2022 Health Alliance Northwest Key Benefits Guide - MDUNNW22-WAYfoldguide-0621

Northwest, Yakima

2022 Key Medicare Advantage Benefits Made for You

Use the guide inside to see the amount you pay for some commonly used benefits and to learn more about some of the many perks that come with your plan.

Already a member: (877)795-6117 (TTY 711) Looking for a plan: (877) 642-3331 (TTY 711) Daily 8 a.m. to 8 p.m. local time Voicemail used on holidays and weekends, April 1 – September 30 HealthAlliance.org/Medicare

Medicare Advantage vs.

Medicare Supplement Get more out of Medicare with Medicare Advantage.

Medicare Advantage

Medicare Supplement

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

Generally gives you the flexibility to see any doctor who accepts Original Medicare.

Replaces Original Medicare.

Supplements Original Medicare.

May cover benefits that Original Medicare doesn’t.

Only covers expenses covered

by Original Medicare.

No medical underwriting.

Medical underwriting.

Lower premiums than Medicare Supplement plans.

Higher premiums than Medicare Advantage plans.

Who pays in what order: health plan, you.

Who pays in what order: Original Medicare, health plan, you.

Not age- or tobacco-rated.

Age- and tobacco-rated.

(except for guaranteed issue plans)

Helpful Terms Ambulance: What you pay for an ambulance ride in an emergency.

Outpatient surgery: What you pay for an outpatient procedure.

Copayment/coinsurance: The set dollar amount or percentage you pay for a doctor’s visit, at the hospital or at the pharmacy. Copayment is a specific dollar amount (like $20), and coinsurance is a percentage (like 20%).

Perks: Extra services that come with our Medicare Advantage plans but don’t come with Original Medicare.

Drug tier: The cost group a drug belongs to.

Drugs in our Medicare Part D formulary are in one of five groups: • Tier

1 (Preferred Generic).

2 (Generic).

• Tier 3 (Preferred Brand).

• Tier 4 (Non-Preferred Drug).

• Tier 5 (Specialty Tier).

• Tier

Generally, the higher the tier, the more you pay for the drug. Some prescriptions require step therapy (for you to try a lower tier first), prior authorization or a limit on the amount you can receive at one time. If your drug isn’t covered, you can ask for an exception. For more information, see the formulary.

Emergency care: The amount you pay for emergency care, like a trip to the emergency department.

Inpatient hospital care: The amount you pay for a stay in an in-network hospital.* Lab: What you pay for lab services, like blood tests.

Medical deductible: What you pay out-of-pocket before your coverage starts.

Our plans don’t have medical deductibles.

Premium: The amount you pay each month for plan coverage. You must continue to pay your Medicare Part B premium.

Primary care provider (PCP) visit: The amount you pay at the doctor’s office when you visit your in-network primary care doctor.* Skilled nursing facility (SNF): What you pay for an approved stay at a SNF. Specialist visit: What you pay for each visit to an in-network specialist, like a cardiologist or orthopedic doctor.* Urgent care: The amount you pay for urgent or convenient care.

Yearly limit: The limit of how much money you pay for covered medical services, including copayments and coinsurance, each year. It’s also called out-of-pocket maximum. * Review the provider directory at HealthAlliance.org/Medicare for our in-network doctors and hospitals. With an HMO plan, you choose a primary doctor (or PCP) from our broad network. You’re not covered out of network unless it’s for emergency or urgent care.

With a POS plan, you still choose an in-network PCP, but you have the freedom to go out of network. You save money by staying in network, though.

1

2

Plan Costs

Office Visits

Plan†

Network Premium

3 Diagnostic Services

Medical Deductible

Yearly Limit PCP Visit (does not include pharmacy)

Specialist Visit

Virtual Visit

Physical Therapy

Chiropractic Lab

X-Ray

CT/MRI

4

5

6

Emergency Services

Hospital Services

Initial Rx Coverage

Ambulance»

Emergency Care***

Urgent Care+

Outpatient Inpatient Hospital Care^ Hospital Care (including services received)

Skilled Nursing Facility (noncustodial care based on medical necessity)

(for 30-day supply; applies only to Rx plans) Rx Cost by Tier

Rx Deductible

1

2

3

4

5

Rx Gap Coverage

1

SignalAdvantage HMO Basic Rx (HMO)

IN

$0

$0

$7,550

$35

$50

$0

$40

$20

$35

$40

$375

$500

$90

$50

$500

$500/Day (1-4), $0 (Days 5+)

$0/Day (1-20), $188 (Days 21-100)

$0

$2

$15

$47

50%

33%

Tier 1 coverage through the gap

2

SignalAdvantage HMO (HMO)

IN

$45

$0

$5,900

$10

$50

$0

$30

$20

$20

$30

$275

$325

$90

$40

$425

$325/Day (1-6), $0 (Days 7+)

$0/Day (1-20), $188 (Days 21-100)

N/A

N/A

N/A

N/A

N/A

N/A

N/A

3

SignalAdvantage HMO Rx (HMO)

IN

$32

$0

$6,200

$10

$50

$0

$30

$20

$20

$30

$275

$325

$90

$40

$425

$325/Day (1-6), $0 (Days 7+)

$0/Day (1-20), $188 (Days 21-100)

$0

$2

$15

$47

50%

33%

Tier 1 coverage through the gap

4

SignalAdvantage HMO Rx Plus (HMO)

IN

$105

$0

$3,900

$5

$35

$0

$30

$20

$0

$15

$150

$300

$90

$30

$200

$395/Day (1-4), $0 (Days 5+)

$0/Day (1-20), $188 (Days 21-100)

$0

$2

$15

$47

50%

33%

Tier 1 coverage through the gap

5

SignalAdvantage POS Rx (HMO-POS)

IN

$5,900

$10

$50

$30

$20

$5

$30

$275

$395

$395/Day (1-4), $0 (Days 5+)

$0/Day (1-20), $188 (Days 21-100) $0

$2

$15

$47

50%

33%

Tier 1 coverage through the gap

$0

$2

$15

$47

50%

33%

Tier 1 coverage through the gap

OUT

6

SignalAdvantage POS Rx Plus (HMO-POS)

$97

$0

IN OUT

$130

$0

$11,300

30%

30%

$3,900

$5

$35

$6,000

Key: This is a summary of commonly used benefits.

IN means in network, and OON means out of network.

The OON yearly limit includes your combined costs for both in-network and out-of-network care. » Non-emergency cost-sharing may vary.

Contact the plan for details. † Members on POS plans may pay more for preventive care out of network.

30%

30%

$0

$0

30%

30%

30%

30%

30%

$30

$20

$0

$15

$150

30%

30%

30%

30%

30%

$325

$300

$90

$90

$40

30%

30%

30%

$200

$350/Day (1-5), $0 (Days 6+)

$0/Day (1-20), $188 (Days 21-100)

$30 30%

30%

30%

Perks and Programs

*** Emergency care available worldwide.

Be Fit

Dental Coverage

Virtual Health Coverage

Wellness Rewards

Get help paying for dental services, like cleanings, X-rays and more, with coverage up to $1,000 a year.

(SignalAdvantage HMO Basic RX has a $750 limit.)

Talk to a board certified doctor or counselor by phone or secure video through the Hally® app, 24/7.

Earn a $50 gift card for taking specific healthy steps.

+ Also called convenient or walk-in care.

Get fit with a $360/year reimbursement on a variety of fitness activities.

Hearing Benefit

Vision Coverage

Get one routine hearing exam for a $45 copay when you see a TruHearing® provider and lowered rates on up to two TruHearing hearing aids per year.

Get access to vision services beyond what Original Medicare covers, including a routine vision exam with an in-network provider.

^ You pay nothing for days 91 and beyond in network.

Care Coordination Connect to a team of providers who work with your doctor to make sure you have the resources you need.

Northwest, Yakima

Health Alliance Northwest™ complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Spanish: ATENCIÓN: Si habla español, servicios de asistencia lingüística, de forma gratuita, están disponibles para usted.

Llame (877) 750-3350 (TTY 711). Chinese: 注意：如果你講中文，語言協助服務，免費的，都可以給你。呼叫 (877) 750-3350 (TTY 711).

Health Alliance Northwest is a Medicare Advantage Organization with a Medicare contract. Enrollment in Health Alliance Northwest depends on contract renewal.

Out-of-network/non-contracted providers are under no obligation to treat Health Alliance Northwest 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. Other pharmacies/physicians/providers are available within our network.

MDUNHA22-WAYfoldguide-0621 • H1463_22_99223_M