2023 Northwest Yakima Fold Guide

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.

May cover benefits that Original Medicare doesn’t.

No medical underwriting.

Lower premiums than Medicare Supplement plans. Who pays in what order: health plan, you. Not age- or tobacco-rated.

Supplements Original Medicare.

Only covers expenses covered by Original Medicare. Medical underwriting. (except for guaranteed issue plans)

Higher premiums than Medicare Advantage plans.

Who pays in what order: Original Medicare, health plan, you. Age- and tobacco-rated.

Helpful Terms

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

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%).

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).

• Tier 2 (Generic).

• Tier 3 (Preferred Brand).

• Tier 4 (Non-Preferred Drug).

• Tier 5 (Specialty 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.

Outpatient surgery: What you pay for an outpatient procedure.

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

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.

IN

†

The

yearly limit includes

costs for both in-network and out-of-network

» Non-emergency cost-sharing may

Contact the plan for details.

on POS plans may pay more for preventive care out

network.

are amounts you pay per day.

Be Fit

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

Companion Benefit

Get up to 30 hours of in-home support yearly (in one-hour increments).

Dental Coverage

Get help paying for dental services, like cleanings, X-rays and more with coverage up to $1,250 a year. (Signal Advantage POS Basic Rx has a $750 limit and Signal Advantage has a $1,000 limit).

Hearing Benefit

Get one routine hearing exam for a $0 copay when you see a TruHearing® provider and lowered rates on up to two TruHearing hearing aids per year.

OTC4Me

Get 10% off on over-the-counter (OTC) products online or by phone.

Virtual Health Coverage

Telehealth Benefit

Connect with your primary care provider or specialist over the phone or online without the inconvenience of going to the doctor's office or sitting in a waiting room. Copayment may apply.

Virtual Visits

Talk to a board certified doctor or counselor by phone or secure video through Haly.com, 24.7.

Vision Coverage

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

Wellness Rewards

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

Gap

Coverage Gap

Through

Covered Through