDES
or above
Near or above goal Less than 150 mg/dL
200 220
Borderline High 150-199
Very High 500 or above
High 200-499
Polyunsaturated fatty acids – A type of healthy fat that 80 240 can help lower blood cholesterol levels. 260 60 40 20
300
280
0
100
200
300
400
500
600
CHOLESTEROL Type of Cholesterol
Goal
Borderline High
High
Total
Below 200
200-239
240 or higher
LDL (“bad”)
Below 100
100-159
160 or higher
HDL (“good”)
Women: 50 or higher Men: 40 or higher
Women: below 50 Men: below 40
N/A
Staying Fit in Stevens Point Thanks to over 100 members who attended our Network Health Member Day at the Stevens Point YMCA on July 30. We appreciated the chance to meet so many members and explain more about how our fitness benefit works. Members enjoyed tours of the YMCA, giveaways and a presentation on how to achieve a healthy blood pressure. Plus, several members used their one-week pass to try out the YMCA**, and others signed up for a membership.
Consumer Marketing Manager Melanie Draheim and Network Health Ambassador Robert Pflum
Member events like these promote good physical and social health in our communities. If you’re interested in helping with future events or joining the Network Health Medicare Ambassadors, please call Anne Rappert at 920-720-1348. **Other health club providers are available in our network.
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NetworkHealthMedicare.com
Want more health tips? Check out our new blog at copilotwi.com. We add helpful information about health and well-being every week, so be sure to visit often.
Foods to BOOST Your Mood E
veryone has their favorite comfort food—usually it’s something tasty but high in calories and fat. According to new research, if you want to improve your mood, you should be reaching for healthier options instead. Check out the list below to learn what foods can help you feel happier.
Fish
– You probably already know fish is good for your body, but it’s good for your mind and mood, too. Both tuna and salmon contain high amounts of vitamin D and omega-3 fatty acids, which greatly lower your risk for depression, according to a study from the University of Tennessee.
Whole Grains
– Time to switch out the white bread for whole grain foods such as bread, rice, pasta and cereal. These contain a lot of selenium, a mineral proven to assist in important brain functions that help keep you feeling happy.
Salads
– To keep you smiling, eat foods high in folate (also called vitamin B9). Spinach and lettuce are great sources of folate. An easy way to get more folate in your diet is to eat a salad before dinner. This will also help you from overeating during your main course.
Nuts
– If you want to stay positive, you need to get plenty of protein. Almonds, cashews and pistachios are all good snacks to give your serotonin production a boost. Serotonin is a chemical your brain produces that makes you feel good. You don’t need to eat a lot of nuts to get the benefits—as little as one ounce a day is enough.
Dark Chocolate
– According to a British study, people who consumed one serving of dark chocolate per day for a month reported being happier than the placebo group. Researchers believe this is because of the antioxidants found in cocoa. But, don’t overdo it. Even though dark chocolate is healthier, it also packs a lot of calories. Nutritionists recommend sticking to a one-ounce serving. NetworkHealthMedicare.com
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COVER STORY
“
I thought my retirement money would be going to health care.
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I felt so fortunate when I found out about Network Health Medicare Advantage plans.
8 | C oncierge
NetworkHealthMedicare.com
Peace of Mind
assurance As a baby boomer and a retired nurse, Jane Barnetzke has a unique perspective on health care.
J
ane devoted her professional life to caring for others. Working over 40 years as a registered nurse has allowed Jane to see firsthand how the industry has evolved. Jane worked in dialysis for most of her career. Dialysis is a life-support treatment that uses special equipment to filter harmful waste from a person’s blood. Dialysis is needed when a person’s kidneys fail to function properly and are unable to filter toxins from the blood on their own. People suffering from kidney failure need this life-saving treatment to survive. Unfortunately, it’s an expensive treatment and the cost can catch people off guard. In 2007, the average cost of dialysis was $73,008 per year, according to the Archives of Internal Medicine. This high cost was a sharp reminder to Jane about the need for quality health care coverage. Jane also had a personal experience that shaped her views on health care and insurance. In her late thirties, Jane was diagnosed with rheumatoid arthritis. Rheumatoid arthritis can be a very painful condition where the body attacks its own tissues. It can happen at any age, but typically doesn’t occur
until after 40. It’s a progressive disease, but fortunately the medications Jane has been taking have helped her manage it well. She explains, “I’m lucky compared to a lot of people I know with the condition.” While Jane felt lucky, there were serious concerns as well. Because of her diagnosis, she no longer qualifed for commercial health insurance. With her experience as a nurse, Jane understood the importance of getting a health insurance plan that would effectively protect her financially. When Jane approached age 65, she began seriously researching the different Medicare insurance options available to her. Because Medicare is a government program, she explained, “I knew I would qualify, but I wasn’t sure what type of coverage would be available.” When Jane started shopping, she knew there were a few important factors that would help her make a decision. “I wanted the freedom to see the doctors that I chose.” Because of her condition, access to her specialists was incredibly important. Jane decided to sit down with an agent to help her choose. “It took the burden off of me, and things became very clear.” Jane’s agent selected four different
By Cassie Ashman Photography by Beth DesJardin, Trove Photography NetworkHealthMedicare.com
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a good time “It’s to be 65 and older.” companies for Jane to compare. Together, they reviewed the premium, drug coverage and maximum out-of-pocket costs. “The coverage and the costs were just so much better with Network Health.” Plus, with Network Health, Jane could see the doctors and specialists she wanted. “I thought my retirement money would be going to health care. I felt so fortunate when I found out about Network Health Medicare Advantage plans.” Jane selected the Network PlatinumPlus Pharmacy PPO plan. This plan offers a $0 deductible and Network Health’s lowest outof-pocket maximum. It also offers
“
COVER STORY
comprehensive drug and medical coverage for an affordable monthly payment. “For me, PlatinumPlus Pharmacy was the best plan, and I considered the cost to be minimal for the coverage I was getting.” Jane says, “It’s a good time to be 65 and older.” Although the costs of medical care will continue to rise, older adults are able to limit their financial liability through Medicare plans with low out-of-pocket maximums. “Health care is a partnership— you have to start somewhere. Why not start with a good health plan?” says Jane.
EXTRA HELP for Members Who Need Joint Replacement Network Health will offer a new benefit in 2015 that will provide extra support following joint replacement surgery (hip or knee). The benefit, called Home Again, will provide the tools members need to rehabilitate and recover in their own home.
The Home Again benefit includes— • A pre-surgery assessment by a registered nurse and a physical or occupational therapist from a certified home health agency • A home safety assessment • A personal rehabilitation and recovery care plan to assure a safe transition back home • Up to four weeks of physical therapy and nursing care • Two hours of personal care per week for two weeks (this could include laundry, light housekeeping or running errands) • 10 home-delivered meals • One month of Lifeline®, a personal emergency response system 10 | C oncierge
What does it cost? This benefit is available at no additional cost to Network Health Medicare Advantage (PPO and SNP) members.
Is Home Again right for me? Everyone’s needs are different. While most people want to recover in their own home following a hospital stay, some may need more attention and care. Talk to your doctor to find out if you would benefit from Home Again.
How can I learn more? Call your health care concierge or 800-378-5234 (TTY 800-947-3529), Monday - Friday, 8 a.m. - 8 p.m. Your concierge can contact your doctor to see if you’re a candidate for Home Again.
wellness
Help Stop Antibiotic Resistance
D
Keep medicine working for you
id you know antibiotic resistance is one of the world’s most pressing public health threats? According to the Centers for Disease Control and Prevention (CDC), antibiotics are the most important tool we have to combat life-threatening bacterial diseases.
Antibiotic resistance occurs when bacteria change in a way that reduces or eliminates the effectiveness of antibiotics. Bacterial change happens when antibiotics are used to treat illnesses other than bacterial infections.You might expect antibiotics to work for every illness, but they don’t. Antibiotics can cure bacterial infections, not viral infections. Treating viruses with antibiotics does not work, and it increases the likelihood that you will become ill with an antibiotic-resistant bacterial infection.
The CDC recommends you—
w w w w w
Take antibiotics exactly as your doctor prescribes. Do not skip doses, and do not stop taking them when you start feeling better. Only take antibiotics prescribed for you. Don’t share or use leftover antibiotics. They treat specific types of infections. Taking the wrong medicine may keep you from getting better and can cause bacteria to change and multiply. Do not save antibiotics for the next illness. Once you’ve taken what your doctor instructed, throw away any leftover medication. Wash your hands and get recommended vaccines to prevent infection. Do not ask for antibiotics when your doctor thinks you do not need them. Remember, antibiotics have side effects. If your doctor says you don’t need one, taking one may do more harm than good.
Do you know how health plans make their decisions?
Visit NetworkHealthMedicare.com and click Member’s Corner. Next, look for the Resources heading and click How Health Plans Make Their Decisions. You’ll learn important information about service and appropriateness of care. NetworkHealthMedicare.com
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wellness
?
You can call us at 800-378-5234 (TTY 800-947-3529), Monday - Friday, 8 a.m. - 8 p.m.
Ensuring the Service You Deserve A
t Network Health, we make every effort to make sure our members are receiving the service they need and deserve. We believe that’s a big reason why 98 percent of Medicare members who join Network Health, stay.* So if you have concerns, we want you to understand your options. You have the right to file an appeal if you don’t agree with Network Health’s decision about your care or insurance coverage and you believe that– • Network Health will not approve or give you care it should cover. • Network Health is stopping care you still need. • Network Health has denied payment for services or items you received that are not covered, and you think they should be covered. You must file your appeal in writing within 60 calendar days after the date of the denial. Although, if you have a good reason for missing the deadline, we can give you more time.
Who may file an appeal?
You or someone you name to act for you (called your authorized representative) may file an appeal. You can name a relative, friend, advocate, attorney, doctor or someone else to act for you. If you’d like to do this, you and the person you choose must sign, date and send us a statement naming that person to act for you. To learn how to name your authorized representative, call us.
How do I file an appeal?
You can send us your appeal by faxing it to 920-720-1908 or writing to Network Health Insurance Corporation, P.O. Box 120, Menasha, WI 54952.
What happens after I file an appeal?
If you file an appeal we’ll review our decision, and if payment of your claim is still denied, we will forward your appeal request to MAXIMUS Federal Services, a CMS Contractor, for an independent review. Medicare provides this service—a new and impartial review of your case outside of your Medicare Advantage organization. If you disagree with the independent review decision, you’ll be notified of your additional appeal options and rights.
How can I file a complaint?
If you’re dissatisfied with the service or quality provided by your plan, we’re here to work with you through any issues. 12 | C oncierge
You have the right to file a grievance (a formal complaint) about how Network Health provided services. Examples of situations appropriate for a grievance include: • Difficulty getting through on the phone • Concerns about the quality of care you receive • Interpersonal issues (for example, a rude provider or staff member) • Failure to respect your rights You can submit your grievance over the phone or in writing within 60 calendar days from the date of the event. Call us or write to Network Health Insurance Corporation, P.O. Box 120, Menasha, WI 54952. We will complete a full investigation as quickly as your case requires and let you know the results no later than 30 calendar days from the date we received your request. If we need more time to make a determination, we’ll let you know about that extension within 24 hours.
The Quality Improvement Organization (Formerly MetaStar) is Now KEPRO
Effective August 1, 2014, KEPRO became the new Beneficiary and Family Centered Care Quality Improvement Organization for the Centers for Medicare & Medicaid Services (CMS) in Wisconsin. KEPRO has a group of doctors and other health professionals who are paid by the Federal Government to check on and help improve the quality of care for people who receive Medicare. KEPRO is an independent organization not associated with your plan. You should contact KEPRO in any of these situations. • You have a complaint about the quality of care you received. • You think coverage for your hospital stay is ending too soon. • You think coverage for your home health care, skilled nursing facility care or Comprehensive Outpatient Rehabilitation Facility services is ending too soon.
How you can contact KERPRO
Call toll-free 855-408-8557 (TTY 855-843-4776), fax 844 834-7130, visit www.keproqio.com or write to KEPRO at 5201 W Kennedy Blvd., Suite 900, Tampa, FL 33609.
NetworkHealthMedicare.com
2015
Stress free guide to the Annual Enrollment Period Follow the simple steps in this guide to make sure you’re in the right plan for 2015 NetworkHealthMedicare.com
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STEP 1
Review Your Plan Materials
You should’ve already received your Annual Notice of Change materials. This year, we gave you the option to receive these materials by mail or email. Make sure to read all of the material to best understand any upcoming changes to your plan. Each piece of information is important.
w Annual Notice of Change booklet This contains a table showing changes to your plan effective January 1, 2015. w Evidence of Coverage This is your plan policy that outlines all the details about your plan. w Provider Directory This booklet lists in-network doctors and hospitals you can use. w Pharmacy Directory and Formulary The Pharmacy Directory is a list of pharmacies and the Formulary is a list of drugs. You’ll only receive these materials if you have a plan with drug coverage.
STEP 2
Know Your Needs
After reviewing your plan materials, consider how any upcoming changes will affect you. To find the plan that fits you best, consider these questions and review the chart and information on the next few pages.
OCONTO SHAWANO PORTAGE
w What
plans are you eligible for?
To qualify, you’ll need to live in the plan’s service area and have Medicare Parts A and B. Check out the map to see our service area.+
KEWAUNEE
WAUPACA OUTAGAMIE WINNEBAGO
BROWN
MANITOWOC
WAUSHARA* CALUMET MARQUETTE GREEN FOND DU LAC LAKE SHEBOYGAN
w Do you take prescription medications? If yes, you’ll need a plan that includes drug coverage.
DODGE
w What can you afford? Network PlatinumPlus offers our lowest out-of-pocket maximum. 14 | C oncierge
+NetworkPrime (MSA) is available throughout the State of Wisconsin. *Network PlatinumSelect and Network PlatinumPlus are not available in Waushara county. NetworkHealthMedicare.com
All costs listed are for in-network services.
A QUICK SUMMARY Deductible Premium
Out-of-Pocket Maximum
Network PlatinumPlus (PPO) Network PlatinumPlus Pharmacy (PPO) $0 Network PlatinumPlus: $67 per month Network PlatinumPlus Pharmacy: $97 per month $2,000 per year combined (in and out-of-network)
Network PlatinumPremier (PPO) Network PlatinumPremier Network PlatinumSelect (PPO) Pharmacy (PPO) $40 $0 per month (Includes drug coverage) $3,400 per year combined (in and out-of-network)
Total Possible Costs (see What’s That? below)
Network PlatinumPlus: $2,804 Network PlatinumPlus Pharmacy: $3,164
$3,400
Hospital Stays
$95 copay per day for days 1-3. $165 copay per day for days 4-20. You pay nothing for days 21-100. $15 per visit $15 copayment $65 per visit $200 copayment $200 per visit $0 copayment
$300 copay per day for days 1-5. $150 copay per day for days 6-20. You pay nothing for days 21 and beyond. $16.25 per visit $16.25 copayment $65 per visit $200 copayment $350 per visit $0 copayment
Primary Care Office Visit Urgent Care Emergency Room Ambulance Outpatient Services Annual Wellness Visit with Lab Tests Preventive Services Platinum Fitness
$0 Network PlatinumPremier: $170 per month Network PlatinumPremier Pharmacy: $244 per month $1,900 per year in-network; $5,000 per year combined (in and out-of-network) Network PlatinumPremier: $3,940 Network PlatinumPremier Pharmacy: $4,828 $0 each day for a Medicare-covered stay $0 per visit $0 per visit $65 per visit $0 copayment $0 per visit $0 copayment
Plan covers all Medicare-covered Plan covers all Medicare-covered Plan covers all Medicare-covered preventive services at $0 preventive services at $0 preventive services at $0 ** Up to $36 per month toward a full Up to $36 per month toward a full Up to $36 per month toward a full gym membership for health club gym membership for health club gym membership for health club providers available in our network providers available in our network providers available in our network **Other health club providers are available in our network. Participating YMCAs in Wisconsin.
Network PlatinumPlus (PPO) or Network PlatinumPlus Pharmacy (PPO)
This plan offers a $0 deductible, low copayments and our lowest out-of-pocket maximum. It has great medical coverage and is available with prescription drug coverage to help you pay for your medications. If you’re looking for a plan with comprehensive coverage at an affordable price, this plan may be a good fit for you.
Network PlatinumSelect (PPO)
This plan has a $0 monthly premium and includes medical and prescription drug coverage. It can be a good a match if you don’t use a lot of health care services and would rather pay copayments instead of a monthly premium.
Network PlatinumPremier (PPO) or Network PlatinumPremier Pharmacy (PPO)
If you’d rather not pay copayments when you use health care services, this plan provides that option. You’ll pay more for your monthly premium, but then you’ll pay $0 for most services. Drug coverage can be included, too. If you don’t like having a copayment every time you visit the doctor, or if you go to the doctor often, you might want this plan.
WHAT’S THAT?
TOTAL POSSIBLE COSTS
Premium for the year + out-of-pocket maximum. This amount does not include prescription drug costs or costs for services not covered by Medicare. NetworkHealthMedicare.com
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NetworkPrime (MSA)
This year, Network Health is offering a new kind of plan. NetworkPrime is a Medicare Medical Savings Account (MSA) plan. Here’s how it works.
This is a unique Medicare Advantage plan which covers your hospital and medical care (known as Medicare Parts A and B). Once you’ve paid a certain amount for health care (called the deductible), the plan beings paying.
Medicare MSA Plans Have Two Parts
High-Deductible Health Plan
NetworkPrime has a $3,500 deductible and a $0 monthly premium.
Medical Savings Account
This is a special savings account used for health care costs. Once a year, the plan deposits money into your account, and you can use this money to pay for health care before you meet the deductible. NetworkPrime deposits $1,500 into this account once a year.
BENEFIT Premium Deductible
NetworkPrime $0 $3,500
Annual deposit Network Health puts into your savings account
Network Health will deposit $1,500 into your medical savings account (prorated based on when you enroll).
Services like hospital stays, doctor visits and emergency room visits
All Medicare-covered services are billed at the Medicare-approved amount until you reach the deductible. You pay nothing after you reach your deductible.
Engage wellness program
This is an optional benefit. You’ll get a Fitbit® Zip™ and up to $75 in gift card rewards for making healthy choices. This program is available for a monthly payment of $6.20.
WHAT’S THAT?
MEDICARE MSA PLAN
This is a special type of Medicare Advantage plan that combines a high-deductible health insurance plan with a medical savings account. MSA plans are offered by private companies like Network Health and work with Medicare to provide your coverage. You can use the medical savings account to pay for health care services, while the high-deductible plan limits your out-of-pocket costs.
NetworkCares (PPO SNP)
Did you know we also offer a plan for Medicare members with special needs? If you receive both Medicare and Medicaid, you may be eligible. This plan includes medical and drug coverage, plus eye and dental benefits and your own health care team. To learn more, call 800-983-7587 (TTY 800-947-3529), Monday through Friday, 8 a.m. to 8 p.m. 16 | C oncierge
NetworkHealthMedicare.com
Cost for a One-Month Supply of Drugs INITIAL COVERAGE
When your coverage starts, you pay copayments until your total drug costs (what you and Network Health pay) reach $2,960
Network PlatinumSelect, Network PlatinumPlus Pharmacy and Network PlatinumPremier Pharmacy
Preferred Pharmacy $2 for Tier 1 $8 for Tier 2 $42 for Tier 3 $85 for Tier 4
Standard Pharmacy $4 for Tier 1 $13 for Tier 2 $45 for Tier 3 $90 for Tier 4
COVERAGE GAP
You enter the coverage gap when your total drug costs reach $2,960.
You pay 65% and Network Health pays 35% for generic drugs. For brand name drugs, you pay 45%, Network Health pays 5% and the drug manufacturer pays 50%.
CATASTROPHIC COVERAGE
You enter catastrophic coverage when your total out-of-pocket costs reach $4,700. You pay the greater of $2.65 or 5% of the cost for generic drugs and $6.60 or 5% of the cost for brand name drugs.
33% for Tier 5
WHAT’S THAT? NETWORK PHARMACIES
We have contracts with pharmacies to provide you prescription drugs. That means you must use these network pharmacies for your drugs to be covered. See our Pharmacy Directory for a list, or click Search Pharmacies on our website at NetworkHealthMedicare.com.
STEP 3 w
TIER
This is the cost-sharing level that a drug is assigned to. Generally, the higher the tier the more you pay. Tier 1 - Preferred generic $2 or $4 Tier 2 - Non-preferred generic $8 or $13 Tier 3 - Preferred brand $42 or $45 Tier 4 - Non-preferred brand $85 or $90 Tier 5 - Specialty 33%
Make Your Choice
If your current plan is still the best fit, then you’re all set. There isn’t anything else you need to do. Any changes to your plan will start on January 1.
w If you think you want to switch to one of our other plans,
call your health care concierge or Network Health agent and he or she will help you out.
The benefit information provided is a brief summary, not a complete description of benefits. Premiums, copays, coinsurance and deductibles may vary based on the level of Extra Help you receive. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change January 1 of each year. Limitations, copayments and restrictions may apply. Please contact the plan for further details. You must continue to pay your Medicare Part B premium unless otherwise paid for by Medicaid or by another third party. NetworkHealthMedicare.com
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All members enjoy discounts at local stores, restaurants and businesses throughout northeast Wisconsin just by showing their Network Health Medicare Advantage member ID card. For a list of businesses, go to NetworkHealthMedicare.com, click Member’s Corner, Get Member Discounts and Extras and View all Discounts.
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EXCLUSIVE EXTRAS
PLATINUM PERKS
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HEALTH MED ORK ICA W T
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Every Network Health Medicare Advantage plan comes with the following. To get the most out of your plan, make sure to continue to take advantage of all these extras.
NO WORRIES WHILE TRAVELING
If you like to travel to visit family and friends, or head south for the winter, you can relax knowing you’re still covered when you’re away from home. w We cover emergency care worldwide (up to a certain amount). w When you’re outside Wisconsin, anywhere in the U.S., you can get care at the same cost you would at home.
SUPPORT TO KEEP YOU HEALTHY w w w
Services like home health assessments and health coaching are provided at no cost. Access to programs,workshops and educational materials that can help you manage conditions like COPD, diabetes and heart disease. Help from a team of registered nurses who can personally work with you to manage your health.
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HEALTH CARE CONCIERGE SERVICE
Your own, personal health care concierge right here in Wisconsin. You’ll continue to have a direct line to this person, and he or she can act on your behalf and assist you in any way you need..
QUESTIONS?
If you don’t understand something, it’s our job to make it easier. Call 800-378-5234 today. TTY users call 800-947-3529. We’re available Monday – Friday, 8 a.m. to 8 p.m. (From October 1 – February 14, we’re here every day, 8 a.m. to 8 p.m.)
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CONDITION MANAGEMENT PROGRAMS
If you have a health condition, you also have access to a team of registered nurses who can provide information and educational resources to help you manage your condition. Here are a few things they do. w Offer educational workshops and events in your community w Healthy Living with Diabetes workshop w Living Well with Chronic Conditions workshop w Falls prevention workshop called Stepping On w Help you monitor your condition and offer opportunities for you to successfully manage your health w Promote healthy lifestyle behaviors such as exercise and eating right w Support communication between you and your doctor w With your permission, work with a caregiver or family member to educate them about your condition so they can best care for you
ONE-ON-ONE HELP
Our care management program connects you with a Network Health registered nurse who works with you to– w Review medications and treatments and answer any questions you may have w Help you develop your own support system and a personal health record w Inform you about signs your health is worsening, and when you should contact your doctor w Work with your health care providers to make sure they’re aware of changes to your health
$0 FOR SERVICES TO KEEP YOU HEALTHY
Did you know many preventive services are 100 percent covered? That’s right. Services that help you avoid getting sick–like immunizations, screenings, tests and your annual wellness visit–often won’t cost you anything. To learn more, call your health care concierge or visit the Member’s Corner section of NetworkHealthMedicare.com. In the Discover Healthy Benefits section, you’ll find a helpful checklist that explains what services might be recommended for you.
WHAT’S THAT?
PREMIUM
The set monthly amount you pay for your plan.
NetworkHealthMedicare.com
PPO
PPO stands for preferred provider organization. It’s a type of plan where you have the freedom to choose any doctor, but you’ll pay less when you use doctors and hospitals in the plan’s network.
DEDUCTIBLE
The amount of money you must pay, not including premiums, before the insurance company begins paying for services.
OUT-OF-POCKET MAXIMUM This is the yearly limit on your total costs for medical services.
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1570 Midway Pl. Menasha, WI 54952 Health or Wellness or Prevention Information
Meet Dawn Mason
To help you get to know your health care concierge a little bit better, watch for a feature on a different concierge in every issue of our newsletter. DAWN MASON
D
awn Mason is an important part of our health care concierge team. Each fall, she helps organize and facilitate Network Health’s member appreciation events across northeast Wisconsin. This is where you get the opportunity to learn about plan changes for the upcoming year. We hope to see you this fall at the event nearest you. Q: What should everyone know about the Annual Enrollment Period? A: “This fall, make sure to read your plan materials carefully. Unfortunately, many people don’t realize how their plan will change for the upcoming year. To avoid surprises, look over everything and don’t be afraid to ask your concierge questions.” Q: What is the most important thing to consider when comparing plans? A: “It’s not just about copayments and premiums. When you’re evaluating plans, make sure to look at the out-ofpocket maximum and figure out your total possible costs. This will ensure you find a plan that fits your budget.” Q: How did Dawn begin her career as a health care concierge? A: Before she began working at Network Health, Dawn was an administrative assistant for an insurance agent. Eventually, she got her insurance license and worked as both an agent and an assistant. After seven years, she was ready for a change and joined Network Health’s health care concierge team.
Q: What does Dawn enjoy most about her job? A: “Talking with members. I’m sure all the concierges say that, but it’s the truth.” Dawn also enjoys planning the member appreciation events. “It’s great to meet members in person. I love it.” Q: How is Network Health different from other places she’s worked? A: “The customer care is phenomenal. What other company has over 50,000 members and still takes the time to connect with them personally?” She enjoys working for a company that puts people first. “It says a lot about us that you get a real person when you call.” Q: How does Dawn spend her free time? A: “I’m very family oriented.” When Dawn is not working, she spends a lot of time with her family. “My sisters are my best friends,” says Dawn. She also has two sons and a daughter-in-law. Plus, in February, she’ll be a grandma for the first time. She gets a big smile on her face when she talks about her future grandchild and admits there’s a good chance she’ll spoil him or her.
COMING SOON - NEW ONLINE PROGRAMS
As a way to help improve your knowledge of health conditions, Network Health will be offering new online educational programs through Emmi®. The programs will be available to all Network Health Medicare Advantage members. Watch for an important announcement about how Emmi® can help you in our next issue of Concierge.