PPO II - EmblemHealth

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2013 Evidence of Coverage for PPO II) II SECTION Chapter 6: 3 What you benefi pay ts for are your not covered Part D prescription by the plan? drugs cost for this service. You can then ask our plan to pay our share of the cost by using the procedures described in Chapter 7 of this booklet. • You will be reimbursed the amount charged by the doctor for administering the vaccine less any diff erence between the amount the doctor charges and what we normally pay. (If you get Extra Help, we will reimburse you for this diff erence.) Section 8.2 You may want to call us at Customer Service before you get a vaccination Th e rules for coverage of vaccinations are complicated. We are here to help. We recommend that you call us fi rst at Customer Service whenever you are planning to get a vaccination. (Phone numbers for Customer Service are printed on the back cover of this booklet.) • We can tell you about how your vaccination is covered by our plan and explain your share of the cost. • We can tell you how to keep your own cost down by using providers and pharmacies in our network. • If you are not able to use a network provider and pharmacy, we can tell you what you need to do to get payment from us for our share of the cost. SECTION 9 DO YOU HAVE TO PAY THE PART D “LATE ENROLLMENT PENALTY”? Section 9.1 What is the Part D “late enrollment penalty”? Note: If you receive “Extra Help” from Medicare to pay for your prescription drugs, the late enrollment penalty rules do not apply to you. You will not pay a late enrollment penalty, even if you go without “creditable” prescription drug coverage. You may pay a fi nancial penalty if you did not enroll in a plan off ering Medicare Part D drug coverage when you fi rst became eligible for this drug coverage or you experienced a continuous period of 63 days or more when you didn’t have creditable prescription drug coverage. (“Creditable prescription drug coverage” is coverage that meets Medicare’s minimum standards since it is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage.) Th e amount of the penalty depends on how long you waited to enroll in a creditable prescription drug coverage plan any time after the end of your initial enrollment period or how many full calendar months you went without creditable prescription drug coverage. You will have to pay this penalty for as long as you have Part D coverage. Th e penalty is added to your monthly premium. (Members who choose to pay their premium every three months will have the penalty added to their three-month premium.) When you fi rst enroll in our plan, we let you know the amount of the penalty. Your late enrollment penalty is considered part of your plan premium. If you do not pay your late enrollment penalty, you could be disenrolled for failure to pay your plan premium. 115
116 2013 Evidence of Coverage for PPO II Chapter 6: What you pay for your Part D prescription drugs Section 9.2 How much is the Part D late enrollment penalty? Medicare determines the amount of the penalty. Here is how it works: • First count the number of full months that you delayed enrolling in a Medicare drug plan, after you were eligible to enroll. Or count the number of full months in which you did not have creditable prescription drug coverage, if the break in coverage was 63 days or more. Th e penalty is 1% for every month that you didn’t have creditable coverage. For example, if you go 14 months without coverage, the penalty will be 14%. • Th en Medicare determines the amount of the average monthly premium for Medicare drug plans in the nation from the previous year. For 2012, this average premium amount was $31.08. Th is amount may change for 2013. • To get your monthly penalty, you multiply the penalty percentage and the average monthly premium and then round it to the nearest 10 cents. In the example here it would be 14% times $31.08, which equals $4.35. Th is rounds to $4.40. Th is amount would be added to the monthly premium for someone with a late enrollment penalty. Th ere are three important things to note about this monthly late enrollment penalty: • First, the penalty may change each year, because the average monthly premium can change each year. If the national average premium (as determined by Medicare) increases, your penalty will increase. • Second, you will continue to pay a penalty every month for as long as you are enrolled in a plan that has Medicare Part D drug benefi ts. • Th ird, if you are under 65 and currently receiving Medicare benefi ts, the late enrollment penalty will reset when you turn 65. After age 65, your late enrollment penalty will be based only on the months that you don’t have coverage after your initial enrollment period for aging into Medicare. Section 9.3 In some situations, you can enroll late and not have to pay the penalty Even if you have delayed enrolling in a plan off ering Medicare Part D coverage when you were fi rst eligible, sometimes you do not have to pay the late enrollment penalty. You will not have to pay a penalty for late enrollment if you are in any of these situations: • If you already have prescription drug coverage that is expected to pay, on average, at least as much as Medicare’s standard prescription drug coverage. Medicare calls this “creditable drug coverage.” Please note: � Creditable coverage could include drug coverage from a former employer or union, TRICARE, or the Department of Veterans Aff airs. Your insurer or your human resources department will tell you each year if your drug coverage is creditable coverage. Th is information may be sent to you in a letter or included in a newsletter from the plan. Keep this information, because you may need it if you join a Medicare drug plan later.
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