Medicare health plan comparison chart plan year 2020

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MEDICARE HEALTH PLANS COMPARISON CHART PLAN YEAR 2020

The plan year for HealthSelectSM MA PPO and KelseyCare Advantage MA HMO is January 1 to December 31. The plan year for the other plans is September 1 to August 31.This chart is intended to provide a general comparison of GBP benefits and is subject to change.

Benefit

Original Medicare4

(Medicare rates are subject to change)

Calendar year deductible $185

Office visits in

conjunction with an

20%

illness or injury

Specialty physician office visit

20%

Diagnostic tests and x-rays, including allergy 20% testing

Diagnostic mammography

20%

Diagnostic lab services $0

Preventive services*

(such as screening mammogram, physical, well woman exam, prostate

$01,3 Does not cover lab tests

cancer screening, etc.)

Mental health and substance use disorder

a. Outpatient physician or mental health provider 20% office visits

b. Hospital--Inpatient stay (semi-private room and days board, and intensive care unit)

$05 after the following amounts for each benefit period: $1,316 deductible for days 1-60 $329 copay per day (days 61-90) $658 copay per lifetime reserve day (days 91-150)

c. Outpatient facility care

(partial hospitalization/ day treatment and extensive

20%

outpatient treatment)

HealthSelect MA PPO

(No coordination with Medicare is necessary)

None

$0

$0

Medicare Primary, HealthSelectSM Secondary

(HealthSelect and Medicare coordinate benefits for you)

$200 per individual $600 per family

$0 copay / 30%4,7 coinsurance

$0 copay / 30%4,7 coinsurance

$0

$0 copay / 30%4,7 coinsurance

$0

$0 copay / 30%4,7 coinsurance

$0

$0 copay / 30%4,7 coinsurance

$01,3 Covers screening lab tests

$0*

$0

$0 copay / 30%4,7 coinsurance

$0 per admission

$08 copay / 30%4,7 insurance

$0

$0 copay / 30%4,7 coinsurance

Medicare Primary, GBP HMO Secondary

(GBP HMO plans coordinate benefits with Medicare for you)

Community First, Scott and White None $0 copay / $25 or $406,7 copay $0 copay / $407 copay $0 copay / 20%7 coinsurance $0 copay / 20%7 coinsurance $0 copay / 20%7 coinsurance

$01

$257

$08 If provider doesn't accept Part A, then coverage is $150 copay/day up to $750 per admission and $2,250 per Calendar Year. 20%7, after copay

$25 copay7 Prior authorization required

KelseyCare Advantage MA

HMO

(No coordination with Medicare is necessary) None $0 $0 $0 $0 $0

$01,3

$0

$0

$0

Office surgery and diagnostic procedures

20%

$0

$0 copay / 30%4,7 coinsurance

20% coinsurance7

$0

Immunizations*

$0

$0

High-tech radiology

(CT scan, MRI, nuclear 20%

$0

medicine)

Allergy injections and serum

20%

$0

Chart_2019_MedicareComparison

$0 $0 copay / 30%4,7 insurance

$0 copay / 30%4,7 coinsurance

$0

$0

$0 copay /

$100 copay plus 20%

$0

coinsurance7

$0 copay / 20%7 coinsurance

$0

9/17/2019

Benefit Routine eye exam

Vision (Contact lens fitting exams are not covered)

Routine hearing test

Diagnostic speech and hearing testing

Speech and hearing therapy

Original Medicare4

(Medicare rates are subject

to change)

HealthSelect MA PPO

(No coordination with

Medicare is necessary)

Does not cover

$01

Frames: You pay 100% for non-covered services 20% for one pair of eyeglasses after each cataract surgery with an intraocular lens.

$0 for one pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens.

Contacts: You pay 100% for non-covered services 20% for one set of contact lenses after each cataract surgery with an intraocular lens.

$0 for one pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens.

Does not cover

Does not cover

20%

$0

20%

$0

Medicare Primary, HealthSelect Secondary

(HealthSelect and Medicare coordinate benefits for you) 30%1,4 coinsurance Frames: Does not cover

Contacts: Does not cover

30%4 coinsurance

$0 copay / 30%4,7 coinsurance

$0 copay / 30%4,7 coinsurance

Medicare Primary, GBP HMO Secondary

(GBP HMO plans coordinate benefits with Medicare for you)

Community First, Scott and White

$40 copay2

KelseyCare Advantage MA HMO

(No coordination with Medicare is necessary)

$01

Not covered Community First: You receive a $125 allowance every 2 years in lieu of glasses9 Scott & White: Does not cover

$150 plan coverage limit for eyewear, glasses, and/or contact lenses every two years unrelated to postcataract surgery.10 Allowance can only be used on date of service.

Without office visit: 20% coinsurance, With office visit: $40 copay plus 20% coinsurance

$0 copay for up to one supplemental routine hearing exam every year1,2

Without office visit: $0 copay / 20%7 coinsurance With office visit: $0 copay / $40 copay plus 20% coinsurance7 Without office visit: $0 copay / 20% coinsurance7 With office visit: $0 copay / $40 copay plus 20% coinsurance7

$0 for Medicarecovered diagnostic hearing exams $0

Hearing aids

Does not cover

$1,000 benefit allowance per ear every 3 years

$1,000 benefit allowance per ear every 3 years

$1,000 benefit allowance per ear every 3 years (Repairs not covered)

$1,500 plan coverage limit for hearing aids every 2 years (Does not include battery replacement) $0 copayment for up to one hearing aid fitting/ evaluation every year2

Chiropractic care

20% for Medicarecovered chiropractic services

30% for specialist office visit for routine services, up to a maximum of a $75 benefit per visit. Benefit is limited to 30 visits per plan year. $0 Medicare-covered chiropractic services.

$0 copay / 30%4,7 coinsurance

Urgent care clinic

20%

$0

$0 copay / 30%4,7 coinsurance

Emergency room care

20% Plus emergency room copay (waived if admitted to hospital within 3 days of emergency room visit)

In U.S.: $0 Outside U.S. and Puerto Rico: 20% after $100 deductible. Limited to $25,000 per plan year or 60 consecutive days, which ever is greater.

$0 copay/30%4,7 coinsurance

Community First: $0 copay / $40 copay7 Benefit is limited to 30 visits per plan year. Scott & White: Without office visit: 20%7; with office visit: $40 copay plus 20%7. Benefit is limited to 35 visits per calendar year; 5 per month

$0 copay / $50 copay plus 20% coinsurance7

$0 for each Medicarecovered visit $0

$0 copay/ $150 copay plus 20% coinsurance7. In-area and out-of-area covered at copay listed.

In U.S.: $0 Outside U.S.: 20% after $250 deductible

Benefit

Original Medicare4

(Medicare rates are subject

to change)

HealthSelect MA PPO

(No coordination with

Medicare is necessary)

$0 after the following

amounts for each benefit

period5:

Inpatient hospital

$1,316 deductible for

(semi-private room and days 1-60 days board, and intensive $329 copay per day

$0

care unit)

(days 61-90)

$658 copay per lifetime

reserve day (days 91-

150)

Outpatient surgery

20%

Specified copay for outpatient hospital

$0

facility charges

Medicare Primary, HealthSelect Secondary

(HealthSelect and Medicare

coordinate benefits for you)

Medicare Primary, GBP HMO Secondary

(GBP HMO plans coordinate benefits with Medicare for you)

Community First, Scott and White

KelseyCare Advantage MA HMO

(No coordination with

Medicare is necessary)

$08 copay / 30%4,7 insurance

$08 If provider doesn't accept Part A, then coverage is $150 copay/day up to $750 per admission and $2,250 per Calendar Year. 20% after copay7

$0 No limit to the number of days covered by the plan each benefit period5

$0 copay / 30% 4,7 insurance

$0 copay / $100 copay plus 20% coinsurance7

$0

Skilled nursing facility

Days 1-20: $0 (3-day hospital stay required) Days 21-100: $164.50 coinsurance per day Per benefit period5

$0 up to 100 days per benefit period (no 3-day hospital stay is required) You pay 100% after 100 days

No deductible Plan pays 100%

$0 copay / 20%7 coinsurance

Days 1-100: $0 copayment per day Plan covers up to 100 days each benefit period5 No prior hospital stay is required

Home health care Hospice

$0

5% of the Medicareapproved amount for inpatient respite care $5 copay for pain management drugs

$0 copay/30%4,7

coinsurance for home

infusion therapy

$0

Plan pays 100% for all other home health care

$0 copay / 20%7 coinsurance

services with a maximum

of 100 visits per calendar

year

Same benefits as under $0 copay /

Original Medicare

30%4,7 coinsurance

$0 copay / 20%7 coinsurance

$0

Same benefits as under Original Medicare You must receive care from a Medicarecertified hospice

Ambulance

20%

$0

$0 copay/30%4,7

coinsurance Emergency care only. Not applicable to non-

$0 copay / 20%7 coinsurance

$0

emergent transportation

services.

Private duty nursing

Does not cover

30% Pays a maximum benefit of $8,000 per calendar year

30%4 Unlimited hours

$0 copay / 20%7 coinsurance

Does not cover

*Under the Affordable Care Act, certain preventive health and women's services are paid at 100% (at no cost to the participant) conditioned upon physician billing and diagnosis. In some cases, you may still be

responsible for payment on some services. Some age requirements may apply. 1 One per calendar year. 2 One per plan year. 3 No copayment for a pap smear once every 24 months; once every 12 months for those at high risk. 4 After payment of deductible. HealthSelect note: Medicare and HealthSelect deductibles run concurrently. Participant may be responsible for some charges when the provider does not accept Medicare

assignment. 5 A "benefit period" starts the day you go into the hospital. It ends after 60 days in a row without returning to hospital care. If you go into the hospital after one benefit period has ended, a new benefit period will

begin. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you may have. 6 Copayment amount depends on whether treatment is provided by a PCP or specialist. 7 Payment amount is dependent upon the coordination of benefits (COB) between your carrier (HealthSelect, Community First, Scott and White) and Original Medicare. Sometimes this means your expense is

$0, but charges will vary depending upon COB. Please reference your Master Benefit Plan Document (MBPD) for more information. 8 In the event that the provider/facility does not accept Medicare assignment (so the charges are not covered by Medicare and therefore not subject to COB); you may be responsible for copay(s) and/or a

coinsurance. Please see your Master Benefit Plan Document (MBPD) for more information. 9 ERS cannot and does not guarantee the length of time that a specific type of "Value-Added" product shall be offered. Any questions or concerns about these products should be directed to your carrier. 10 Does not count toward out-of-pocket maximum.

How much does it cost?

Premiums for ERS Medicare Advantage plans are much lower than what you're paying now to cover a Medicare-eligible

dependent. You must continue paying Medicare Part B premiums with all health plans.

Plan Year 2020 (January 1 ? December 31, 2020)

Coverage level

HealthSelect MA PPO Premium

HealthSelect of Texas? Premium

Your savings with HealthSelect

MA PPO

KelseyCare Advantage MA HMO Premium

Retiree only Retiree & spouse Retiree & children Retiree & family Surviving spouse only Surviving children only Surviving spouse & children

$0.00 $151.70 $151.70 $303.40 $303.40 $303.40 $606.80

$0.00 $358.00 $239.70 $597.70 $716.00 $479.40 $1,195.40

$0.00 $206.30

$88.00 $294.30 $412.60 $176.00 $588.60

$0.00 $127.12 $127.12 $254.24 $254.24 $254.24 $508.48

Your savings with KelseyCare

Advantage MA HMO

$0.00

$230.88

$112.58

$343.46

$461.76

$225.16

$686.92

Plan Name

Plan Administrator

Prescription Drug

Description

HealthSelect MA PPO

Humana (855) 377-0001

HealthSelectSM Medicare Rx Humana administers your Medicare; doctors and through UnitedHealthcare other providers file one claim with Humana.

HealthSelect of Texas HealthSelect Secondary

Blue Cross and Blue Shield of Texas (800) 252 - 8039

HealthSelect Medicare Rx Medicare pays primary and HealthSelect pays through UnitedHealthcare secondary.

KelseyCare Advantage MA HMO

KelseyCare Advantage (Houston area) (877) 853-9075

HealthSelect Medicare Rx through UnitedHealthcare

KelseyCare Advantage administers your Medicare; doctors and other providers file one claim with KelseyCare Advantage. (available only to members in the Houston area)

Scott and White Health Plan (HMO)

Scott and White (Central Texas) (800) 321-7947

Optum Rx

Medicare pays primary and HMO pays secondary. (available only to members in the Central Texas area)

Community First Health Plans (HMO)

Community First (San Antonio area) (877) 698-7032

Navitus Health Solutions

Medicare pays primary and HMO pays secondary. (available only to members in the San Antonio area)

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