2022 OSF MedAdvantage Guide

Strong Partnership, Strong Providers

Many Medicare insurers offer plans with similar benefits. When everything seems the same, what makes one a better fit for you?

The strength of the OSF MedAdvantage network means our members receive covered care from trusted doctors, clinics and hospitals throughout Illinois.

The OSF MedAdvantage Core and Open plans have two tiers of providers: Tier 1 and Tier 2. Plus, the Open plan has out-of-network coverage. The OSF MedAdvantage Enrich plan does not have a tiered network; it has coverage for in-and out-of-network providers.

You can find a list of some of the providers, clinics and hospitals that are in network in the provider flier. For a full list, go to OSFMedAdvantage.org and use our Find a Doctor search.

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.

Find a plan that fits.

Your health care 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:

• Comfort of having an in-network primary care provider to oversee all your care.

• $0 monthly premium with 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 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.

• No out-of-pocket costs when you go to the doctor or get medical care.

• Includes extra perks, like dental, fitness and digital health benefits.

Find an overview of your plan options and benefits in our 2023 Key Benefits Guide.

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

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.

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.

Our plans have built-in prescription coverage, so all your medical and pharmacy benefits are in one place.

Rx Benefits

Our prescription drug plans help you save with special programs, discounts and more.

90-Day Supply Option

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.

Medication Therapy Management

If you take multiple medications, this program can help you use them safely and effectively.

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).

Drug Compare Tool

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.

Coverage Through the Gap

If your total prescription spend adds up to $4,660, 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 $7,400.

Benefits

Stages of Pharmacy Coverage

Most people stay in this stage. Few people reach this stage. Even fewer people reach this stage.

Initial Coverage

You pay the following until the amount you pay plus the amount we pay reaches $4,660.

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 $4,660. Here, you pay the following until you reach $7,400.

• 25% for covered generic drugs.

• 25% for covered brand-name drugs.

If your total prescription spend adds up to $4,660, 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 $7,400.

Catastrophic Coverage

Catastrophic coverage begins when your out-of-pocket drug costs reach $7,400. 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

• $4.15 for covered generic drugs (including brand-name drugs treated as generic) and $10.35 for covered brand-name drugs.

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 and 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.

A Team Focused on You

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.

Care Coordination

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.

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.

Health Coaching

Health coaches are your health partners. They’ll help you reach your health goals in the following areas and more: • Nutrition. • Weight loss. • Staying active.

Community Outreach

Find helpful resources.

Care for yourself to help prevent illness and hospital stays.

Set and reach health and wellness goals.

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. Understand and manage health issues, like diabetes and asthma.

Use your health benefits to save money.

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 department, 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 department.

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 plan.

• 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 plan.

• 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.

Services include:

• Companionship (like playing games, eating lunch or having a conversation).

• Transportation.

• Technical support (like setting up streaming platforms or teaching you how to make a video call).

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 (877) 673-4951.

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 class fees.

• Gym memberships.

• Online fitness subscriptions.

• Weight loss subscriptions.

• Ski memberships.

• Rowing.

• Golf.

• Bowling.

• Tennis.

• Pickleball.

• Recreational league fees.

• Pool exercise classes.

• 5K/10K race fees.

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 or personal equipment.

Companion Benefit*

Get up to 30 hours of in-home support yearly through the Papa Pal program. This service gives you access to a friendly companion who can help you with a variety of tasks. Plus, they can be a fun person to chat with. And they can go with you to places like a library, park, doctor’s office, pharmacy and more.

• Light help around the house.

• Light exercise.

• Grocery shopping.

• Help with your pet.

Services are typically provided in one-hour increments.

Comprehensive Dental Coverage

We cover up to $2,000 a year for use on dental services, like cleanings, X-rays and more. 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. There’s no set network, so you can go to any dentist you choose. (OSF MedAdvantage Enrich has a $1,750 coverage limit.)

You may have a copay or coinsurance for some dental services. Check your Summary of Benefits.

Digital Health Options

OSF MedAdvantage plans include options to receive care and navigate your health digitally from the comfort of your home. Also included is the ability to connect 24/7 with OSF OnCall Urgent Care – at no extra cost. Chat, video call or send us your questions about a minor illness or injury – anytime, day or night. And then there’s Clare, our chatbot at osfhealthcare.org. 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.

*Not available on Enrich.

We offer plenty of perks and programs to help guide you toward better health.

Disease Management Programs

Get connected to resources, motivation, support and reminders to help you manage the following and more:

• Asthma.

• Diabetes.

• High blood pressure.

Hally.com

• Congestive heart failure.

• Migraines.

• 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®.

We value giving you a high-quality member experience with a variety of options to fit your busy lifestyle. And as a member of our health plan, you get access to Hally® health, our comprehensive suite of health and wellness resources, programs, perks and offerings. Hally health is your ally and partner in helping you live your healthiest life.

Get secure, instant access to your coverage by logging in to hally.com. And manage your health plan anytime, anywhere.

Hearing Benefit*

Through TruHearing®, you can get one routine hearing exam for a $0 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.

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.

Preventive Care

Here are just some of the many services we cover:

• Yearly wellness visit.

• 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. Copayment may apply.

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.

• An appeal is a type of complaint you can file if you disagree with the plan’s decision to not cover health care services you’re trying to get or have already gotten.

You must file an appeal in writing within 60 days of the decision or as soon as you can.

• A 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.

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

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.

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, if you’re already on a Medicare Advantage plan, you can switch to Original Medicare (and join a stand-alone prescription drug plan).

Or you can switch from one Medicare Advantage plan to another.

Special Enrollment Period

You can enroll in a new plan or change your plan in certain situations. Here are some examples:

• 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 at least six months of the year.

• 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

Online

Visit OSFMedAdvantage.org to get started.

By Phone

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

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.

After You Enroll

If you enroll in a Medicare Advantage plan during the Annual Enrollment Period, your coverage will begin January 1, 2023.

In the meantime, we’ll help you get settled with the following:

• 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.

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.

OSF Star Ratings

Click on the link below to view the most up-to-date star ratings for your service area.

2022 Star Ratings

2023 Star Ratings (Available Mid-October 2022)