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Published byTamsyn Lawson Modified over 9 years ago
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Offered Exclusively Through Seniors Choice is the premier group retiree medical plan for employees and retirees age 65+ which originates where Medicare ends.
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The Basics Employer Options Underwritten by Guarantee Trust Life in Glenview, IL Administered by MBA MBA, Inc. owner/distributor
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SC Benefit Design Optional Benefits “How Deductibles Work” SC Part D Eligibility TEFRA Prospects Enrollment Today’s Discussion
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The Seniors Choice Plan Design Basic Plan F Design Base Plan Benefits No Lifetime Maximum Part A & B Deductible Coverage Coverage for Excess Charges Included Skilled Nursing up to 100 Days Foreign Travel included
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The Seniors Choice Plan Design Cont. $10 – Office Visit, Lab and X-ray Co-pay $10- Durable Medical Equipment $20 – All other outpatient services $100 – Emergency Room Co-pay (waived if admitted) Excess charges are covered (up to 15% above MAC) No Co-pay plan is also available
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Deductible Options Multiple Deductible Options ◦ From $0 to $4,000 All deductible options include the Medicare Part B deductible ($147) Sponsor can choose one or as many deductibles as desired Non-traditional Deductible
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Example Deductible Enrolled in SC $500 deductible plan option Member incurs $1,000 in physician services Member Out of Pocket Calculation Physicians Services$1,000 Subtract Medicare Part B Deductible($147) Balance after Part B Deductible$853 Subtract 80% of Claim Paid by Medicare($682.40) Remainder Owed (Member pays this amount)$170.60 Part B Deductible (Member pays this amount)$147 Member Total Out-of-Pocket$317.60 Remaining Annual Deductible Calculation Seniors Choice Annual Plan Deductible$500 Subtract Out-of-Pocket amount paid by member which includes the Medicare Part B Deductible ($317.60) Remaining Annual Plan Deductible$182.40
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Optional Benefits Comprehensive Wellness Benefit ◦ Up to $250 per calendar year Private Duty Nursing Benefit ◦ $100 per 8 hour shift; 30 shifts per calendar year. At Home Recovery Benefit ◦ Certified by a doctor ◦ Approved by Medicare Additional Skilled Nursing Coverage ◦ From 101 days to 365 days
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Enhanced Benefits EPIC Hearing Service Plan Included with all plans National network of local ear physicians and audiologists Testing, evaluations and hearing aid fittings by licensed audiologists Savings of 35% to 65% on brand name hearing aids Toll free telephone support No Administrative forms or paperwork
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Enhanced Benefits Outlook Vision Services Outlook Vision Services ◦ Included with all plans ◦ Discounts on eye exams at approved locations ◦ Up to 50% off eyewear ◦ Up to 50% discount on mail order contact lens replacement ◦ Providers within a 15 minute drive for 85% of the U.S. population
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Part D Late Enrollment Penalty A Penalty will be assessed to anyone who: 1. Did not join a Medicare drug plan when they were first eligible for Part A and/or Part B OR 2. Went without creditable prescription drug coverage for 63 days or more Penalty will be for ALL fully uncovered months Calculate number of fully uncovered months: Example: Uncovered from 5/16/06 - 12/31/08 = 31 months Penalty is 1% for each number of fully uncovered months: Example: 31 months x 1% = 31% Multiply penalty percent by current national base beneficiary premium* Example: (2012): $31.00 x 31% = $9.61 Cost of Standard Part D plan premium + $9.61 (late enrollment penalty) = Part D total monthly premium The penalty will be added to the standard premium of any Part D plan for which the member enrolls. The member will have to pay the penalty each month as long as he/she has the Medicare prescription drug coverage. *The current national base beneficiary premium is set by CMMS (Medicare) and is subject to change each calendar year. Previous Years: [2011: $32.34] [2010: $31.94] [2009: $30.36] [2008: $27.93] [2007: $27.35] [2006: $32.20]
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Plan Highlights Always Guaranteed Acceptance Full takeover of pre-existing conditions Enhanced Benefits Optional Benefits Part D Coverage Gap coverage
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Eligibility for Seniors Choice Group Retiree Medical Plans Enrollee Qualification ◦ Currently Age 65 or over ◦ Enrolled in Medicare Parts A & B ◦ SC grandfathers any individual who has been employed by the sponsoring entity
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Group Sponsorship Requirement A group of 1 life may sponsor SC – Sole proprietors such as : Lawyers Dentists Doctors Insurance Agents Real Estate Agents
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Tax Equity and Fiscal Responsibility Act (TEFRA) Employers with 20 or more FT/PT employees 20 or more weeks in the current or preceding year The 20 weeks do not have to be consecutive The requirements are based on the number of employees, not the number of individuals covered under the medical plan.
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Seniors Choice Prospects Groups of Under 20 employees ◦ Age 65 and over FT Employees TEFRA does not apply thus Medicare is primary Premiums are generally higher for employees age 65 and over Can raise the average age of group
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Seniors Choice Prospects Continued Groups with 20 or More Employees ◦ Must comply with TEFRA regulations ◦ Employees eligible for the employer sponsored group plan are ineligible for SC ◦ Employees not eligible for the employer sponsored group plan are eligible for SC
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Why Choose SC over a Traditional Medicare Supplement or MA Plan? Tax benefits for premium contribution SC is always guaranteed issue Section 125 POP eligible Portable Extensive Part D Plan Open Enrollment Every December Enhanced Benefits Included
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Example Number EES10 Number of EES 65+1 Group Premium w/65$5,500 Group Premium w/o/65$4,000 Seniors Choice Premium w/Rx for 65 yr. old $4,000 + $450 =$4,450 Monthly Savings = $1,050
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How To Enroll In Seniors Choice Sponsoring Employers Must: – Complete Employer Trust Participation Agreement – Employer may sponsor one or as many deductibles as they desire If voluntary, the Optional Prescription Drug Benefit is elected by the enrollee Enrollee and/or Spouse Must: – Complete Enrollment Form – Make check or money order payable to “Seniors Choice” – Make copy of Medicare I.D. card and Medical I.D. card, if applicable
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Remember... This is Group Retiree Medical Insurance All Agents and Brokers must be appropriately licensed where the employer is domiciled Any and all Marketing Materials utilized in connection with SC must first be approved in writing by Merchants Benefit Administration, Inc. prior to use
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