1. Retiree Health benefit Plan Options
Yosemite Community College District
November 15, 2016
Presented by: Lola Nickell & Bobbie Wellwood – SISC

2. Items for Discussion Section I: What’s Available?
Section II: Overview of Plan Options
Brief summary of each plan, refer to Plan Benefit Summary for details
Section III: Review of Plans & Differences
Section IV: SISC Retiree Direct Bill Program
Section V: Retirees Turning 65 – Medicare Enrollment Timing & Process
Section VI: Review

3. Section I: What’s Available?
There are three types of plans available through YCCD:
Blue Shield PPO - Medicare Coordination of Benefits (COB) Plans
Most expensive: Single $506 to $538 (varies by plan)
2. Kaiser Permanente Senior Advantage (KPSA) Plan (HMO)
Less expensive than PPO: Single $329
May enroll mid year. Contact Benefits Department at least 60 days in advance.
3. Companion Care Medicare Supplement Plan
Less expensive than PPO: Single $419

4. Section II: Overview of Plan Options
Blue Shield PPO - Medicare Coordination of Benefits Plans
Enrollment in Medicare Part A & B is required to avoid expensive premium surcharges for missing Medicare.
Member retains original Medicare A & B
Member may access medical services with any U.S. provider who accepts Medicare assignment. To maximize Plan benefits and minimize potential out of pocket cost, use providers in the Blue Shield PPO network.
Members enrolled on the Blue Shield PPO plan are not enrolled in Medicare Part D drug coverage. The Prescription Drug Plan, administered by Navitus Health Solutions, mirrors the Active Employee benefit.
Monthly Single Rates: $506 to $538 (varies by plan)

5. Section II: Overview of Plan Options
Retires Age 65+ with Medicare: PPO Plans
Option 1
Option 2
Service
Blue Shield PPO 100-D $30, Rx $10/$35 ($200 Brand Ded)
Blue Shield PPO 80-G $30, Rx $10/$35 ($200 Brand Ded)
Office Visits
$30 (Deductible waived)
Generic Rx
$10 (30 days or $0 at Costco)
Brand Rx
$35
Rx Deductible for Brand/Specialty
Per calendar year: $200 individual, $500 family max
Rx Out of Pocket Max
$2,500 / $3,500
Medical Deductible
$300 individual / $600 family
$500 individual / $1,000 family
Medical Out of Pocket Max
$1,000 / $3,000
$2,000 / $4,000
Member cost share for in-network, covered services after deductible 0%
20%
Member cost share for in-network, covered services, once Out of Pocket Max is met. $0
Deductibles and Out of Pocket Maximums are based on a calendar year (January-December).
PPO Members age 65+ with Medicare A&B: Your Medical Plan pays secondary to Medicare. Your pharmacy benefit typically does not coordinate with Medicare.

6. Section II: Overview of Plan Options
Retires Age 65+ with Medicare: PPO Plans (Continued)
Option 3
Option 4
Service
Blue Shield PPO 80-C $20, Rx $10/$35 ($200 Brand Ded)
Blue Shield PPO 90-G $30, Rx $9/$35
Office Visits
$20 (Deductible waived)
$30 (Deductible waived)
Generic Rx
$10 (30 days or $0 at Costco)
$9 (30 days or $0 at Costco)
Brand Rx
$35
Rx Deductible for Brand/Specialty
Per calendar year: $200 individual, $500 family max
None
Rx Out of Pocket Max
$2,500 / $3,500
Medical Deductible
$200 individual / $500 family
$500 individual / $1,000 family
Medical Out of Pocket Max
$1,000 / $3,000
Member cost share for in-network, covered services after deductible
20%
10%
Member cost share for in-network, covered services, once Out of Pocket Max is met. $0
Deductibles and Out of Pocket Maximums are based on a calendar year (January-December).
PPO Members age 65+ with Medicare A&B: Your Medical Plan pays secondary to Medicare. Your pharmacy benefit typically does not coordinate with Medicare.

7. Section II: Retirees Age 65+ : Overview of Options
Kaiser Permanente Senior Advantage (KPSA)
Medicare Advantage Plan (HMO) with Medicare Part D prescription drug coverage
Enrollment in Medicare Part A & B required
Family member under 65 continues on KP not KPSA.
Medicare must be assigned to the Plan
Member can un-assign Medicare at open enrollment if dis-enrolling in KPSA to move to Blue Shield or CompanionCare.
Member must live in the Plan’s service area
Except emergencies, services must be authorized by the Plan
Kaiser Permanente Senior Advantage Plans include automatic enrollment in Medicare Part D Prescription Drug Plan – No “Donut Hole” or Coverage Gap .
Most Medicare Prescription Drug Plans have a coverage gap (also called the "donut hole"). This means there's a temporary limit on what the drug plan will cover for drugs
Monthly Single Rates: $329

8. KAISER PERMANENTE SENIOR ADVANTAGE $10 OV, $10-20 RX
Section II Benefit Overview: Kaiser Permanente Senior Advantage Plans – Retirees age 65+ with Medicare A&B
SERVICES
KAISER PERMANENTE SENIOR ADVANTAGE $10 OV, $10-20 RX
Ambulance (Ground or Air)
$50/Trip
Annual Physical Examination and Medicare approved immunizations
No charge
Acupuncture/Chiropractic
$10 co-pay 30 combined visits
DME - Durable Medical Equipment (Kaiser DME formulary guidelines apply)
100%
Hospitalization
Inpatient
$0 admission
Emergency Room
$50 co-pay/waived if admitted
Laboratory Services
Mental Health - Outpatient unlimited visits
$10 co-pay per individual visit; $5 co-pay per group visit
Physician Services/Basic Health Services
Office visits
$10 co-pay per visit
Consultation, diagnosis & treatment by a specialist
Prescription Drugs
Generic: $10 co-pay a 100 day supply
Using Kaiser pharmacies. Not subject to donut hole.
Brand: $20 co-pay for a 100 day supply
Vision Care
Examination for eyeglasses
Glaucoma testing
Standard frame/lenses every 24 months
$150 frame and lens allowance every 24 months
Retiree plans with Medicare A&B
Retirees must live in an approved zip code of the Kaiser Permanente California Service Area and Centers for Medicare and Medicaid (CMS)

9. Kaiser Permanente Senior Advantage
New Feature: Silver & Fit Exercise and Healthy Aging Program
Available only to KPSA members
Benefits include:
Gym Membership at participating clubs
Home Fitness Program
Healthy Aging Resource Library
To learn more about Silver & Fit, including how to register and find fitness facilities near you, visit SilverandFit.com.

10. Section II: Overview of Plan Options
CompanionCare
Medicare Supplement Plan with Part D prescription drug coverage
Enrollment in Medicare Part A & B required
Member retains original Medicare A & B
Member may access medical services with any U.S. provider who accepts Medicare assignment
Member self-refers to any U.S. provider who accepts Medicare assignment
When the medical service is approved by Medicare, and the provider accepts Medicare assignment, the member cost share is zero.
Member co-pays for prescriptions: $9 generic, $35 brand. Costco zero copay program does NOT apply.
SISC’s CompanionCare Plan is a Medicare Supplement Plan administered by Anthem Blue Cross. The CompanionCare Plan includes automatic enrollment Medicare Part D Prescription Drug Plan, administered by Navitus Health Solutions. – NO “Doughnut Hole” or Coverage Gap
Monthly Single Rates: $419

11. COMPANIONCARE MEDICARE SUPPLEMENT PLAN Based on Calendar Year
Section II: Benefit Overview: CompanionCare – Retirees age 65+ with Medicare A&B
SERVICES
COMPANIONCARE MEDICARE SUPPLEMENT PLAN Based on Calendar Year
MEDICARE
COMPANIONCARE
Inpatient Hospital (Part A)
Pays all but first $1,288 for 1st 60 days
Pays $1,288
Pays all but $322 a day for the 61st to 90th day
Pays $322 a day
Pays all but $644 a day Lifetime Reserve for 91st to 150th day
Pays $644 a day
Pays nothing after Lifetime Reserve is used (refer to Evidence of Coverage)
Pays 100% after Medicare and Lifetime reserve are Exhausted up to 365 days per lifetime
Skilled Nursing Facility (must be approved by Medicare)
Pays 100% for 1st 20 days
Pays nothing
Pays all but $161 a day for 21st to 100th day
Pays $161 a day for 31st to 100th day
Pays nothing after 100th day
Deductible (Part B)
$166 Part B deductible per year
Pays $166
Continues on next slide.

12. COMPANIONCARE MEDICARE SUPPLEMENT PLAN Based on Calendar Year
Section II: Benefit Overview: CompanionCare – Retirees age 65+ with Medicare A&B (Continued)
SERVICES
COMPANIONCARE MEDICARE SUPPLEMENT PLAN Based on Calendar Year
MEDICARE
COMPANIONCARE
Basis of Payment (Part B)
80% Medicare Approved (MA) charges after Part B deductibles
Pays 20% MA charges including 100% of Medicare Part B deductible
Medical Services (Part B) Doctor, x-ray, appliances & ambulance
80% MA charges
20% MA charges
Lab
100% MA charges
Pays nothing
Physical/Speech Therapy (Part B)
80% MA charges up to the Medicare annual benefit amount
Pays 20% MA charges up to the Medicare annual benefit amount (PT & ST Combined)
Blood (Part B)
80% MA charges after 3 pints
Pays 1st 3 pints un-replaced blood and 20% MA charges
Travel Coverage (when outside the US for less than 6 consecutive months)
Not covered
Pays 80% inpatient hospital, surgery, anesthetist and in-hospital visits for medically necessary services for 90 days of treatment per lifetime. For details call Anthem customer service
Outpatient Prescription Drugs
Medicare Part D Prescription drug plan through Navitus Health Solutions
Due to Medicare restrictions the following programs are not available with CompanionCare: $0 generic copay at Costco & Diabetic Supplies for Generic copay
Retail Pharmacy: day supply - $9 Generic copay / $35 Brand copay Mail Order: day supply - $18 Generic copay / $90 Brand copay
Pharmacy benefits are administered through Navitus Health Solutions MedicareRx using a Med D formulary. Some exclusions and prior authorizations may apply. Members that have questions regarding their medication coverage can call Navitus Health Solutions MedicareRx at or TYY users please call 711.

13. Section III : Review of Plan Types & Differences
Important Details
Blue Shield PPO COB
Kaiser Permanente Senior Advantage (KPSA)
CompanionCare Medicare Supplement
Providers
U.S. Providers who Accept Medicare Assignment; Use Blue Shield PPO providers to maximize benefits and minimize potential member cost share
KPSA
U.S. Providers who Accept Medicare Assignment
Must live in plan service area
No (U.S. only)
Yes
Must receive non-emergency services in service area
Medicare A & B required for enrollment
Not mandatory, but expensive surcharges will apply
Medicare assigned to Plan No
Retain Original Medicare
No, Assigned to Plan
Auto-Enrollment in Medicare Part D Prescription Drug Plan
May enroll outside of annual open enrollment per SISC process (minimum 60 days in advance)

14. Section IV: Retiree Direct Billing Program Overview
Self-pay retirees are billed directly by SISC
SISC has a team dedicated to managing monthly billing for District retiree medical plans.
The SISC team can assist you with all questions about:
Direct Bill Program billing and premium payment
Enrollment in SISC Direct Bill Plan Options
Your medical plan benefits will be administered entirely by the SISC Office. All communication regarding benefits and payments will be coming from and directed to the SISC office.
Upon receipt of your enrollment, SISC will send you a Welcome Letter with an explanation of the payment process.

15. Section IV : Retiree Program Overview, Continued
You will receive a monthly statement from SISC at the beginning of each month. The payment is for that coverage month and is due to SISC by the 20th.
SISC can accept advance payments for multiple months. Advance payments will be reflected on the monthly statement.
You may pay by check or an automatic electronic funds transfer.
US Mail:
SISC III Health Benefits
PO Box 1591
Bakersfield, CA

16. Section IV: Retiree Direct Billing Program
Self-pay retirees are billed directly by SISC
Dental and Vision plan through SISC Direct Bill
The following dental and/or vision plans are offered to Direct Bill members if they are currently enrolled in Dental and Vision through YCCD
*Delta Dental Premier Incentive Plan $1500
The Delta PPO plan is not offered through Direct Bill. Benefits start at 70% if enrolled on Delta PPO.
*VSP C $20
Compared to YCCD plan, premium is a bit lower, benefits every year, copay $20
*The dental and vision plans listed above are the only choices offered under this program. If the retiree currently has a different dental or vision plan with the school district and they wish to continue with one or both of these products, they will have to change to the plans listed above in order to participate in this program. The retiree will not have the option of staying on the district dental and/or vision plan if they participate in SISC Retiree Direct Bill.

17. Section V: General Information Retirees Turning 65 – Medicare Enrollment Timing and Process
SISC will send retirees/spouses turning 65 a letter approximately 90 days prior to their birthday as a reminder to apply for Medicare Parts A &B.
Contact the SISC office 90 days prior to your 65th birthday if you would like to continue your SISC coverage after age 65.  SISC can then send you the necessary enrollment forms or information required to move to an over 65 plan.
You must enroll and remain enrolled in Medicare Part A and Part B on the first date of Medicare eligibility, otherwise, non-refundable premium surcharges will be applied from the first date of Medicare eligibility. You are eligible for Medicare the first day of the month before your 65th birthday.

18. Section V: General Information – Medicare Plans
When considering other options (outside of SISC)…
Keep your annual Notice of Creditable Coverage
Compare plans carefully (example: KPSA SISC vs. individual)
Understand the Medicare Part D Coverage Gap (“Donut Hole”)
Not everyone will enter the coverage gap. The coverage gap begins after you and your drug plan have spent a certain amount for covered drugs. In 2016, once you and your plan have spent $3,310 ($3,700 in 2017) on covered drugs, you're in the coverage gap. This amount may change each year.
SISC plans do NOT have a Part D coverage gap
Plan ahead so that you maintain continuous coverage
Notify SISC/YCCD if you plan to terminate coverage
Terminate coverage with YCCD only after you have a new plan in place
Avoid Medicare late enrollment penalties

20. Resources
Medicare & You Handbook - published annually
Stanislaus County HICAP office
(209)
Toulumne County HICAP office
(209) ext. 226

21. Section VI: Review Multiple plan options available through YCCD
The CompanionCare and KPSA options are less expensive than PPO
You may change mid-year to CompanionCare or KPSA with at least 60 days notice to the YCCD Benefits Department
If you want to change back to PPO, you will need to wait until the annual Open Enrollment (October 1st effective date)
KPSA
KP Enrollment form and KPSA election form + Medicare card copies
for each covered member
CompanionCare
CompanionCare Enrollment Form + Medicare card copies for each covered member

22. Thank you for your attendance.
Questions?
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