OSF MedAdvantage Guide 2022 Medicare Advantage + Prescription Drug Coverage
It’s time to get more from Medicare. Medicare Advantage from a trusted provider OSF MedAdvantage Core (HMO) OSF MedAdvantage Open (HMO-POS) OSF MedAdvantage Enrich (HMO-POS)
(877) 633-2531 (TTY 711) Daily from 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1 – September 30
Table of Contents Strong Partnership, Strong Providers
Understand your coverage when you travel.
Find a plan that fits.
Assist America Global Emergency Services
OSF MedAdvantage Open and Core Plans
Get total care from start to finish.
OSF MedAdvantage Enrich Plan
Appeals and Grievances
Pharmacy Basics
Enrollment
Perks and Programs
Timelines and Requirements
Care coordinators
Enrollment Process
2020 OSF MedAdvantage Service Area Map
Strong Partnership, Strong Providers
Winnebago
Stephenson
Jo Daviess
Carroll
Lake
McHenry
Boone
Ogle Kane
DeKalb Whiteside
DuPage Cook
Lee Kendall Bureau
Rock Island
Many Medicare insurers offer plans with similar benefits. When everything seems the same, what makes one a better fit for you?
Will La Salle
Henry
Grundy
Mercer
Putnam Stark
Kankakee
Marshall
Knox
Livingston
Warren
Woodford
Peoria
Iroquois
Henderson
Fulton
McDonough
Tazewell
Ford
McLean
Hancock Mason Schuyler Adams
Champaign
Menard
Cass
Brown
Vermilion
De Witt
Logan
Piatt Macon
Sangamon
Morgan Pike
Douglas
Scott
Edgar
Moultrie Christian
The strength of the OSF MedAdvantage network means our members receive covered care from trusted doctors, clinics and hospitals throughout Illinois.
Check out the list below to see some of the providers that are in-network for all plans. For a full listing of all providers, go to OSFMedAdvantage.org and use our Find a Doctor search. Calhoun
Greene
Shelby
Macoupin
Clark
Montgomery
Cumberland
Jersey
Effingham
Fayette
Crawford
Jasper
Bond
Madison
The OSF MedAdvantage Core and Open plans have two tiers of providers: Tier 1 and Tier 2. The Enrich plan does not have a tiered network; it has in and out of network providers.
Coles
Clay
Lawrence
Richland
Marion
Clinton
Wabash
St. Clair
Check out the list below to see some of our providers. Go to OSFMedAdvantage.org for a full list. Wayne
Washington
Randolph
Edwards
Jefferson
Monroe
Perry
Hamilton
White
Franklin
Jackson
Williamson
Union
Alexander
Johnson
Pulaski
Saline
Pope
Gallatin
Hardin
Massac
map-medservicearea20OSF-0119
Tier 1 In-Network Providers Bloomington/Normal
Monmouth
Galesburg
Ottawa
OSF HealthCare St. Joseph Medical Center OSF Medical Group OSF HealthCare St. Mary Medical Center OSF Medical Group
Kewanee
OSF HealthCare Saint Luke Medical Center OSF Medical Group
Mendota
OSF HealthCare Saint Paul Medical Center OSF Medical Group
OSF HealthCare Holy Family Medical Center OSF Medical Group OSF HealthCare Saint Elizabeth Medical Center OSF Medical Group
Pekin
OSF Medical Group
Peoria
OSF HealthCare Cardiovascular Institute OSF HealthCare Illinois Neurological Institute OSF HealthCare Saint Francis Medical Center OSF Medical Group OSF Orthopedics
Pontiac
OSF HealthCare Saint James - John W. Albrecht Medical Center OSF Medical Group
Princeton
OSF HealthCare Saint Clare Medical Center OSF Medical Group
Rockford
OSF HealthCare Cardiovascular Institute OSF HealthCare Illinois Neurological Institute OSF HealthCare Saint Francis Medical Center OSF Medical Group
Streator
OSF Medical Group
Washington
OSF Medical Group
Find a plan that fits. Your healthcare coverage should match your needs and preferences, so we offer plans to fit different lifestyles. All of our Medicare Advantage plans offer strong networks of trusted doctors while giving you friendly customer service close to home, care coordination with a personal touch and plenty of perks to help keep you healthy.
If staying in network or having lower monthly premiums gives you peace of mind, you might prefer OSF MedAdvantage Core:
If you travel often or like having freedom to see doctors in and out of network, you might prefer OSF MedAdvantage Open: •
Flexibility to see out-of-network providers but may save money by staying in network.
•
Low monthly premium with reduced cost-sharing when you go to the doctor or get care.
•
Plenty of perks and programs to help you get and stay healthy.
If you want peace of mind knowing you won’t have cost-sharing when you get care, you might prefer OSF MedAdvantage Enrich: •
Ability to see any doctor who accepts Medicare.
•
Comfort of having an in-network primary care provider to oversee all your care.
•
No out-of-pocket costs when you go to the doctor or get medical care.
•
$0 monthly premium with cost-sharing when you go to the doctor or get care.
•
Includes extra perks, like dental, fitness and digital health benefits.
•
Plenty of perks and programs to help you get and stay healthy. Find an overview of your plan options and benefits made for you in our 2022 Key Medicare Advantage Benefits guide.
We don’t require a referral, but your doctor might. When your doctor directs you to another provider, it’s called a referral. We don’t require this, but your doctor might. Check with your doctor before you see a specialist or other provider to make sure you’ve taken the proper steps. If we don’t have an in-network specialist to treat your specific condition, we’ll help you find one. And you’ll still pay the in-network cost if you get prior authorization from us.
OSF MedAdvantage Open and Core Plans These plans have lower monthly premiums, no medical deductible and predictable copayments on services like doctor visits, hospital stays and labs. Both the Open and Core Plans have pharmacy coverage and plenty of perks and programs to help you get and stay healthy.
OSF MedAdvantage Enrich Plan OSF MedAdvantage Enrich lets you see any doctor who accepts Medicare, and you have no out-of-pocket costs when seeking medical care. Plus, the Enrich plan includes extra perks like dental, fitness and digital health benefits.
Pharmacy Basics Our plans have built-in prescription coverage, so all your medical and pharmacy benefits are in one place. Late Enrollment Penalty If you don’t enroll in a prescription drug (Part D) plan when you’re first eligible, you may have to pay a penalty for enrolling later. That penalty will increase for every month you didn’t have prescription coverage.
Drug Formulary A formulary is the list of drugs we cover. Generally, we only cover drugs listed in the formulary. You can find it at OSFMedAdvantage.org or in the back pocket of this guide. You can’t be enrolled in a Medicare Advantage HMO or HMO-POS plan and a stand-alone prescription drug plan (PDP) at the same time.
2022 Rx Benefits Our prescription drug plans help you save with special programs, discounts and more. 90-Day Supply Option
Drug Compare Tool
Limit your trips to the pharmacy with two convenient options. With our mail-order benefit, you can get a 90-day supply of your drugs delivered directly to you for two copays. If you prefer to get your drugs at a retail pharmacy, you can visit any in-network pharmacy and get a 90-day supply for three copays.
See how much you’ll pay each month and how much you could save by switching to a pharmacy with lower prescription costs or by taking a lower-cost drug. You can check costs at different pharmacies and see the differences in costs between retail (pickup) or mail order (delivery of a 90-day supply). You can also estimate your total annual drug costs.
Medication Therapy Management If you take multiple medications, this program can help you use them safely and effectively.
No Rx Deductible Most plans don’t have a pharmacy deductible, but for the OSF MedAdvantage Enrich plan, you must meet a $175 yearly deductible on Tiers 3 – 5. After that, you pay the copays listed in the Stages of Pharmacy Coverage chart.
Extra Help You might be able to get help to pay for your prescription drug premiums and costs through the Extra Help program. To see if you qualify, call one of the following: • (800)
MEDICARE (800-633-4227), 24 hours a day, seven days a week (TTY 877-486-2048).
• The
Social Security Administration at (800) 772-1213, 7 a.m. to 7 p.m., Monday through Friday (TTY 800-325-0778).
• The
Illinois Department of Human Services at (800) 843-6154, 8 a.m. to 5 p.m., Monday through Friday (TTY 866-324-5553).
Coverage Through the Gap If your total prescription spend adds up to $4,430, you’ll reach the coverage gap. With your OSF MedAdvantage plan, you’ll continue to pay your copay for Tier 1 medications until your out-of-pocket expenses reach $7,050.
2022 Rx Benefits Stages of Pharmacy Coverage Most people stay in this stage.
INITIAL COVERAGE
$4,430 Few people reach this stage.
COVERAGE GAP $7,050
Even fewer people reach this stage.
CATASTROPHIC COVERAGE
Initial Coverage You pay the following until the amount you pay plus the amount we pay reached $4,430.
If your total prescription spend adds up to $4,430, you’ll reach the coverage gap. With your OSF MedAdvantage plan, you’ll continue to pay your copay for Tier 1 medications until your out-of-pocket expenses reach $7,050.
Coverage Gap The coverage gap, sometimes called the “donut hole,” begins when the amount you pay plus the amount we pay for your prescription drugs reaches $4,430. Here, you pay the following until you reach $7,050: • 25%
for covered generic drugs.
• 25%
for covered brand-name drugs.
Catastrophic Coverage Catastrophic coverage begins when your out-of-pocket drug costs reach $7,050. Here, we pay for most of your drug costs for the rest of the year, while you pay the greater of the following: • 5%
of the cost or
• $3.95
for covered generic drugs (including brand-name drugs treated as generic) and $9.85 for covered brand-name drugs.
Plan Name
Prescription Deductible
Rx Tier 1
Rx Tier 2
Rx Tier 3
Rx Tier 4
Rx Tier 5
OSF MedAdvantage Core (HMO)
$0
$2
$15
$47
50%
33%
OSF MedAdvantage Open (HMO-POS)
$0
$2
$15
$47
50%
33%
OSF Enrich (HMO)
$0
$2
$15
$47
40%
30%
Perks and Programs Fitness, dental, travel … sound like your type of plan? Enjoy special programs and extra perks to help you stay healthy on the go and close to home.
Care coordinators, health coaches help you meet your health goals. We’re not only here to help when you get sick or hurt. We’re here to help you stay healthy in the first place. Whether you’d like to speak to a dietitian, want to quit smoking or need help understanding a recent diagnosis, we’ve got you covered. We give you programs to help you achieve your goals or get you back on track.
The care coordination team will reach out to members to offer their services. Members can also request these services rather than waiting to be contacted. You don’t have to do it alone. We’re there for you every step of the way.
A Team Focused on You
Health Coaching
We connect you to a team that works with your doctors and takes your personalized plan a step further, giving you extra help and resources along the way.
Health coaches are your health partners. They’ll help you reach your health goals in the following areas and more:
Care Coordination
Community Outreach
A care coordination team is made up of many providers, like registered nurses, social workers, health coaches, dietitians, pharmacists and others whose main goal is to make sure our members have the resources they need to stay healthy or work through their medical issues.
Find helpful resources.
Care for yourself to help prevent illness and hospital stays.
• Nutrition.
• Weight
loss.
• Staying
active.
Community is important to us, so we like to get out and meet our members. We’ll be at health fairs, senior expos and other events ready to educate and talk with our current members and others throughout the community. Led by our team of liaisons, we’re excited to build relationships with the people we serve.
Set and reach health and wellness goals.
Use your health benefits to save money.
Understand and manage health issues, like diabetes and asthma.
Coordinate your care when you have complicated health conditions.
Understand your coverage when you travel. Going to the doctor is probably one of the last things on your mind while traveling. But if sickness or injury strikes, you have coverage for any emergency room, urgent care center (also called convenient care or a walk-in clinic) or ambulance at the in-network cost-share amount. And you’ll be covered if you’re admitted to the hospital through the emergency room. POS plans offer out-of-network coverage for routine care, including physical therapy or doctor’s visits, but with an HMO, any routine care you receive while out of network won’t be covered. Some services, like physical therapy, may be covered if they’re deemed medically necessary for you to be able to return home.
How You’re Covered •
•
•
•
Break your ankle while hiking? Your emergency care is covered both in and out of network, and so is any emergency surgery you need as a result. Need routine physical therapy? You’re covered on a POS plan, but you may have to pay more for being out of network. You’re not covered on an HMO. Take a tumble and need physical therapy in order to return home? You’re covered at the in-network level regardless of where you get your care. Come down with a cold or flu? Urgent care, convenient care and walk-in clinics are covered both in and out of network.
•
Need a routine physical? You’re covered on a POS plan, but you may have to pay more for being out of network. You’re not covered on an HMO.
•
If you have questions about other situations, give us a call at the number on the back of this guide.
Helpful Travel Reminders You have Digital Health Options to get care and navigate your health digitally. You can also call our OSF 24/7 Nurse Line to get 24/7 answers to your health questions, like whether you need to set up an appointment or see a doctor right away. Help is just a phone call away with Assist America® when you travel 100 miles or more from home. And remember, no matter where you are, urgent or emergency care is covered at the in-network benefit level.
Assist America Global Emergency Services Have peace of mind on your dream vacation with Assist America global emergency services. No matter where you’re traveling, when you’re 100 miles or more from home, help is just a phone call away, 24 hours a day and 365 days a year. Assist America can connect you to prompt medical attention and help make sure you’re admitted to reliable hospitals when needed. Plus, it can even help in some situations that are not health-related.
Here are just some of its many features: •
Prescription assistance if you need medication or left your prescription behind.
•
Compassionate visit from someone close to you if you need to be hospitalized for more than a week.
•
Emergency medical evacuation.
•
Lost luggage assistance.
•
Interpreter and legal referrals.
All Assist America benefits apply on all of our Medicare Advantage plans, but when you’re out of network, our HMO plans cover only emergency and urgent care. Assist America will not pay you back for ambulance and other services you arrange on your own. In a life-threatening emergency, always call the ambulance right away. There is no added cost for the service itself, but there could still be a cost with any medical care. Other conditions and exclusions may apply.
Get total care from start to finish. We offer plenty of perks and programs to help guide you toward better health. OSF 24/7 Nurse Line You can access registered nurses anytime, anywhere with the OSF 24/7 Nurse Line. Our team of trained and highly qualified nurses is available when and where you need us. We can help answer questions about your health, connect you to care or help guide you to the best location to receive the care you need. Call the OSF 24/7 Nurse Line anytime at (833) OSF KNOW (833-673-5669).
Be Fit Get paid back for a variety of fitness activities. You choose how you want to work out, and we pay you back up to $360 a year. Activities include the following and more: • Fitness • Gym
class fees.
memberships.
• Online
fitness subscriptions.
• Weight • Ski
loss subscriptions.
memberships.
• Rowing.
An in-network doctor or licensed plan provider must request these services. Services are provided in two-hour increments.
Comprehensive Dental Coverage We cover up to $1,500 a year for use on dental services, like cleanings, X-rays and more (copayment applies; see the Summary of Benefits for specific copayment amounts). You pay the dentist and then send us the receipt. If your dentist submits the claim for you, you don’t need to send us the receipt. (OSF MedAdvantage Enrich has a $1,000 coverage limit.)
Digital Health Options The OSF MedAdvantage plans include options to receive care and navigate your health digitally from the comfort of home. Through OSF OnCall Connect applications, we help you digitally monitor the following conditions: • High
blood pressure.
• Asthma.
• Golf.
• Diabetes.
• Dialysis.
• Bowling.
• COPD.
• Depression.
• Tennis.
• Heart
failure.
• Pickleball. • Recreational • Pool
league fees.
exercise classes.
• 5K/10K
race fees.
Also included is the ability to connect 24/7 with OSF OnCall Urgent Care – at no extra cost. Connect through a video call or send us your questions about a minor illness or injury – any time, day or night.
If your fees are more than $360 a year, you pay the difference. If they’re less, we pay you back the amount you paid. Be Fit doesn’t cover fitness trackers, personal trainers or personal equipment.
In addition, you have Clare, our chatbot. Clare can help you find a clinic near you, schedule a vaccination, help make an appointment, direct you to the care you need based on symptoms you may be having and much more.
Companion Benefit*
Access all of these digital care options from osfhealthcare.org/member.
Get up to 30 hours a year of in-home support through PAPA if you have asthma, congestive heart failure, chronic obstructive pulmonary disease (COPD), vascular disease or diabetes. Services include: • Companionship.
• Light
• Transportation.
• Light
• Technical
support.
exercise.
help around the house.
• Grocery
shopping.
*Not available on Enrich.
Disease Management Programs
Preventive Care
Get connected to resources, motivation, support and reminders to help you manage the following and more:
Here are just some of the many services we cover:
• Asthma.
• Congestive
• Diabetes.
• Migraines.
• High
heart failure.
blood pressure.
Hally App ®
Manage your health plan and get the care you need anytime, anywhere. • See
all your account activities in one place.
• Access
your virtual ID card.
• Search
for doctors and other resources.
• Get
cost estimates.
• Check
claims status.
Visit the App Store or Google Play to download the Hally app. App Store is a service mark of Apple Inc., registered in the U.S. and other countries. Google Play and the Google Play logo are trademarks of Google LLC.
Hearing Benefit* Through TruHearing®, you can get one routine hearing exam for a $45 copayment and lowered rates on up to two TruHearing hearing aids per year when you see a TruHearing provider.
Online Access Get instant access to your coverage anytime at OSFMedAdvantage.org. Our secure member website stores important plan information in one easy place. You can also find information about our member app on our website.
OTC4Me Get a 10% discount code for a wide variety of competitively priced over-the-counter (OTC) products with OTC4Me. You can order online or by phone, and all orders are shipped directly to you. Shipping is free on orders over $25.
• Yearly
wellness visit.
• Routine
screenings (like mammograms or colorectal cancer screenings).
• Flu
shot.
Quit For Life®* Get help ending your tobacco use with: •
One-on-one coaching from a quit coach.
•
Quit plan made just for you.
•
Helpful tools, like Text2Quit®.
•
Web Coach®, an online learning and support community.
Telehealth Coverage If you need to interact with your primary care provider (PCP) or specialist over the phone or online, you’re covered through the telehealth benefit. If you see an OSF provider, many outpatient appointments can be completed through OSF MyChart. While some medical care requires in-person appointments, many visits can be effective and convenient through secure phone or video chat.
Vision Coverage* Get access to vision services beyond what Original Medicare covers, including a routine vision exam with an in-network provider. Plus, get a $150 allowance for eyewear.
Wellness Rewards* Take steps toward better health while working your way toward a $50 gift card. Have a yearly wellness visit or physical, plus complete two other activities outlined at OSFMedAdvantage.org to qualify for your $50 gift card.
whiskerDocs Connect to 24/7 help from veterinary technicians with whiskerDocs. You can call, chat or email with questions about your animals’ health or well-being. The service helps with cats, dogs, birds, reptiles and pocket pets (like rabbits or hamsters). About 60% of issues are taken care of over the phone without a visit to the veterinarian. *Not available on Enrich.
Appeals and Grievances We want you to feel at home with your plan, so we help you understand the protections we have in place. Our OSF MedAdvantage plans offer safeguards to make sure you’re treated fairly and have the chance to voice your opinion if you think you’ve been mistreated. appeal is a type of complaint you can file if you disagree with the plan’s decision to not cover healthcare services you’re trying to get or have already gotten.
grievance is a type of complaint you can make about your plan. Some examples are poor quality of care, bad customer service or feeling like an employee is encouraging you to leave the plan.
• A
• An
You must file an appeal in writing within 60 days of the decision or as soon as you can.
You can file a grievance by calling Member Services at (877) 933-8480 (TTY 711), daily from 8 a.m. to 8 p.m. local time. Voicemail is used on holidays and weekends from April 1 to September 30. You can also email MemberServices@HealthAlliance.org.
Enrollment We make enrollment simple with multiple options to choose from and helpful customer service along the way.
Timelines and Requirements The Centers for Medicare & Medicaid Services (CMS) sets certain times during the year when people can enroll in a Medicare Advantage or prescription drug plan. Annual Enrollment Period
Special Enrollment Period
From October 15 to December 7, you can enroll in Medicare Advantage or a stand-alone prescription drug plan, or you can switch plans. If you enroll during this period, your coverage begins January 1 of the following year.
You can enroll in a new plan or change your plan in certain situations. Here are some examples:
Initial Enrollment Period You have a seven-month initial enrollment period to enroll in Original Medicare, Medicare Advantage or a prescription drug plan. It starts three months before the month you turn 65, includes the month of your 65th birthday and ends three months after the month you turn 65. •
If you enroll one to three months before your 65th birthday, your coverage begins the first day of the month you turn 65.
•
If you enroll during your birth month, your coverage begins the first day of the following month.
•
If you enroll one to three months after the month you turn 65, your coverage begins the first day of the month after you enroll.
From January 1 to March 31, you can switch from one Medicare Advantage plan to another or join a stand-alone prescription drug plan.
•
Permanent address change.
•
Loss of coverage due to employment change.
•
Becoming eligible for a low-income subsidy.
Contact us for other situations that qualify.
Who is eligible for our plans? •
You must have Medicare Parts A and B and live in the service area.
•
You must continue to pay your Medicare Part B premium if not otherwise paid for by Social Security or another third party.
Enrollment in the plan will automatically disenroll you from any other Medicare Advantage plan. Enrollment in the plan won’t automatically disenroll you from a Medicare Supplement plan. You must contact that plan to disenroll.
Enrollment Process How to Enroll
After You Enroll
Online Visit OSFMedAdvantage.org to get started.
If you enroll in a Medicare Advantage plan during the Annual Enrollment Period, your coverage will begin January 1, 2022.
By Phone
In the meantime, we’ll help you get settled with the following:
Call (877) 633-2531 (TTY 711), daily from 8 a.m. to 8 p.m. local time. Voicemail is used on holidays and weekends from April 1 to September 30.
By Mail
•
Member materials, which we’ll mail to you.
•
Member ID card to use instead of your red, white and blue Medicare card at the doctor, hospital and pharmacy.
Fill out and mail us the enrollment form in the back of this guide. You can also download it from OSFMedAdvantage.org.
OSF MedAdvantage Application Processing Center 3310 Fields South Dr. Champaign, IL 61822
Broker If you attend a learning event, the person presenting can schedule an appointment to help you enroll.
OSF MedAdvantage is administered by Health Alliance Medicare – a Medicare Advantage Organization with a Medicare contract. Enrollment in OSF MedAdvantage depends on contract renewal. Other pharmacies, physicians and providers are available in our network. Out-of-network/non-contracted providers are under no obligation to treat Health Alliance Medicare members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. Every year, Medicare evaluates plans based on a 5-star rating system.
Call us at (877) 633-2531 (TTY 711), daily from 8 a.m. to 8 p.m. local time. Voicemail is used on holidays and weekends from April 1 to September 30. OSFMedAdvantage.org MDMKOS22-guidebk-0621 • H1463_22_99211_M
OSF MedAdvantage Star Ratings Click on the link below to view the most up-to-date star ratings for your service area. 2021 OSF MedAdvantage Star Ratings 2022 OSF MedAdvantage Star Ratings (Available Mid-October 2021)
OSF MedAdvantage is administered by Health Alliance Medicare - a Medicare Advantage Organization with a Medicare contract. Enrollment in OSF MedAdvantage depends on contract renewal. Every year, Medicare evaluates plans based on a 5-star rating system. MDMKOS22-starrtgissuu-0921 | H1463_22_101992_M