Medicare 2014 Summary of Changes

Date Issued: 2/28/2014

The following list summarizes changes to our EmblemHealth Medicare products, which became effective January 1, 2014:

  • A comprehensive dental benefit has been added to the VIP Essential (HMO) plan. The benefit is administered by Healthplex.
  • The VIP High Option plan was retired on December 31, 2013. Members enrolled in this plan have been transitioned to the EmblemHealth VIP Essential network. Practitioners who participate in both networks have maintained their members. Members whose PCP’s did not participate in VIP essential have been transitioned to new PCPs.
  • The PPO High Option plan was terminated in all service areas on December 31, 2013. This plan was consolidated with EmblemHealth PPO III on January 1, 2014. PPO III benefits will prevail.
  • Two new employer group Prescription Benefit Plans have been created: one PPO and one HMO. The plans are similar to the existing VIP Premier and Group Access Rx plans; however, the plans cover the members’ Part B premiums up to a pre-defined amount, ($104.90) for 2014.
  • Members are now responsible for cost-sharing in the EmblemHealth PPO-SNP plan. This cost-sharing affects most services after the plan payment.
  • The formulary was expanded from 4 tiers to 5 for the direct pay (individual) Medicare Advantage Prescription D (MAPD) plans. An additional generic drug tier with low cost sharing was added to the formulary to encourage drug adherence. Cost-sharing on the second generic tier was increased.
  • Cost-sharing of 20 percent now applies to renal dialysis services. Currently cost-sharing for renal dialysis is $0.
  • Coverage for diabetic supplies is limited to supplies provided by Abbott Diabetes Care.
  • The annual physical exam is covered as a preventive service, with $0 copay for all plans.
  • Supplemental (annual) Pap and pelvic exams are no longer covered for MAPD plans. Preventive Pap and pelvic exams are covered every 2 years with a $0 copay.
  • The Part B drug copay of 20 percent takes effect for outpatient claims.
  • Supplemental education including health education, enhanced disease management and a nurse hotline is covered for all HMO and PPO plans.
  • DME in-network coinsurance for PPO plans was reduced to 10 percent.