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2023-employer-group-product-certification.pdf
- 1. ©2021 MVP Health Care
CONFIDENTIAL & PROPRIETARY INFORMATION.
September 2022
2023 Employer Group Product Certification
Program
MVP Health Care
Medicare Advantage
Training
- 2. ©2021 MVP Health Care, Inc.
Training Instructions
MVP’S Medicare Advantage Employer Group Product
Training:
• This training will take you approximately 30 minutes to
complete
• There is no audio, and you can advance each slide on your
own
• A required knowledge check will be provided at the end of
the training program
• Completion of the knowledge check is a requirement
with a score of 85% or higher
CONFIDENTIAL & PROPRIETARY INFORMATION. 2
- 3. ©2021 MVP Health Care
Medicare Advantage Overview
CONFIDENTIAL & PROPRIETARY INFORMATION.
- 4. ©2021 MVP Health Care, Inc. 4
Medicare Review
The Four Parts of Medicare
Medicare and its benefits can be broken into four parts:
• Part A - Hospital Insurance
• Part B – Medical Insurance
• Part C – The Medicare Advantage (MA) program
• Part D – The Prescription Drug Plan (PDP)
Part A and Part B are referred to as Original Medicare because these benefits
are administered, and the claims are paid by Medicare.
Part C and Part D are offered by private insurers. The Centers for Medicare and
Medicaid Services (CMS) pays private insurers to administer benefits and pay
claims on behalf of CMS.
Note: often, private insurers will offer both the Part C and Part D plans
in one combined plan.
These plans are known as MA-PD plans (Medicare Advantage-
Prescription Drug plans).
- 5. ©2021 MVP Health Care, Inc. 5
Medicare Part A - Overview
Medicare Part A is also known as Hospital Insurance.
Part A covers:
• Inpatient hospital
• Skilled Nursing Facility (SNF)
• Nursing home care
• Home health services
• Hospice care
Medicare Review
- 6. ©2021 MVP Health Care, Inc. 6
Medicare Part A – Eligibility
In order to be eligible for Part A, you must:
• be a U.S. citizen and 65 years old or older or;
• be a permanent U.S. resident for five or more continuous years and
be 65 years old or older
If you are not 65 or older, you can still qualify for Part A if:
• you are a U.S. citizen or legal resident under 65 years old but have
a qualifying disability, such as blindness, or a qualifying medical
condition, such as Lou Gehrig's Disease
• you have received disability benefits from Social Security or the
Railroad Retirement Board for 24 months
• you are a disabled widow or widower between age 50 and age 65
but have not applied for disability benefits because you're already
getting another kind of Social Security benefit
Medicare Review
- 7. ©2021 MVP Health Care, Inc. 7
Medicare Part A – Premium Information
Most people don’t have to pay a monthly premium for Part A because they
(or a spouse) paid Medicare taxes for at least 40 quarters (10 years) while
they were working. Other ways that a person may qualify for premium-fee
Part A include:
• You already get retirement benefits from Social Security or the
Railroad Retirement Board
• You're eligible to get Social Security or Railroad benefits but haven't
filed for them yet.
• You or your spouse had Medicare-covered government employment.
If you're under 65, you can get premium-free Part A if:
• You got Social Security or Railroad Retirement Board disability
benefits for 24 months
Medicare Review
- 8. ©2021 MVP Health Care, Inc. 8
Medicare Part B – Overview, Eligibility, and Premium
Information
Medicare Part B is also known as Medical Insurance and covers:
• Doctor services
• Mental Health services
• Lab work
• X-rays
• Durable medical equipment (DME)
• Other medical services not covered under Part A
• Certain drugs not covered under Part D
Anyone receiving or entitled to Part A is eligible for Part B.
Unlike Part A, signing up for Part B is voluntary and everyone
must pay a monthly premium based on their income.
Medicare Review
- 9. ©2021 MVP Health Care, Inc. 10
Medicare Part C Overview and Premium Information
Medicare Part C is also known as Medicare Advantage (MA). MA
plans are health plans approved by Medicare and run by private
insurance companies as an alternative to Original Medicare. CMS pays
these private insurers to administer benefits and pay claims on behalf
of CMS. MA plans must have the same or better benefits than
Original Medicare. MA plans may include additional coverage such as
wellness education, eye care, or dental coverage.
MA plan members do not show their Medicare card for coverage.
They show the MA plan’s benefit card to obtain services.
Members joining an MA plan must continue to pay their premiums for
both Medicare Parts A (if they have one) and B and may have to pay
an additional premium for their MA plan.
Medicare Review
- 10. ©2021 MVP Health Care, Inc. 11
Part C Eligibility
To be eligible for an MA plan, individuals must:
• Be currently enrolled in and continue to pay applicable premiums for
both Medicare Parts A* and B
• Be permanent residents in the MA plan’s service area**
• Pay an MA plan’s premium, if needed
*Most beneficiaries do not pay a monthly premium for Part A coverage if
they paid the applicable Medicare taxes while working.
**There are certain employer group waivers that may allow retirees to be
covered outside of the MA plan’s employer group service area
There is no pre-existing condition requirement for any MA
plan, including the age and income of the beneficiary.
Premiums for MA plans are not rated based on pre-existing
conditions, age or income.
Medicare Review
- 11. ©2021 MVP Health Care, Inc. 12
Medicare Part C – Emergent and Urgent Care
MA members will be covered outside of the plan’s
service area, and worldwide, for all:
• Urgently needed care
• Emergency care
MA members will be covered outside of the plan’s
service area, and nationwide, for:
• Dialysis
These services would be treated as in-network for
purposes of the member’s financial responsibility
(copays, coinsurance and/or deductibles).
Medicare Review
- 12. ©2021 MVP Health Care, Inc. 13
Medicare Part C – Maximum Out-of-Pocket Limits
(MOOP)
MA plans have an Out Of Pocket Maximum (OOP max) limit to help
protect members from catastrophic medical expenses. The OOP max limits
how much a member must pay in copays, coinsurance, and deductibles
before the plan will pick up 100% of covered expenses.
For example, if a member has MVP Preferred Gold with Part D (HMO-POS)
with a $4,000 OOP max, once the member has paid $4,000 worth of copays,
coinsurance and/or deductibles, the member will be covered at 100% for all
covered medical services.
Non-medical expenses, such as Part D copays and eyewear allowances, do
not count towards a member’s OOP max.
Note: The OOP max amount may differ between plans
Medicare Review
- 13. ©2021 MVP Health Care, Inc. 14
Medicare Review
Medicare Part D – Plan Types
Part D is prescription drug coverage subsidized by the Federal
government and administered by private companies. For many
beneficiaries, a Part D plan may be their only way to save on drugs
and protect them from catastrophic drug costs. There are two
different types of Part D plans:
• Stand Alone Prescription Drug Plan (PDP) PDPs are plans
that provide coverage for Part D prescription drugs only. PDPs
can be combined with Original Medicare, Medigap, or some
Part C plans.
• Medicare Advantage Prescription Drug Plan (MA-PD)
combines Part C and Part D plans from one health insurer, such
as MVP Health Care.
- 14. ©2021 MVP Health Care, Inc. 15
Medicare Part D – Standard Benefit
The Medicare Part D Standard Benefit is CMS’s standardized Part D benefit
structure. The Part D Standard Benefit is amended each year by CMS. All
plans offering Part D coverage must assure that their plans offer, at
minimum, the standard Part D benefit. Most plans offering Part D
coverage have plan options that exceed the minimum coverage set by
CMS. For 2022, the Medicare Part D Standard Benefit is:
• Deductible - $505
• Coinsurance – 25% on all drugs after deductible is met, up to the
Initial Coverage limit
• Initial Coverage Limit - $4,660 – 25% coinsurance on generic drugs
and brand name drugs in coverage gap
• Out-Of-Pocket Cost Threshold - $7,400 - once this has been
reached, coinsurance for generic drugs will be $4.15 or 5%,
whichever is greater, brand names will be $10.35 or 5%, whichever is
greater.
Medicare Review
- 15. ©2021 MVP Health Care, Inc. 16
Medicare Part D – Key Concepts
To understand Part D, there are several key concepts that
you’ll need to be familiar with:
• Part D Cost Sharing
• Deductibles, Copays, and Coinsurance
• The Coverage Gap
• The Medicare Coverage Gap Discount Program
• True Out of Pocket (TrOOP)
• Catastrophic Coverage
• Pharmacy Networks
• Preferred and Non-Preferred Cost-Sharing
Pharmacies
• Prior Authorization
Medicare Review
- 16. ©2021 MVP Health Care, Inc. 17
Part D – Cost Sharing
Medicare Part D plans are designed to help beneficiaries with
their prescription drug costs through cost sharing. Part D
plans may accomplish this through:
Deductibles –the amount a beneficiary must pay out of
pocket for prescription drug costs before a Part D plan’s
benefits “kick in”. Some Part D plans have deductibles,
some do not.
Coinsurances –the percentage of drug cost a beneficiary
must pay for their prescription drugs. For example, if a
beneficiary’s Part D plan has a 25% coinsurance for
prescription drugs, the beneficiary shares 25% of the cost
of the drug – the plan pays 75%.
Copays –similar to coinsurances, but instead of paying a
percentage of the cost of a prescription drug, the
beneficiary pays a set fee.
Tiers –a level or category of prescription drugs in a
prescription drug plan, usually depending on the type of
drug (generic, brand name, specialty, etc.). Each tier has a
specific copay or coinsurance.
Medicare Review
- 17. ©2021 MVP Health Care, Inc. 18
Part D – Benefit Four Stages:
Deductible Stage –the beneficiary pays for prescription drugs out of pocket until the
deductible amount is reached. Not all Part D plans have a deductible.
Initial Coverage Stage –the beneficiary pays either a coinsurance or copay for their
prescription drugs. The Initial coverage stage lasts until the total drug cost - the
amount the member has paid out of pocket, plus the amount paid by the plan and any
assistance programs, such as SPAPs or LIS - reaches $4,660.
Coverage Gap –also known as the “Donut Hole”. During this stage, there is a “gap” in
coverage from the plan – meaning the Part D plan pays a lesser share of the cost of
prescription drugs, and the beneficiary pays a greater share. Drug manufacturers also
pay a percentage for brand name drugs. This stage continues until the total amount
paid by the member, manufacturer, SPAPs, and LIS reaches $7,400 annually. This
is called True Out of Pocket, or TrOOP.
Catastrophic Coverage Stage –After TrOOP reaches $7,400 beneficiaries are
considered to be in the Catastrophic Coverage Stage. Beneficiaries will pay a 5%
coinsurance or $4.15 for generic drugs, $10.35 for brand name drugs, whichever is
greater.
Medicare Review
- 18. ©2021 MVP Health Care, Inc. 19
Part D – Medicare Prescription Drug Plan Overview
Part D is Medicare’s prescription drug plan. Part D provides coverage
for basic and catastrophic non-Part B prescription drug costs and is
administered by private insurance companies contracted through CMS.
Beneficiaries can receive Part D coverage from a stand-alone Prescription
Drug Plan (PDP) or as prescription drug coverage included in the benefits
of an MA plan (MA-PD).
Beneficiaries cannot purchase a Part C plan with one company and a Part D
plan from another company. If a beneficiary has a Part C plan with one
company and elects a Part D plan from another company, they will be
automatically disenrolled from the Part C plan and enrolled in Original
Medicare.
Exceptions: Beneficiaries can purchase a Medicare Medical
Savings Account (MSA) or a Private Fee-For-Service (PFFS) plan
with one company and purchase a Part D plan with another
company.
Medicare Review
- 19. ©2021 MVP Health Care, Inc. 20
Part D – Eligibility and Premium Information
Unlike Part C, where a beneficiary must be enrolled in Part A and
enrolled in Part B; to be eligible for Part D, individuals can be enrolled in
Part A or Part B.
Creditable Coverage is prescription drug coverage that is at least
equal to the benefits provided by the CMS Standard Medicare Part
D benefit.
• Like MA plans, PDPs and MA-PDs can only offer equivalent or better
coverage than the CMS Standard Medicare Part D benefit.
• Plans may charge a premium for Part D coverage. If a member delay’s
enrollment into a Part D plan, or switches from prescription drug
coverage that is not creditable to a Part D plan, a Part D Late
Enrollment Penalty (LEP) may be added to the beneficiary’s monthly
Part D premium, and will remain for as long as the member is
enrolled in Part D.
Medicare Review
- 20. ©2021 MVP Health Care, Inc. 21
Part D – Cost Sharing Subsidies for Low-Income Individuals
There are both state funded programs and Medicare funded programs that
may be available to help beneficiaries with their prescription drug costs.
State funded assistance programs are known as State Prescription Assistance
Plans or SPAPs. The SPAP for New York is the Elderly Pharmaceutical
Insurance Coverage, or EPIC. Vpharm is the name of Vermont’s SPAP. Not
all states have a SPAP.
LIS (low income subsidy), or “Extra Help” is a Medicare program to help
people with limited income and resources pay Medicare prescription drug
costs, such as premiums, deductibles, coinsurance, and copayments. The LIS
program is available to anyone who meets Medicare’s income requirements. If
a person would like to know if they qualify, they should call the Social Security
Administration (SSA) Office.
Note: If a person qualifies for LIS with their Medicare
prescription drug coverage costs, Medicare will pay part of
their plan’s premium. The person will be billed for the
amount that Medicare does not cover.
Medicare Review
- 21. ©2021 MVP Health Care, Inc. 22
Medicare Review
What Payments DO NOT Count Toward TrOOP?
• Monthly Premiums - such as Part D Premium
• Employer or Union coverage payments
• Government Funded Health program payments – such as
Medicaid, Tricare, VA, or Worker’s Comp
• Other Health Plan payments
• No Fault Insurance payments
• Unqualified SPAPs not affiliated with Part D
• Part D excluded Drugs
• Drugs bought outside of the U.S.
- 22. ©2021 MVP Health Care
2023 Formulary Tier Design
Tier 1 Preferred Generics
Tier 2 Non-Preferred Generics
Tier 3 Preferred Brands/Non-Preferred Generics
Tier 4 Non-Preferred Drugs
Tier 5 Specialty medications > $670 per month
Medicare Review
- 23. Part D Drugs in the Gap from
2020 and going forward
Generics
• Member – 25% (Counts toward Troop)
• MVP – 75%
Brands
• Member – 25% (Counts toward Troop)
• MVP – 5%
• Drug Maker – 70% (Counts toward Troop)
24
©2020 MVP Health Care, Inc.
- 24. ©2021 MVP Health Care, Inc.
5% Coinsurance or
$4.15 / $10.35 Copay
201
Plan may or may not
have a deductible
STAGE 3:
Coverage Gap
MVP, Member &
Pharmaceutical
Manufacturer
share cost in the
Coverage Gap
STAGE 4:
Catastrophic
STAGE 2:
Initial Coverage
STAGE 1:
Deductible
Members, Plan &
Pharmaceutical
Manufacturers
share in cost in Coverage
Gap
Members Pay:
Generic Drugs: 25%
Brand Name Drugs: 25%
This stage the member
will have copay or
coins, depending on
plan Tier structure
Stage 4: Member pays greater of
5% or copay until year end
Stage 3: Member pays cost sharing
until their year-to-date out-of-pocket
costs (their payments), Manufacturer’s
payments, and SPAP and/or LIS
assistance reaches $7,400
(in 2023)
Stage 2: Member pays Tier copay or
coinsurance until member’s Total Drug
Costs reaches $4,660
(in 2023)
Total Drug Costs include what member,
plan, and SPAP or LIS paid this calendar
year
Stage 1: From Day 1 until
Deductible is met, if applicable
Part D Stages
25
CONFIDENTIAL & PROPRIETARY INFORMATION
- 25. ©2021 MVP Health Care
2023 MVP’s Medicare Advantage
Employer Group Plans
CONFIDENTIAL & PROPRIETARY INFORMATION.
- 26. ©2021 MVP Health Care, Inc. 27
MVP must offer the same base benefits across all service
areas. Riders, however, can differ between plans and regions.
For example, if MRIs are part of MVP’s base benefits, then MRIs
must be covered in all our plans. However, if dental benefits are
offered as a rider, then dental benefits may be selected by one
employer group and not by another.
Basic Underwriting Rules
Underwriting guidelines, including which riders are
available for each plan, can be found at the Broker section
of MVP’s website.
- 27. ©2021 MVP Health Care, Inc. 28
According to Medicare guidelines, all termination requests
must be terminations going forward. MVP cannot process
requests for retro-active terminations.
When terminating a member from an employer group plan,
members must receive notice at least 21 days prior to the
effective date of the termination, and the notice must come
from the Employer Group, not the plan.
CMS Termination Rules
- 28. ©2021 MVP Health Care, Inc. 29
When submitting paper applications, the applications must include:
• The group name and the group number.
• The signature date. The signature date on all applications must
be no greater than 90 days prior to the effective date.
The signature date is the date the member signed their
application. The signature date is not:
• The effective date of the plan,
• The date the beneficiary became eligible for Medicare, or
• The date of employment or retirement.
Example: Alex is eligible for Medicare on March 1st. He signs his application for
his Employer Group’s Medicare Advantage plan through MVP on March 1st.
Alex’s signature date is March 1st.
March 1st cannot be the effective date of Alex’s Employer Group MA plan.
Employer Group Applications
- 29. ©2021 MVP Health Care, Inc. 30
When submitting group changes, such as address changes,
enrollment changes, or group contact information updates,
the employer group portal cannot be used for MVP’s
Medicare plans. Medicare group changes can be :
• Submitted to your MVP Account Manager or Account
Executive
• Faxed to 585-327-2227, attention: Gold Enrollment, or
• Emailed to goldenrollment@mvphealthcare.com.
Submitting Group Changes to MVP
- 30. ©2021 MVP Health Care, Inc. 31
Working After the age of 65
Many people are choosing to continue to work after age 65. There
are several options for these individuals to obtain health care.
Working individuals over 65 should be encouraged to speak directly
with their Human Resources dept. for help choosing an option that
best fits their needs.
• If the employer has less than 20 employees, they can mandate all employees/spouses over 65
obtain coverage through Medicare.
• If the employer has 20 or more employees, the employer has to offer group coverage to
employees/spouses over 65. The employee has the right to keep group coverage or sign up for
Medicare.
• In a group with 20 or more, employees/spouses over 65 can keep their group coverage and sign
up for Part A, and delay enrolling in Part B and Part D without penalty.
• For employees nearing 65 or over 65 who would like to continue working &contributing to an HSA
they should be advised to not enroll in Medicare. Once enrolled in Medicare Parts A or B, an
employee cannot contribute to an HSA. Employees should delay applying for social security
benefits, as once social security benefits begin, a person is automatically enrolled in Part A
Options include:
- 31. ©2021 MVP Health Care, Inc. 32
Plan Similarities
There are several similarities across MVP’s MA plans. For example:
• Eligibility requirements are the same
• All plans utilize the same pharmacy benefits manager,
CVS/caremark
• MVP’s Medicare Advantage plans do not use the CIGNA network
• MVPs MA members can see any participating provider across all
of MVP’s regions
• Emergency care and urgent care are covered worldwide. Dialysis
is covered nationwide.
• Members have access to the SilverSneakers network of fitness
centers
- 32. ©2021 MVP Health Care
Product Design Methodology
Evidence
Based
Innovation
Competitive
Intelligence
Market
Research
Customer
Centric
Product
CONFIDENTIAL & PROPRIETARY INFORMATION
- 33. ©2021 MVP Health Care
Non-Health Related
Supplemental Benefits Increase
CMS Agenda focuses on SDOH
Medicare Advantage Market Headlines
PROPRIETARY & CONFIDENTIAL
- 34. ©2021 MVP Health Care
Uncovering Unmet Needs
EBI
Data
Teamwork
Innovation
Complexity
Worldview
Ethical
Standards
Unmet
Need
- 35. ©2021 MVP Health Care
Minimize the
likelihood my
Care will be
Disrupted
Minimize the time it
takes to identify tools
to manage a new
health condition
Minimize the
time it takes to
identify tools to
manage an
existing health
condition
Evidence Based Innovation
CONFIDENTIAL & PROPRIETARY INFORMATION
- 36. ©2021 MVP Health Care
2023 Employer Group Portfolio
CONFIDENTIAL & PROPRIETARY INFORMATION
2023 Plan Name Options
HMO-POS (H3305)
MVP Preferred Gold with Part D (HMO-POS) Base, Standard, Buy-Up
*West Only MVP Preferred Gold without Part D (HMO-POS) Buy-Up
PPO Plans (H9615)
MVP USACare with Part D (PPO) Base, Standard, Buy-Up, Premier
PDP Plan (S0586)
MVP RxCare Plan (PDP) N/A
- 37. ©2021 MVP Health Care
Changes Across Portfolio
CONFIDENTIAL & PROPRIETARY INFORMATION
• Mix of cost share changes to industry standard
– SNF Copay change to CMS maximum (for those plans with a
traditional SNF benefit)
– Emergency Room cost share increase (some plans)
– Advanced Radiology (some plans)
• Part D benefit standard changes
– $4,660 Initial Coverage Limit (ICL)
– $7,400 TROOP
– $4.15 / $10.35 Catastrophic Copays
- 38. ©2021 MVP Health Care 39
Preferred Gold HMO-POS Changes
CONFIDENTIAL & PROPRIETARY INFORMATION
Plan Name Benefit Description 2022 Benefit 2023 Benefit
Preferred Gold Base Emergency Room $75 $95
Skilled Nursing $188 per day (21-100) $196 per day (21-100)
Advanced Radiology $100 $125
Preferred Gold Standard Emergency Room $75 $95
Skilled Nursing $188 per day (21-100) $196 per day (21-100)
Advanced Radiology $75 $100
Preferred Gold Buy-Up No Changes N/A N/A
- 39. ©2021 MVP Health Care 40
USACare PPO Changes
CONFIDENTIAL & PROPRIETARY INFORMATION
Plan Name Benefit Description 2022 Benefit 2023 Benefit
USACare Base Emergency Room $75 $95
Skilled Nursing $188 per day (21-100) $196 per day (21-100)
Advanced Radiology $75 $100
USACare Standard Emergency Room $75 $95
Skilled Nursing $188 per day (21-100) $196 per day (21-100)
Advanced Radiology $35 $50
USACare Buy-Up Advanced Radiology $25 $35
USACare Premier No Change N/A N/A
- 40. ©2021 MVP Health Care 41
Supplemental Benefits
CONFIDENTIAL & PROPRIETARY INFORMATION
Vision
• Embedded
with each
plan
offering
Dental
• Will offer 2
different
variations
of riders
for
purchase
Hearing
• Embedded
with each
plan
offering
- 41. ©2021 MVP Health Care 42
Vision
$100 Eyewear Allowance
• Once every 24 months
• Use any provider
• Can be used towards
frames, lenses, & contacts
- 42. ©2021 MVP Health Care
Preventive Dental
Increased preventive dental services from 2 x-ray, 2 oral
exams, and 2 cleanings per calendar year
Comprehensive Dental
• $1000 per calendar year with $100 deductible
– Emergency
– Routine & Restorative
• fillings and diagnostic oral exams
– Oral Surgery
• simple and bony extractions
– Endodontics
• root canal
– Periodontics
• scaling and root planing
– Prosthodontics
• crowns and dentures
43
Dental Rider Options
PROPRIETARY & CONFIDENTIAL
- 43. ©2021 MVP Health Care
Hearing
PROPRIETARY & CONFIDENTIAL
$600 per ear Allowance to
apply towards TruHearing’s
pricing for
all top 6 manufacturers
TruHearing Brand Advanced:
$699 Copay
TruHearing Brand Premium:
$999 Copay
OR
$0 Routine & Diagnostic
Hearing Exam
- 44. ©2021 MVP Health Care
• 14 meals delivered post-discharge
from an Inpatient Admission
• $0 cost to the member
• Fits Multiple Dietary Needs
Meal Delivery Service
- 45. ©2021 MVP Health Care
The existing $200 Well-Being
Rewards will be retired 12/31/2022.
Wellness offerings within our
products are being redesigned for
a 2024 plan year launch.
Well-Being Rewards
- 46. ©2021 MVP Health Care
Access to 15,000 gyms across the
United States at no-cost
“Get Set Up Program”
• Over 2K classes covering Art, Business &
Entrepreneurship, Communications, Creativity, Financial
Planning, Health & Wellness, Hiring & Jobs, Social Hours,
Technology, and Travel
• Classes are live, interactive, and taught 24/7 by instructors
from all over the world
• Seniors join without downloading Zoom to learn, create,
and share their knowledge in a positive environment that
helps to reduce social isolation and loneliness
• Opportunities available for seniors to teach classes and
earn additional income
Silver Sneakers
- 47. ©2021 MVP Health Care, Inc. 48
Employer Group Plan Benefit Levels
There are different benefit levels available for MVP’s
Employer Group HMO-POS and PPO Plans:
• Base
• Standard
• Buy-up
• Premier (Premier is only available with our
PPO plans, not HMO-POS)
As benefit levels go from Base to Premier, the
premiums increase, however the copays/coinsurances
decrease, and the benefits are richer.
- 48. ©2021 MVP Health Care, Inc. 49
Plan Details – Preferred Gold HMO-POS
Preferred Gold HMO-POS requires members to select a PCP and
reside in our service area. An HMO-POS works like a standard HMO
plan but allows the beneficiary to see non-par providers whether the
provider is in or out of our service area for most services.
Generally, the member’s out-of-network(OON or POS) benefits are
limited and do not have the same coverage as the member’s in-
network (INN or HMO) benefits.
There are some services that are covered under the INN or HMO
benefit that are not covered under the OON or POS benefit, such as
skilled nursing facility stay, mental health services, and diabetic
supplies.
Note: Out of network benefits are usually more
costly to the member.
- 49. ©2021 MVP Health Care, Inc. 50
Plan Details – USACare PPO
USACare PPO does not require members to select a PCP
and there are special residency requirements, approved by
CMS, that allow members to live outside of MVP’s MA
service area. The USACare PPO plan has the exact same
benefits, copays, and coinsurance for both in-network and
out-of-network providers. USACare members can see any
provider that accepts Medicare.
- 50. ©2021 MVP Health Care, Inc. 51
RXCare PDP— Plan Details
RxCare PDP is MVP’s stand-alone prescription drug plan offered to Employer
Groups. RxCare PDP is designed to be paired with non-Medicare Advantage
medical plans that Employer Groups may have for their retiree medical
coverage. RxCare PDP cannot be paired with a Medicare Advantage plan
from a different insurance carrier. RxCare PDP is offered to all Employer
Groups within our Employer Group service area, and offers coverage options
that are equal to or better than the Standard Part D benefit. Like USA Care
PPO, RxCare PDP has special residency requirements, approved by CMS, that
allow members to live outside of MVP’s MA service area.
RxCare PDP may be an attractive option for certain Employer Groups, as it
shifts the administrative burden and risk of operating an in-house
prescription drug plan from the employer group to MVP.
- 51. ©2021 MVP Health Care, Inc. 52
Part D Late Enrollment Penalty Rules
for Employer Groups
The Part D Late Enrollment Penalty (LEP) is the amount added to a member’s Part
D premium if, at any time after the member’s initial enrollment period is over, there is
a period of 63 or more days in a row when the member doesn’t have Part D or other
creditable coverage.
Creditable Coverage is prescription drug coverage that is at least equal to the
benefits provided by the Standard Medicare Part D benefit. Employers who offer
Non-Medicare prescription drug coverage should inform employees annually if the
coverage is creditable. If a Medicare beneficiary elects their employer’s Non-
Medicare prescription drug coverage, and that coverage is not creditable, they may
have to pay a Part D LEP if they later enroll in Part D plan or an MA-PD.
*LEP amounts are billed one month behind the current bill. MVP does not receive LEP
information from Medicare prior to billing. The Group agrees to pay the members’ LEP
amounts billed and may collect these amounts from the members. LEP amounts owed
do not go to MVP; these amounts go to Medicare.
- 52. ©2021 MVP Health Care
Knowledge Check
CONFIDENTIAL & PROPRIETARY INFORMATION.
- 53. ©2021 MVP Health Care, Inc.
Test Your Knowledge!
Congratulations – you’ve completed 2023 MVP Employer
Group Product Training.
Reminder: You must now take MVP’s knowledge check
and score an 85% or better. You will be allowed
multiple attempts to pass and will receive a score upon
completion of the exam.
CONFIDENTIAL & PROPRIETARY INFORMATION. 54
- 54. ©2021 MVP Health Care
Contact:
Thank you.
We appreciate you for being a valuable partner.
CONFIDENTIAL & PROPRIETARY INFORMATION.