Member Service Pharmacy
Resume:
BlueCare Plus Annual Notice of Changes for **** *
OMB Approval 0938-1051 (Expires: February 29, 2024) BlueCare Plus (HMO D-SNP)SM offered by Volunteer State Health Plan, Inc. (BlueCare Plus Tennessee)
Annual Notice of Changes for 2023
You are currently enrolled as a member of BlueCare Plus. Next year, there will be changes to the plan’s costs and benefits. Please see page 5 for a Summary of Important Costs, including Premium.
This document tells about the changes to your plan. To get more information about costs, benefits, or rules please review the Evidence of Coverage, which is located on our website at bluecareplus.bcbst.com. You may also call Member Service to ask us to mail you an Evidence of Coverage.
What to do now
1. ASK: Which changes apply to you
Check the changes to our benefits and costs to see if they affect you.
• Review the changes to Medical care costs (doctor, hospital).
• Review the changes to our drug coverage, including authorization requirements and costs.
• Think about how much you will spend on premiums, deductibles, and cost sharing. Check the changes in the 2023 Drug List to make sure the drugs you currently take are still covered.
Check to see if your primary care doctors, specialists, hospitals and other providers, including pharmacies will be in our network next year. Think about whether you are happy with our plan.
H3259_23ANOC001_M (08/22)
BlueCare Plus Annual Notice of Changes for 2023 2
OMB Approval 0938-1051 (Expires: February 29, 2024) 2. COMPARE: Learn about other plan choices
Check coverage and costs of plans in your area. Use the Medicare Plan Finder at www.medicare.gov/plan-compare website or review the list in the back of your Medicare & You 2023 handbook.
Once you narrow your choice to a preferred plan, confirm your costs and coverage on the plan’s website.
3. CHOOSE: Decide whether you want to change your plan
• If you don't join another plan by December 7, 2022, you will stay in BlueCare Plus.
• To change to a different plan, you can switch plans between October 15 and December 7. Your new coverage will start on January 1, 2023. This will end your enrollment with BlueCare Plus.
• Look in Section 2.2, page 13 to learn more about your choices.
• If you recently moved into, currently live in, or just moved out of an institution (like a skilled nursing facility or long-term care hospital), you can switch plans or switch to Original Medicare (either with or without a separate Medicare prescription drug plan) at any time.
Additional Resources
• Please contact our Member Service number at 1-800-***-**** for additional information.
(TTY users should call 711.) Hours are from October 1 to March 31, you may call us seven days a week from 8 a.m. to 9 p.m. ET. From April 1 to September 30, you may call us Monday through Friday from 8 a.m. to 9 p.m. ET. Our automated phone system may answer your call outside these hours and during holidays.
• This material is also available in alternate formats.
• Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies the Patient Protection and Affordable Care Act’s (ACA) individual shared responsibility requirement. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/Affordable-Care-Act/Individuals-and-Families for more information. About BlueCare Plus
• BlueCare Plus Tennessee is an HMO Dual Eligible Special Needs Plan (D-SNP) with a Medicare contract and a contract with the Tennessee Medicaid program. Enrollment in BlueCare Plus Tennessee depends on contract renewal. BlueCare Plus Annual Notice of Changes for 2023 3
OMB Approval 0938-1051 (Expires: February 29, 2024)
• When this document says “we,” “us,” or “our,” it means BlueCare Plus Tennessee. When it says “plan” or “our plan,” it means BlueCare Plus. BlueCare Plus Annual Notice of Changes for 2023 4
OMB Approval 0938-1051 (Expires: February 29, 2024) Annual Notice of Changes for 2023
Table of Contents
Summary of Important Costs for 2023 5 SECTION 1 Changes to Benefits and Costs for Next Year 6 Section 1.1 – Changes to the Monthly Premium 6 Section 1.2 – Changes to Your Maximum Out-of-Pocket Amount 6 Section 1.3 – Changes to the Provider and Pharmacy Networks 7 Section 1.4 – Changes to Benefits and Costs for Medical Services 7 Section 1.5 – Changes to Part D Prescription Drug Coverage 11 SECTION 2 Deciding Which Plan to Choose 13 Section 2.1 – If you want to stay in BlueCare Plus 13 Section 2.2 – If you want to change plans 13 SECTION 3 Changing Plans 14 SECTION 4 Programs That Offer Free Counseling about Medicare and TennCare (Medicaid) 14 SECTION 5 Programs That Help Pay for Prescription Drugs 15 SECTION 6 Questions 15 Section 6.1 – Getting Help from BlueCare Plus 15 Section 6.2 – Getting Help from Medicare 16 Section 6.3 – Getting Help from TennCare (Medicaid) 16 BlueCare Plus Annual Notice of Changes for 2023 5
OMB Approval 0938-1051 (Expires: February 29, 2024) Summary of Important Costs for 2023
The table below compares the 2022 costs and 2023 costs for BlueCare Plus in several important areas. Please note this is only a summary of costs. If you are eligible for Medicare cost sharing assistance under TennCare (Medicaid), you pay $0 for your deductible, doctor office visits, and inpatient hospital stays.
Cost 2022 (this year) 2023 (next year)
Monthly plan premium*
* Your premium may be higher
or lower than this amount. See
Section 1.1 for details.
$32.70 (Note: Because you
receive "Extra Help", your
premium is $0.)
$32.80 (Note: Because you
receive "Extra Help", your
premium is $0.)
Doctor office visits
Primary care visits:
$0 copay per visit
Specialist visits:
$0 copay per visit
Primary care visits:
$0 copay per visit
Specialist visits:
$0 copay per visit
Inpatient hospital stays $0 copay per stay $0 copay per stay Part D prescription drug
coverage (Tier 1)
(See Section 1.5 for details.)
Deductible: $0
Copayment during the Initial
Coverage Stage:
• Generic: $0 to $3.95 copay
• Brand: $0 to $9.85 copay
Deductible: $0
Copayment during the Initial
Coverage Stage:
• Generic: $0 copay
• Brand: $0 copay
Maximum out-of-pocket
amount
This is the most you will pay
out-of-pocket for your covered
Part A and Part B services.
(See section 1.2 for details.)
$7,550
You are not responsible for
paying any out-of-pocket
costs toward the maximum
out-of-pocket amount for
covered Part A and Part B
services.
$8,300
You are not responsible for
paying any out-of-pocket
costs toward the maximum
out-of-pocket amount for
covered Part A and Part B
services.
BlueCare Plus Annual Notice of Changes for 2023 6
OMB Approval 0938-1051 (Expires: February 29, 2024) SECTION 1 Changes to Benefits and Costs for Next Year Section 1.1 – Changes to the Monthly Premium
Cost 2022 (this year) 2023 (next year)
Monthly premium
(You must also continue to pay your
Medicare Part B premium unless it is
paid for you by TennCare (Medicaid).)
$32.70 (Note: Because
you receive "Extra
Help", your premium is
$0.)
$32.80 (Note: Because
you receive "Extra
Help", your premium is
$0.)
Section 1.2 – Changes to Your Maximum Out-of-Pocket Amount Medicare requires all health plans to limit how much you pay “out-of-pocket” for the year. This limit is called the “maximum out-of-pocket amount.” Once you reach this amount, you generally pay nothing for covered Part A and Part B services for the rest of the year. Cost 2022 (this year) 2023 (next year)
Maximum out-of-pocket amount
Because our members also get
assistance from TennCare
(Medicaid), very few members ever
reach this out-of-pocket maximum.
You are not responsible for paying any
out-of-pocket costs toward the
maximum out-of-pocket amount for
covered Part A and Part B services.
Your costs for covered medical services
(such as copays) count toward your
maximum out-of-pocket amount. Your
costs for prescription drugs do not
count toward your maximum out-of-
pocket amount.
$7,550 $8,300
Once you have paid
$8,300 out-of-pocket for
covered Part A and Part
B services, you will pay
nothing for your
covered Part A and Part
B services for the rest of
the calendar year.
BlueCare Plus Annual Notice of Changes for 2023 7
OMB Approval 0938-1051 (Expires: February 29, 2024) Section 1.3 – Changes to the Provider and Pharmacy Networks Updated directories are located on our website at bluecareplus.bcbst.com. You may also call Member Service for updated provider and/or pharmacy information or to ask us to mail you a directory.
There are changes to our network of providers for next year. Please review the 2023 Provider Directory to see if your providers (primary care provider, specialists, hospitals, etc.) are in our network.
There are changes to our network of pharmacies for next year. Please review the 2023 Pharmacy Directory to see which pharmacies are in our network. It is important that you know that we may make changes to the hospitals, doctors and specialists
(providers), and pharmacies that are a part of your plan during the year. If a mid-year change in our providers affects you, please contact Member Service so we may assist. Section 1.4 – Changes to Benefits and Costs for Medical Services Please note that the Annual Notice of Changes tells you about changes to your Medicare benefits and costs.
We are making changes to costs and benefits for certain medical services next year. The information below describes these changes.
Cost 2022 (this year) 2023(next year)
Chiropractic Services -
Routine Visits
Not Covered $0 copay
20 routine chiropractic visits
per year
Dental Services Preventive &
Comprehensive Dental
Services: $5,000 Allowance /
yearly
Preventive dental services:
$0 copay
•Routine oral exams, up to
two per year (one standard
exam per six-month period)
•Cleanings, up to two per year
(one cleaning per six-month
period)
•Dental X-rays (one set (up to
BlueCare Plus Annual Notice of Changes for 2023 8
OMB Approval 0938-1051 (Expires: February 29, 2024) Cost 2022 (this year) 2023(next year)
4) bitewing films per 12-
month period; one panoramic
or full mouth X-ray per 36-
month period)
Comprehensive dental
services: $3,800 combined
yearly allowance may be
used to pay for these
supplemental dental services:
• Fillings
• Extractions
• Dentures (removable
dentures; complete,
immediate and partial; limited
to one in any 60-month
period)
Note: Cosmetic procedures
are not covered.
This combined allowance is
added to your flex card.
Flex Card Not Covered $3,800 combined flex card
allowance
See the Benefits Chart in
Chapter 4 of the plan's
Evidence of Coverage for
more details.
This combined allowance is
loaded on an easy-to-use flex
card. The card comes prepaid
by the plan. And you can use
it to pay for dental, vision and
BlueCare Plus Annual Notice of Changes for 2023 9
OMB Approval 0938-1051 (Expires: February 29, 2024) Cost 2022 (this year) 2023(next year)
hearing services covered by
the plan.
Hearing Services $2,500 Allowance yearly $3,800 combined yearly allowance may be used to pay
for a routine hearing exam
and hearing aids.
Benefit is limited to one per
ear, per year (maximum of
two hearing aids per year) and
is limited to hearing aids
available in the applicable
TruHearing catalog. You
must see a TruHearing
provider to use this benefit.
This combined allowance is
added to your flex card.
Housing Utilities Not Covered $50 monthly allowance for housing utilities (including
water, gas, electric and
cable/internet)
Your housing and utilities
allowance is added to a
reloadable card you can use to
pay your bills.
Any unused amount does not
roll over.
This is part of a special
supplemental benefit and is
available only to members
who meet eligibility
requirements.
BlueCare Plus Annual Notice of Changes for 2023 10 OMB Approval 0938-1051 (Expires: February 29, 2024) Cost 2022 (this year) 2023(next year)
Over-the-counter (OTC)
/ Healthy Food
We provide a debit card
that gives you a fixed
dollar amount each month to
buy certain OTC products
and healthy food at
participating retail locations. You
can also get these items by mail,
phone, or web.
Over-the-counter (OTC):
This benefit helps you
get products you need to stay
well – things like bandages,
pain relievers, cold
remedies, toothpaste and much
more. You can pick generic
or brand-name items.
Healthy Food:
This benefit also covers
healthy food, like fruits and
vegetables. This is part of a
special supplemental benefit and
is available only to members who
meet eligibility requirements.
See the Benefits Chart in Chapter
4 of the Evidence of Coverage
(EOC) for more details.
$150 monthly benefit
allowance
This allowance doesn’t roll
over. Any remaining balance
will expire at the end of each
month.
$200 monthly benefit
allowance
This allowance doesn’t roll
over. Any remaining balance
will expire at the end of each
month.
Podiatry Services -
Routine Foot Care
Not Covered $0 copay
6 routine podiatry visits per
year
Vision Care Routine eye exam and
Glasses/Contacts:
Routine eye exam and
Glasses/Contacts:
BlueCare Plus Annual Notice of Changes for 2023 11 OMB Approval 0938-1051 (Expires: February 29, 2024) Cost 2022 (this year) 2023(next year)
$400 Allowance yearly
$3,800 combined yearly
allowance may be used to pay
for these covered
supplemental vision services:
• routine vision exams
• glasses (lens and/or
frames)
• contact lenses
This combined allowance is
added to your flex card.
Section 1.5 – Changes to Part D Prescription Drug Coverage Changes to Our Drug List
Our list of covered drugs is called a Formulary or “Drug List.” A copy of our Drug List is provided electronically.
We made changes to our Drug List, including changes to the drugs we cover and changes to the restrictions that apply to our coverage for certain drugs. Review the Drug List to make sure your drugs will be covered next year and to see if there will be any restrictions. Most of the changes in the Drug List are new for the beginning of each year. However, during the year, we might make other changes that are allowed by Medicare rules. For instance, we can immediately remove drugs considered unsafe by the FDA or withdrawn from the market by a product manufacturer. We update our online Drug List to provide the most up to date list of drugs.
If you are affected by a change in drug coverage at the beginning of the year or during the year, please review Chapter 9 of your Evidence of Coverage and talk to your doctor to find out your options, such as asking for a temporary supply, applying for an exception and/or working to find a new drug. You can also contact Member Service for more information. BlueCare Plus Annual Notice of Changes for 2023 12 OMB Approval 0938-1051 (Expires: February 29, 2024) Changes to Prescription Drug Costs
There are four “drug payment stages.”
The information below shows the changes to the first two stages – the Yearly Deductible Stage and the Initial Coverage Stage. (Most members do not reach the other two stages – the Coverage Gap Stage or the Catastrophic Coverage Stage.)
Changes to the Deductible Stage
Stage 2022 (this year) 2023 (next year)
Stage 1: Yearly Deductible
Stage
Because we have no
deductible, this payment stage
does not apply to you.
Because we have no
deductible, this payment
stage does not apply to you.
Changes to Your Cost Sharing in the Initial Coverage Stage Stage 2022 (this year) 2023 (next year)
Stage 2: Initial Coverage
Stage
During this stage, the plan
pays its share of the cost of
your drugs, and you pay
your share of the cost.
The costs in this row are for
a one-month (30-day) supply
when you fill your
prescription at a network
pharmacy that provides
standard cost sharing. For
information about the costs
for a long-term supply or for
mail-order prescriptions,
look in Chapter 6, Section 5
of your Evidence of
Coverage.
Your cost for a one-month
supply filled at a network
pharmacy with standard cost
sharing:
Generic Drugs:
You pay $0 to $3.95 per
prescription
Brand Drugs:
You pay $0 to $9.85 per
prescription
Once you have paid $7,050
out-of-pocket for Part D drugs,
you will move to the next stage
(the Catastrophic Coverage
Stage).
Your cost for a one-month
supply filled at a network
pharmacy with standard cost
sharing:
Generic Drugs:
You pay $0 per prescription
Brand Drugs:
You pay $0 per prescription
Once you have paid
$7,400 out-of-pocket for Part
D drugs, you will move to the
next stage (the Catastrophic
Coverage Stage).
BlueCare Plus Annual Notice of Changes for 2023 13 OMB Approval 0938-1051 (Expires: February 29, 2024) SECTION 2 Deciding Which Plan to Choose
Section 2.1 – If you want to stay in BlueCare Plus To stay in our plan, you don’t need to do anything. If you do not sign up for a different plan or change to Original Medicare by December 7, you will automatically be enrolled in our BlueCare Plus.
Section 2.2 – If you want to change plans
We hope to keep you as a member next year but if you want to change plans for 2023 follow these steps:
Step 1: Learn about and compare your choices
• You can join a different Medicare health plan,
• -- OR-- You can change to Original Medicare. If you change to Original Medicare, you will need to decide whether to join a Medicare drug plan. To learn more about Original Medicare and the different types of Medicare plans, use the Medicare Plan Finder (www.medicare.gov/plan-compare), read the Medicare & You 2023 handbook, call your State Health Insurance Assistance Program (see Section 4), or call Medicare
(see Section 6.2).
Step 2: Change your coverage
• To change to a different Medicare health plan, enroll in the new plan. You will automatically be disenrolled from BlueCare Plus.
• To change to Original Medicare with a prescription drug plan, enroll in the new drug plan. You will automatically be disenrolled from BlueCare Plus.
• To change to Original Medicare without a prescription drug plan, you must either: o Send us a written request to disenroll. Contact Member Service if you need more information on how to do so.
o – or – Contact Medicare, at 1-800-MEDICARE (1-800-***-****), 24 hours a day, 7 days a week, and ask to be disenrolled. TTY users should call 1-877-***-****. If you switch to Original Medicare and do not enroll in a separate Medicare prescription drug plan, Medicare may enroll you in a drug plan unless you have opted out of automatic enrollment.
BlueCare Plus Annual Notice of Changes for 2023 14 OMB Approval 0938-1051 (Expires: February 29, 2024) SECTION 3 Changing Plans
If you want to change to a different plan or to Original Medicare for next year, you can do it from October 15 until December 7. The change will take effect on January 1, 2023. Are there other times of the year to make a change? In certain situations, changes are also allowed at other times of the year. Examples include people with TennCare (Medicaid), those who get “Extra Help” paying for their drugs, those who have or are leaving employer coverage, and those who move out of the service area. If you enrolled in a Medicare Advantage plan for January 1, 2023, and don’t like your plan choice, you can switch to another Medicare health plan (either with or without Medicare prescription drug coverage) or switch to Original Medicare (either with or without Medicare prescription drug coverage) between January 1 and March 31, 2023. If you recently moved into, currently live in, or just moved out of an institution (like a skilled nursing facility or long-term care hospital), you can change your Medicare coverage at any time. You can change to any other Medicare health plan (either with or without Medicare prescription drug coverage) or switch to Original Medicare (either with or without a separate Medicare prescription drug plan) at any time.
SECTION 4 Programs That Offer Free Counseling about Medicare and TennCare (Medicaid)
The State Health Insurance Assistance Program (SHIP) is an independent government program with trained counselors in every state. In Tennessee, the SHIP is called the Tennessee State Health Insurance Assistance Program.
It is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. Tennessee State Health Insurance Assistance Program counselors can help you with your Medicare questions or problems. They can help you understand your Medicare plan choices and answer questions about switching plans. You can call Tennessee State Health Insurance Assistance Program at 1-877-***-**** (Toll-Free). You can learn more about Tennessee State Health Insurance Assistance Program by visiting their website (www.tn.gov/aging/our-programs/state-health-insurance-assistance-program--ship-
.html).
For questions about your TennCare (Medicaid) benefits, contact TennCare (Medicaid) at 1-800- 342-3145, Monday through Friday, 8 a.m. to 5 p.m. in all time zones. Offices are closed on state holidays. TTY users should call 1-877-***-****. Ask how joining another plan or returning to Original Medicare affects how you get your TennCare (Medicaid) coverage. BlueCare Plus Annual Notice of Changes for 2023 15 OMB Approval 0938-1051 (Expires: February 29, 2024) SECTION 5 Programs That Help Pay for Prescription Drugs You may qualify for help paying for prescription drugs.
• “Extra Help” from Medicare. Because you have TennCare (Medicaid), you are already enrolled in “Extra Help,” also called the Low Income Subsidy. “Extra Help” pays some of your prescription drug premiums, annual deductibles and coinsurance. Because you qualify, you do not have a coverage gap or late enrollment penalty. If you have questions about “Extra Help”, call:
o 1-800-MEDICARE (1-800-***-****). TTY users should call 1-877-***-****, 24 hours a day/7 days a week;
o The Social Security Office at 1-800-***-**** between 8 am and 7 pm, Monday through Friday for a representative. Automated messages are available 24 hours a day. TTY users should call, 1-800-***-****; or
o Your State TennCare (Medicaid) Office (applications).
• Prescription Cost sharing Assistance for Persons with HIV/AIDS. The AIDS Drug Assistance Program (ADAP) helps ensure that ADAP-eligible individuals living with HIV/AIDS have access to life-saving HIV medications. Individuals must meet certain criteria, including proof of State residence and HIV status, low income as defined by the State, and uninsured/under-insured status. Medicare Part D prescription drugs that are also covered by ADAP qualify for prescription cost sharing assistance through the Ryan White Program (Tennessee’s AIDS Drug Assistance program). For information on eligibility criteria, covered drugs, or how to enroll in the program, please call the Ryan White Program (Tennessee’s AIDS Drug Assistance program) at 1-615-***-****. SECTION 6 Questions?
Section 6.1 – Getting Help from BlueCare Plus
Questions? We’re here to help. Please call Member Service at 1-800-***-****. (TTY only, call 711.) We are available for phone calls from Oct. 1 to March 31, seven days a week from 8 a.m. to 9 p.m. ET. From April 1 to Sept. 30, you can call us Monday through Friday from 8 a.m. to 9 p.m. ET. Our automated phone system may answer your call outside these hours and during holidays. Calls to these numbers are free.
Read your 2023 Evidence of Coverage (it has details about next year's benefits and costs)
This Annual Notice of Changes gives you a summary of changes in your benefits and costs for 2023. For details, look in the 2023 Evidence of Coverage for BlueCare Plus. The Evidence of Coverage is the legal, detailed description of your plan benefits. It explains your rights and the BlueCare Plus Annual Notice of Changes for 2023 16 OMB Approval 0938-1051 (Expires: February 29, 2024) rules you need to follow to get covered services and prescription drugs. A copy of the Evidence of Coverage is located on our website at bluecareplus.bcbst.com. You may also call Member Service to ask us to mail you an Evidence of Coverage. Visit our Website
You can also visit our website at bluecareplus.bcbst.com. As a reminder, our website has the most up-to-date information about our provider network (Provider Directory) and our list of covered drugs (Formulary/Drug List).
Section 6.2 – Getting Help from Medicare
To get information directly from Medicare:
Call 1-800-MEDICARE (1-800-***-****)
You can call 1-800-MEDICARE (1-800-***-****), 24 hours a day, 7 days a week. TTY users should call 1-877-***-****.
Visit the Medicare Website
Visit the Medicare website (www.medicare.gov). It has information about cost, coverage, and quality Star Ratings to help you compare Medicare health plans in your area. To view the information about plans, go to www.medicare.gov/plan-compare. Read Medicare & You 2023
Read the Medicare & You 2023 handbook. Every fall, this booklet is mailed to people with Medicare. It has a summary of Medicare benefits, rights and protections, and answers to the most frequently asked questions about Medicare. If you don’t have a copy of this document, you can get it at the Medicare website (https://www.medicare.gov/Pubs/pdf/10050-medicare-and- you.pdf) or by calling 1-800-MEDICARE (1-800-***-****), 24 hours a day, 7 days a week. TTY users should call 1-877-***-****.
Section 6.3 – Getting Help from TennCare (Medicaid) To get information from TennCare (Medicaid), you can call TennCare (Medicaid) at 1-855-259- 0701. TTY users should call 1-877-***-****.
Contact this candidate