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Table of Contents

2021 Presbyterian Select Agent Presentation

2021 Enrollment Guide HMO

2021 Enrollment Guide PPO

2021 Enrollment Guide Employer Group Plan 4

2021 Enrollment Guide DSNP

Code of Conduct

Contact Us

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3

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Welcomes Brokers to the Annual

Medicare Product Specific Training

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2021 Presbyterian Medicare Select Agent Product Specific Training

● 2021 Benefit Plan Changes

HMO

PPO

Employer Group Plan 4

DSNP

● Presbyterian Senior Care HMO Enrollment Guide

● Integration Drives Better Health Outcomes

● Administrative Guidelines

● Code of Conduct

● Exam

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Today’s Presentation

2021 Benefit Plan Changes

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● Medicare Advantage HMOsince 1986

Service areas include ALL zipcodes in the following counties:

Still three plans

• Plan 1 – NO prescription drug coverage $0 monthly premium

• Plan 2 with prescription drug coverage $0 monthly premium

• Plan 3 with prescription drug coverage $120 monthly premium

Changes outlined in Enrollment Guide

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2021 Presbyterian Senior Care HMO Individual Plans

• Bernalillo• Cibola• Rio Arriba• Sandoval

• Santa Fe• Soccoro• Torrance• Valencia

https://www.aarp.org/health/conditions-treatments/info-2020/face-mask-myths.html

$0 copay video visits and online visits through Presbyterian

$0 copay for all hearing exams; both routine and Medicare-covered hearing conditions

$0 copay for outpatient mental health visits; including opioid visits

$0 copay for annual routine eye exam

$10 copay eye exams for diagnosis and treatment of diseases and condition of the eye

$0 copay for one diabetic retinopathy screening*

$0 for Tier 1 Preferred generic Rxs

$0 copay for test strips and lancets

$0 copay Basic dental included with buy-up Comprehensive option (details in Enrollment Guide)

2021 Presbyterian Senior Care HMO Individual PlansBenefit Enhancements

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* Part of CMS required screening

● Medicare Advantage PPO since 2005

Statewide

Effective 1/1/2018 only two plans

Plan 1 – MA only, NO Rx coverage $56 monthly premium

Plan 2 – with Rx coverage $188 monthly premium

● All changes outlined in Enrollment Guide

● Enhancements

$0 copay for all hearing exams: both routine and Medicare-covered

$0 copay for annual routine eye exam

$10 copay eye exams for diagnosis of diseases and conditions of the eye

$0 copay for test strips & lancets

$0 copay Basic Dental included with buy-up Comprehensive Option (details in Enrollment Guide)

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2021 Presbyterian MediCare PPO Individual Plans

Since . . . a long, long time ago

Statewide

Point of service (POS) allows members to choose to go in-network or out-of-network to any willing Medicare-approved provider

Medical benefits are stronger than individual plans

Offers unlimited prescription drug coverage

Minor changes outlined in Enrollment Guide

No change in premium: $315

2021 Presbyterian Senior Care HMO-POS Employer Group Plan 4

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$0 copay video visits and online visits through Presbyterian

$0 copay for all hearing exams; both routine and Medicare-covered hearing conditions

$0 copay for outpatient mental health visits; including opioid visits

$0 copay for annual eye exam

$10 copay eye exams for diagnosis and treatment of diseases and condition of the eye

$0 copay for one diabetic retinopathy screening*

$0 for Tier 1 Preferred generic Rxs

$0 copay for test strips and lancets

$0 copay Basic dental included with buy-up Comprehensive option (details in Enrollment Guide)

2021 Presbyterian Senior Care (HMO-POS)Employer Group Plan 4 – Benefit Enhancements

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* Part of CMS required screening

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Presbyterian Dual PlusNicole ChavezDirector DSNP Sales, Outreach & Retention

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2021 Expansion Counties-Plan 004

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Added 13 new counties for 2021:

• Catron• De Baca• Eddy• Guadalupe• Harding• Hidalgo• Lea• Lincoln• Los Alamos• McKinley• Mora• Taos• Union

MedicareSavingsProgram HSD Eligibility Categories

Full Benefit Dual Eligible (FBDE) ● 001 (SSI or Medicaid Extension/aged)● 003 (SSI or Medicaid Extension/blind)

● 004 (SSI or Medicaid Extension/disabled)

● 090 (AIDS)

● 091 (Disabled and Elderly/aged)

● 092 (Brain Injury)

● 093 (Disabled and Elderly/blind)

● 094 (Disabled and Elderly/disabled)

● 095 (Medically Fragile)

● 096(Developmentally Disabled)

Qualified Medicare Beneficiaries(QMB)

● 041● 044

Specified Low-Income MedicareBeneficiary (SLMB)

● 045

Qualified Individual (QI1) ● 042

2021 Eligibility Categories

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Presbyterian Dual Plus (HMO-D-SNP)

2021 Dual Plus-004 Benefit Enhancements

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Increased the OTC benefit from $255 to $275/quarterly

($1,100 annually) with rollover to end of year. Otcnetwork.com

$3,000 in dental coverage annually from $2000 dentaquest.com

50 one-way transportation trips annually from 36

Secure Transportation (no mileage limit)

2021 Dual Plus-004 Benefit Enhancements

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• $0 Annual Hearing Exam

• $0 diabetic supplies (test strips, lancets and meters).

• $275 Annual eyewear allowance through Versant Vision

• $2000 Hearing aid allowance every 2 years through Tru Hearing

• 12 Acupuncture visits

• 25 Chiropractic visits

• Silver sneakers Gym membership

• Post discharge meals

• Telehealth & Video visits

Extra benefit Highlights

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New Mexico

• All Presbyterian Hospitals and Medical Group clinics (www.phs.org/directory).

• Ben Archer Health Center

• Christus St. Vincent Hospital and Physician Group

• First Choice Community Healthcare

• Gila Regional Medical Center

• La Clinica De Familia

• La Familia Medical Center

• Lovelace Hospitals and Medical Group

• Memorial Medical Center

• MountainView Regional Medical Center

• Sierra Vista Hospital

• Mimbres Memorial Hospital

• Gerald Champion Regional Medical Center

• UNM Hospital and Medical Group

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DSNP Network Highlights

El Paso, Texas• Sierra Providence Health Network

(www.thehospitalsofprovidence.com/locations)• Hospitals of Providence in El Paso

– Sierra Medical Center– Sierra Providence East

New Product

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NON-COMMISSIONED PLAN

2021 Dual Plus-005 Benefit Highlights

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Benefits include:

• 20 meals post hospital discharge

• $275 per year eyewear benefit

• SilverSneakers health club membership

• One $0 routine eye exam per year

• One $0 routine hearing exam per year

• Acupuncture benefits

Central Region:

Mindy Romero : Bernalillo, Lincoln, Socorro, Torrance, Valencia

Email: [email protected]

Cell Phone:(505)288-4629

Danny Hernandez: Bernalillo (Westside & South Valley),Catron,

De Baca, Guadalupe, Lea, Sandoval, Santa Fe (excluding 9

pueblos), San Miguel


Cell Phone: (505)264-5087

Community Outreach Sales Team

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21

Northeast:

Colfax, Harding, Mora, Taos, Union & (9 Pueblos)

Kylea Tafoya


Cell Phone: (505)238-9056

Southern:

Dona Ana, Eddy, Grant, Hidalgo, Luna, Otero, Sierra

Jessica Rivera


Cell Phone: (575)528-8796

Northwestern Region CSR:Cibola, Los Alamos, McKinley, Rio ArribaTBD

Dual Plus Community Outreach Manager:TBA

Retention Specialist: TBD

DSNP Sales Coordinator:Esli OrnelasEmail: [email protected]: 505-923-8618


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DSNP Marketing Materials

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• Presbyterian Marketing material filed for agent advertising and mailers

• If you cover events:• Flyers• Brochures• Pull up banners• Tabletop banners• Sandwich boards• Window decals• Polo shirts• Tablecloths• Giveaways

(Request through your CSR for a supply)

Questions?

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Email: [email protected]: 505-923-5455

Cell: 505-235-7836

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Integration Drives Better Health Outcomes

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First, a quick look at our response to COVID-19 . . .

23,895 COVID-19 tests at Balloon Fiesta Park; 10,768 by mobile testing

team; 1,860 at Coors PRESNow site

Completed ~ 28,000 outbound calls to high-risk members in first six (6)

weeks

831,280 calls answered by Presbyterian Customer Service Center during

March, April, and May

Supplied ~7,000 gallons of hand sanitizer supplied by PHP to Native

American facilities and providers across New Mexico

4,780 free meals provided each week for frontline Central Delivery System

hospital staff by Cooper Center cafeteria

8 mini grocery stores set up for hospital staff created by Food Services

200 members in need supplied with food each week by the Food Farmacy

15,000 free meals provided to children in seven communities across the

state

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. . . response to COVID (cont.)

Developing a statewide home monitoring program for members who have

tested positive for COVID-19 but do not require hospitalization

Actively promoting pharmacy home delivery and mail order

Actively promoting telephonic and telehealth options for providers

Offering video visits at no co-pay for all members

75% of all provider visits done virtually

Developed Regional Resource Guide to community services in collaboration

with multiple state agencies

Lincoln County Medical Center opened a new hospital

Presbyterian Española Hospital achieved top 10% nationally for patient

experience

Santa Fe Medical Center and Socorro General Hospital achieved top 25 %

nationally for patient experience

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Integration Drives Better Health Outcomes

Not-for-profit system

9 hospitals and 100+ clinics

Commercial, Medicare, and

Medicaid

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Get Care When and How You Want It

Online Visits

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The Health Plan That’s Available 24/7

No Cost Access for Most Members

• 24/7 PresRN Nurse Advice Line

• 24/7 Video Visits

• 24/7 MyChart

• 24/7 Online Visits with PMG providers

Here When You Need Us, at Your Conveniencehttps:\\pres.today

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NM First Urgent / Emergency Care Hybrids

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Ambulatory

Surgical Centers

Membersatisfaction

Effectiveoutcomes

Cost

Ambulatory Surgical Centers

Lower Cost Setting: 30-50% Reduction

Increased Member Satisfaction

Effective Services

3 Locations Albuquerque Metro Area

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Hospital Observation

Units

Hospital Observation Units

Not everyone who needs overnight care

needs an admission

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Complete CareClinic

The Complete Care Clinic

Personalized Care for Patients With Complex Needs

Provided by PMG Specialists and Care Team

Available only to PHP Members

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Para-medicine

Presbyterian Senior Care (HMO) Enrollment Guide

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Presbyterian Administrative Guidelines• Telephonic Enrollments

• Broker Enrollment Tool

• Employer Group Plans

• Commissions

• Select Agent Responsibilities

● Presbyterian requirements for telephonic enrollments:

All phone enrollments must be recorded and sent digitally to

Presbyterian once the enrollment is completed: Send the digital

file by SECURE email to us at [email protected] in this

format: Broker NPN #_Prospect Last Name, First Name_Date of

Enrollment Example: 34567_ DoeJohn_05272020

If you do not have SECURE email, you can request a SECURE

email be sent to you from [email protected]

Only perform telephonic enrollments through an incoming call

• Few exceptions are outlined in CMS Marketing Guidelines (next page)

If a digital recording is not received, commission could be delayed

or even forfeited.

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Telephonic Enrollments

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Exceptions include:

Approved Scripts – Click on the links below to use approved

scripts provided by Presbyterian (Agent must clearly inform the

beneficiary that the call has moved from a sales presentation to

telephonic enrollment. Agent must do this only with the full and

active concurrence of the beneficiary, ideally by having the

beneficiary answer a yes/no question.)• D-SNP Script

• PSC HMO Script

• PMPPO Script

Audits – Random audits of telephonic enrollments will be

conducted to ensure compliance.

Scope of Appointments – Ensure that all SOAs are completed

and saved for each enrollment.

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Telephonic Enrollments (cont.)

Medicare Online Broker Tool

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Sign InMedicare Online Enrollment Tool

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DashboardMedicare Online Enrollment Tool

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Click onView Dashboard

Search ProfilesMedicare Online Enrollment Tool

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Click onSearch Profiles

View Profiles and StatusMedicare Online Enrollment Tool

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Start Consultation Medicare Online Enrollment Tool

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Click onStart Consultation

Create a New Profile Medicare Online Enrollment Tool

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1. Complete all of the required fields on the “Create a new

profile” page and click “Continue”

2. Continue through the SOA, Health, Subsidy, Drugs and

Pharmacy Tabs.

Send or Upload Scope of AppointmentMedicare Online Enrollment Tool

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Click on SOA

Add Health Information (optional)Medicare Online Enrollment Tool

50

Click on HEALTH

Add Subsidy InformationMedicare Online Enrollment Tool

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Click on SUBSIDY

Add DrugsMedicare Online Enrollment Tool

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Click on DRUGS

Add a PharmacyMedicare Online Enrollment Tool

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Click on PHARMACY

Send a QuoteMedicare Online Enrollment Tool

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Click on SEND QUOTE

Send Choose “Enrollment Form Only”

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Click onEnrollment form only

Beneficiary Receives Two (2) EmailsMedicare Online Enrollment Tool

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1 of 2 emails

2 of 2 emails

Beneficiary Enters Code Medicare Online Enrollment Tool

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Enter Authorization Code

Plan Is Automatically in CartMedicare Online Enrollment Tool

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Click on Enroll

Enrollment Form Medicare Online Enrollment Tool

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Plan ComparisonMedicare Online Enrollment Tool

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Plan DetailsMedicare Online Enrollment Tool

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See Monthly Cost Estimate

Contact Information Medicare Online Enrollment Tool

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1. Form is prepopulated with the information you—the

agent—entered in the profile.

2. Beneficiary proceeds through the enrollment form and submits the enrollment.

3. You are the agent of record

New for AEP 2021More information to come

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• Text to EnrollOffering Agents the Greatest Flexibility in Telework, Customer Engagementand Increasing Medicare Enrollments

• Text to Sign a Scope of AppointmentEngage seniors by offering the flexibility of completing a SOA on their phone

● Enrollment kit must be provided

● Prefer that all enrollments go through the Broker Tool

● Scope of Appointment (SOA) must be submitted with every enrollment

● If you are using paper enrollment form

Deliver, SECURE email, or fax applications within 24 hours

• You can email [email protected] and request a SECURE email to send us back the enrollment

DO NOT MAIL ENROLLMENTS – Our admin offices are closed to any walk-ins. If you cannot fax it or send via SECURE email, please contact Rosanne Tena ([email protected] ) to make alternate arrangements.

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Individual Enrollment Process

● Enrollments effective 1st of the month following the date the healthplan received enrollment form

● Exceptions

● Employer group

Age-ins

Open enrollment period

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Important Enrollment Information

● Enrollment form completed,signed, and dated

Presbyterian Customer Service Centerwill help the new member select a PCP

Office Use Only

● Scope of Appointment Confirmation Form required with each Enrollment received

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Important Enrollment InformationWe make

finding a PCP easy!

● Large group vs. small group

Based on ERISA guidelines

● Under 20 employees

Employer can offer alternatecoverage

Employees eligible for Medicare

Retirees eligible for Medicare

67

Employer Group Rules

● 20 or more employees

Employer cannot offer differentcoverage

Retiree coverage only

● 19 or less employees

Can be for employees andretirees

Employer can require all Medicare eligible to enroll

Premium contribution should be the same proportion as other non-Medicare employees

Employers can include Part B premium when calculating contribution

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Employer Group Rules

● Sponsored-only groups

Employer must administerthe plan

Employer must pay thepremium by way of group invoice

● At least two (2) enrolled

Can be employee/retiree & spouse

● Presbyterian Medicare plans can stand alone

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Employer Group Requirements

● Presbyterian Senior Care (HMO-POS)

Plan 4 premium change to $315 PMPM

Still no Coverage Gap

All benefit changes identified in Enrollment Guide

● Contact Rosanne Tena

Meet with group

Set up best enrollment process

Paperwork due in by 20th of the month

These enrollments are the only enrollments that cannot go through the Broker Tool.

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2021 Employer Group Changes

● What will they lose if they terminate with employer

Never allowed to go back in

Other benefits, e.g., dental, life insurance

● Full or partial premium payment

● Unlimited Rx drug benefit

● Should recommend they check with benefits administrator before they change plans

● May still be able to use employer coverage along with Medicare plan

● Non-creditable plans

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Advising Employer Group Retirees

● Initial year compensation amount for enrollments

effective for 2021 will be $539 equivalent to

maximum CMS fair market value (FMV).

● Initial year compensation will be paid in full and

not pro-rated. This initial year cycle will only be

paid for enrollments that CMS has identified as

initial year.

● When member disenrolls during the initial compensation year we will recoup

the compensation paid to the Select Agent for the total number of months

that the member was not on the plan.

● Exceptions outlined by CMS, such as:

Death Moves out of service area Enrolls Oct 1, Nov 1, or Dec 1 and subsequently uses the AEP to make a change

for Jan 1 Other exceptions outlined by CMS

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Commission Change: Initial Year Compensation

● Renewal year compensation amount for

enrollments effective for 2021 will be based

on $22.50 per member per month

Renewal compensation will be advanced for the months

remaining in the year for new enrollments with Presbyterian.

When a member disenrolls prior to the end of the year

compensation year PHP or PIC will recoup the compensation

paid to the Select Agent for the total number of months the member was not on

the plan.

Renewal commission will increase as CMS increases the FMV each year.

● Renewal year’s compensation begins January 1, or the month in which the

member’s enrollment becomes effective, whichever comes first.

● Renewal compensation will be paid as long as the member remains on PHP

or PIC

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Commission Change: Renewal Year Compensation

● All Medicare training must be obtained from AHIP or Gorman Health

Must email certifications to [email protected] to any marketing and sales activities

● Must attend and pass Presbyterian's Select Agent product specific training

● Refer to the updated Exhibit B of your Presbyterian Producer Agreement

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2021 Presbyterian MA Select Agent Requirements

● Since 2015

● Broker must be licensed and appointed with PHP

● Referral Form must be completed and received by PHP prior to beneficiary enrolling

● Referral must be a NEW referral that PHP is not actively working

● Referral must enroll as a new Medicare Advantage member

● Referral fees are not paid for members switching from one Presbyterian plan to another

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Medicare Referral Program

● A $100 referral/finder fee will be paid for each confirmed referral

● The Centers for Medicare and Medicaid Services (CMS) Compensation Recovery Requirements will apply when beneficiary disenrolls within the first three months of membership

● Brokers are NOT required to take & pass Medicare or Select Agent training

● Referral program cannot be combined with commissions

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Medicare Referral Program

PresbyterianCode of Conduct

2020

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Click to Start Code of Conduct

Training

● Never Assume

They understand what you know . . .

You know what they want or “need” . . .

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Select Agent Requirements

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QUESTIONS?

Thank you!

MEDICARE ADVANTAGE PLANS

Y0055_MPC072020_Accepted_M_07282020

Thank you for your interest in Presbyterian Medicare Advantage Plans. Presbyterian offers you the value that comes with our integrated system of physicians, hospitals and health plan – all working together to keep you healthy and provide new and innovative services.

Plan Highlights• More benefits than Original Medicare (Part A and Part B)

• Preventive dental benefit

• No prescription drug deductible

• Coverage for emergency and urgent care anywhere in the world

• Routine acupuncture and chiropractic care

• Gym memberships included through SilverSneakers®

• A convenient and secure website to manage your plan online through myPRES

2021 ENROLLMENT GUIDE

Presbyterian Senior Care (HMO)

2

ABOUT US . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Who We Are . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Our Integrated System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Easy Ways to Access Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Managing the Health of Our Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

MEDICARE BASICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

SUMMARY OF BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

PRESCRIPTION DRUG FORMULARY . . . . . . . . . . . . . . . . . . . . . . . . . . 19

PROVIDERS AND PHARMACIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

GET ENROLLED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

When You Can Enroll . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

How to Enroll . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Individual Enrollment Request Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Sales Appointment Confirmation Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Presbyterian Enrollment Receipt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Pre-Enrollment Checklist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

What to Expect After Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

TABLE OF CONTENTS

Presbyterian complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (505) 923-5420, 1-855-592-7737 (TTY: 711).

D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih (505) 923-5420, 1-855-592-7737 (TTY: 711).

3

• Founded in New Mexico in 1908, Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system of nine hospitals, a medical group, and a health plan.

• Presbyterian’s health system serves one in three New Mexico residents in our clinics, hospitals and as members of our health plan.

• Owned by Presbyterian Healthcare Services, Presbyterian Health Plan, Inc. was formed in 1985 and now has more than 600,000 enrolled in Medicare Advantage, Medicaid, and Commercial/Individual plans.

Presbyterian by the Numbers

More than 13,000

employees – New Mexico’s largest private

employer

600,000 Presbyterian Health Plan members, which includes nearly 42,000 Medicare Advantage members

Nearly 900,000 individual customers (and counting)

112 years of serving

New Mexicans

9 hospitals in 7 communities

Who We Are

ABOUT US

More than 1,100 providers in

Presbyterian Medical Group

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Our Integrated System

As part of an integrated healthcare system, Presbyterian offers patients throughout New Mexico access to dedicated primary care providers, as well as highly specialized care, including cancer care, heart and vascular care, and behavioral health

ABOUT US

PRESBYTERIA

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PR

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TERIAN HEALTH PLAN

PRE

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LIVE

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Residents in Albuquerque and Santa Fe don’t have to guess if a condition is an emergency because medical staff decide the level of care needed. Both urgent and emergency care are open 24 hours a day at two PRESNow locations in Albuquerque’s Northeast Heights and the Westside. In Santa Fe, the Presbyterian Santa Fe Medical Center at 4801 Beckner Rd. on Santa Fe’s south side now offers both options all day, every day.

24/7 Urgent and Emergency Care Under One Roof in Albuquerque and Santa Fe

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PresRN is a great starting point, giving you direct access to medical advice 24 hours a day, 7 days a week, including holidays. There is no charge to call our experienced registered nurses (RNs) for answers to your health or wellness questions. Call (505) 923-5573 or 1-800-887-9917.

MyChart is a secure, web-based portal allowing members with a Presbyterian Medical Group provider to send electronic messages to their care team, request prescription renewals, view medical records or test reports, and schedule office or telephone visits.

Video Visits offer a no-cost, convenient option to see a medical provider anytime – day or night – for non-emergency medical conditions via secure video through a smartphone, tablet or computer webcam. Online Visits are also available for patients who have visited a Presbyterian facility. Visit www .phs .org and select “Get Care Today .”

Primary care physicians can treat most health problems. They may be a general/family practice physician, internal medicine physician, gynecologist, physician assistant, or nurse practitioner.

Urgent care clinics provide care for minor illness and injuries that are not an emergency. For added convenience, Presbyterian now offers same-day, scheduled appointments.

Emergency rooms are for serious medical emergencies or injuries that require immediate medical attention.

Easy Ways to Access Care

ABOUT US

6

• Healthy Solutions Program – A Health Coach provides education and telephonic or video lifestyle coaching to assist you in managing your chronic condition for asthma, coronary artery disease, diabetes or hypertension.

• Case management – Nurses and social workers help you manage your complex medical needs and will help link you with appropriate providers that will work to keep you out of the hospital or emergency room.

• Utilization management reviews – Pre-service, urgent concurrent, and post-service reviews ensure you are receiving the most appropriate covered treatments and services for you.

• Complete Care Clinic – This program provides comprehensive primary care services for adults with chronic or complex illnesses and helps these patients access care and navigate the medical system. The clinic works closely with other programs such as Presbyterian Home Care, Hospital at Home, and Palliative Care.

• National Diabetes Prevention Program – This is a year-long program for eligible members that encourages lifestyle changes to prevent or delay Type 2 diabetes.

Managing the Health of Our Members

ABOUT US

7

Medicare is a federal health insurance program administered by the Centers for Medicare & Medicaid Services (CMS) that provides hospital and medical coverage. There are several parts to Medicare coverage, each with different benefits and costs.

Parts of Medicare

Part A Covers hospitalization, such as inpatient care, hospice care, and some home healthcare, skilled nursing home care and nursing home care. Most people do not have to pay premiums for Part A.

Part BCovers medical services such as doctor’s visits (including most doctor services while you’re in the hospital) and outpatient treatments, as well as medical services and supplies not covered under Part A. Most people pay premiums for Part B.

Part CCommonly called Medicare Advantage, these plans combine Part A and Part B. Part D may also be included as well as other benefits.

Part DPart D covers prescription drug costs and is available to individuals who have Part A, B or C. Joining a health plan that includes Part D prescription drug coverage is voluntary.

MEDICARE BASICS

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Late Enrollment Penalties

• Part B – You may have to pay a late enrollment penalty for Part B if you do not enroll when you first become eligible and then enroll later.

• Part D – You may have to pay a late enrollment penalty if you had any period of 63 days or more without drug coverage that is as good as or better than Part D coverage. The penalty amount would be added to your Medicare Advantage plan premium for as long as you have Part D.

Income Related Monthly Adjusted Amounts (IRMAA)

• In 2020, your Part B and Part D premium may be higher if your income is above $87,000 a year as an individual. You will be notified if these amounts change in 2021.

Automatic Disenrollment

• Medicare beneficiaries cannot be enrolled in a Medicare Advantage plan and a stand-alone Medicare Part D prescription drug plan with another company at the same time. For example, if you enroll in a separate Part D plan, you will automatically be disenrolled from your Medicare Advantage plan.

What You Should Know

MEDICARE BASICS

9Y0055_MPC072033_Accepted_M_08212020

This is a summary of health and drug services covered by Presbyterian Senior Care (HMO) January 1, 2021 to December 31, 2021.

To enroll in Presbyterian Senior Care (HMO):

• You must be entitled to Medicare Part A and enrolled in Medicare Part B.

• You must live in one of these New Mexico counties: Bernalillo, Cibola, Rio Arriba, Sandoval, Santa Fe, Socorro, Torrance or Valencia.

Presbyterian Senior Care (HMO) has a network of doctors, hospitals, pharmacies, and other providers. If you use providers that are not in our network, the plan may not pay for these services.

$0 copay for these valuable benefits and more!

• Basic dental services

• Hearing exam

• Video and online visits

• Preferred generic drugs

• PresRN nurse advice line

• Lab services

• Diagnostic tests

• Foot care

• Diabetic test strips and lancets

• Outpatient mental health visits

2021 SUMMARY OF BENEFITSPresbyterian Senior Care (HMO) Plan 1, Plan 2 with Rx, Plan 3 with Rx


10

Plan 2 with RxYou pay


Plan 1You pay

Monthly Plan Premium (You must also continue to pay your Medicare Part B premium.)

$0 $120 $0

Includes prescription drug coverage

Does not include

prescription drug coverage

Deductible $0 $0 $0

Maximum Annual Out-of-Pocket Responsibility (This is the most you pay in a calendar year for covered medical and hospital services. It does not include prescription drugs.)

$4,500 $3,000 $4,000

Inpatient Hospital Care* (per admission)• Days 1 – 5• Additional Days

$325 per day$0

$225 per day$0

$325 per day$0

Ambulatory Surgery Center / Outpatient Surgery*

$325 $225 $325

Doctor Visits (no referral required)• Primary Care• Specialists• Video Visits

$5$50$0

$5$40$0

$5$50$0

Preventive Care $0 $0 $0

Emergency Care (worldwide)(This copay is waived if admitted to the hospital.)

$90 $90 $90

Urgently Needed Services• In-network• Out-of-network• Outside of United States

$15$65$90

$10$65$90

$15$65$90


* Prior authorization required.

SUMMARY OF BENEFITS

11



Plan 1You pay

Diagnostic Services/ Labs/Imaging• Lab services• Diagnostic tests and procedures• Outpatient x-rays• Diagnostic radiology service* (such as CT, MRA, MRI, PET scans)

$0$0$20$300

$0$0$20$250

$0$0$20$300

Hearing Services (does not go toward maximum out-of-pocket responsibility)• Hearing exam• Hearing aid (from TruHearing)

$0$699 - $999

$0$699 - $999

$0$699 - $999

Dental Services• Medicare covered dental• Basic dental services

$50$0

$40$0

$50$0

Vision Services

• Annual routine exam $0 $0 $0

• Diagnosis/treatment of diseases and conditions of eye

$10 $10 $10

• Annual diabetic retinopathy screening

$0 $0 $0

• Eyeglasses or contact lenses after cataract surgery

20% 20% 20%

Mental Health Services• Inpatient visit (Days 1 - 5)* – Additional days• Outpatient group therapy visit• Outpatient individual therapy visit

$325 per day$0$0$0

$225 per day$0$0$0

$325 per day$0$0$0

Skilled Nursing Facility (SNF)*• Days 1 - 20

(Our plan covers up to 100 days in a SNF.)

$0 per day$95 per day

for days 21-65$0 for days

66-100



61-100



66-100



SUMMARY OF BENEFITS

12



Plan 1You pay

Rehabilitation Services• Cardiac and Pulmonary rehab (limited to 36 visits/year)• Occupational, Physical, and Speech and Language therapy visits

$0

$20

$0

$20

$0

$20

Ambulance (ground and air) $250 $250 $250

Routine Transportation Not covered Not covered Not covered

Medicare Part B Drugs* • Chemotherapy Drugs and other drugs administered by a medical professional• Purchased at a retail pharmacy

20%

$10

20%

$10

20%

$10

Foot Care (podiatry services)• Foot exams and treatment (Medicare covered)

$0 $0 $0

Medical Equipment/Supplies*• Durable Medical Equipment (e.g., wheelchairs, oxygen, continuous glucose monitors/supplies)• Prosthetics (e.g., braces, artificial limbs)

20%

20%

20%

20%

20%

20%

Wellness Programs (e.g., fitness)

$0SilverSneakers® Fitness Program is included.

For participating locations visit www.silversneakers.com

Acupuncture • Medicare covered• Routine (limited to 25 visits/year)

$20$20

$20$20

$20$20

Chiropractic • To correct subluxation• Routine (limited to 25 visits/year)

$20$20

$20$20

$20$20

Home Health Care* $0 $0 $0

Kidney Dialysis 20% 20% 20%



SUMMARY OF BENEFITS

13

Prescription drug coverage is a part of Plan 2 and Plan 3. • The drug coverage is identical except in the Coverage Gap. • There is no deductible for all Tiers.

Coverage Starts Initial coverage

limit $4,130; includes what both you and

your plan pay

Coverage Gap

Catastrophic Coverage

Part D Covered Drugs

30-day supply

90-day mail order(preferred)

Plan 2 Plan 3 Plan 2 and Plan 3

Tier 1: Preferred Generic

$0 $0

25% generic

and brand

applies to all tiers

Drugs noted with "GC" are

$0 for Tier 1 and

$10 for Tier 2

$3.70 or 5% for generics

(whichever is greater)

You stay in this stage

for the rest of

the year.

Tier 2: Non- Preferred Generic

$10 $20

Tier 3: Preferred Brand

$45 $112.5025%

generic and

brand $9.20 or 5% for

brand names


Tier 4: Non- Preferred Brand

$95 $285

Tier 5: Specialty Drugs

33% NA

Catastrophic coverage begins after your out-of-pocket costs = $6,550


SUMMARY OF BENEFITS

14

FIND OUT IF YOU QUALIFY FOR ASSISTANCEPresbyterian offers a personal service that helps you find out if you qualify for these money-saving programs. A trusted partner since 2006, My Advocate™, helps you apply for Extra Help / Low-Income Subsidy and Medicare Savings Programs.

Call My Advocate™ at 1-866-851-0324.

You also have the option to contact:• 1-800-Medicare (1-800-633-4227), 24 hours a day, seven days a week

(TTY 1-877-486-2048)• Social Security, 1-800-772-1213 (TTY 1-800-325-0778)• NM State Human Services Department, 1-888-997-2583 (TTY 1-855-227-5485)

Premium - Your premium for Plan 3 will be reduced based on the LIS level you qualify for. The premium you will pay for Plan 3 if you qualify for the 100% LIS level is $91.80.

Prescription drugs - If you qualify for Low-Income Subsidy (LIS), your prescription drug coverage gap (also known as the donut hole) in your drug coverage is eliminated. You also pay reduced copays for your Part D drugs.

LIS qualifying income levels for 20201 – To qualify, your annual income and resources / assets need to be at or below the following:Single Married

Annual Income1: $19,140 Annual Income1: $25,860

Resources / Assets2: $13,110 Resources / Assets2: $26,1601 Income limits may change in 2021.2 The house you live in, the car you drive, life insurance policies, and burial plots do not count toward the resource / asset limit. Contact Social Security for other income / resource exclusions.

Medicaid and Other Medicare Savings Programs (MSP)

Those who qualify for Extra Help may also qualify for Medicare Savings Programs that help pay Part A and/or Part B premiums. Medicaid programs may also lower your copays, depending on the level for which you qualify.

Extra Help / Low-Income Subsidy (LIS)

SUMMARY OF BENEFITS

15

SUMMARY OF BENEFITS

Your Presbyterian Medicare Advantage Plan now includes dental coverage options, each with a robust network of more than 2,200 in-network dental providers throughout New Mexico. Visit www.dentaquest.com/find-a-dentist-gov for a list of providers.

Basic Services Included

Basic dental coverage is included in your Medicare Advantage medical plan and covers all preventive dental services at 100% for in-network services.

• Oral exams (two every 12 months)

• Cleanings (two every 12 months)

• Dental x-rays (frequency varies by type)

• Fluoride treatments (two every 12 months)

• Periodontal maintenance (four every 12 months)

• Emergency treatment of minor pain

Comprehensive Plan Optional

Comprehensive dental coverage is available for an additional monthly premium of $19 per member. Services must be obtained through an in-network provider.

• Members pay 20% for fillings, extractions, and denture adjustments/repairs

• Members pay 50% coverage for major restoratives (for example, crowns, bridges, root canals, dentures, periodontics, implants, anesthesia)

• Maximum $3,000 calendar year benefit

• No deductible or waiting period

This summary provides only a brief description of your dental benefits. Please refer to your Evidence of Coverage for complete details including limitations and exclusions.

Dental Coverage Worth Smiling About

16

Enjoy Better Hearing and Comprehensive Care

Good hearing is important to your overall health. That’s why we cover a routine annual hearing exam for no copay.

2021 Hearing Aid Coverage

Your plan covers up to two hearing aids per year (one per ear per year).

TruHearing Advanced TruHearing Premium Routine Exam

32 Channels | 6 Programs 48 Channels | 6 Programs TruHearing Network Provider

$699 copay/aid $999 copay/aid $0 exam copay

Your Comprehensive Hearing Benefit Includes:

State-of-the-Art Technology• Enjoy natural, lifelike sound in virtually all

listening situations.• Hear speech clearly, even in noisy

environments.• Stream audio and phone calls directly to your

ears from most smartphones.

Personalized Care• Guidance and assistance from a TruHearing consultant.• Local, professional care from an accredited provider in your area.• A hearing exam plus three follow-up visits for fitting and adjustments.

Help Along Your Way• A worry-free purchase with a 45-day trial and three-year warranty.• 48 free batteries per aid included with non-rechargeable models.• Guides to help you adapt to your new hearing aids at TruHearing.com/GetStarted.

Call TruHearing to learn more and schedule an appointment.

1-866-202-0110 | TTY 711 | 8 a.m. - 8 p.m., Monday - Friday

SUMMARY OF BENEFITS

17

Improve Your Fitness with Free SilverSneakers® Memberships

The SilverSneakers Fitness program is included at no additional cost to you. Visit more than 15,000 participating nationwide locations, including Planet Fitness, Anytime Fitness, Defined Fitness, Chuze Fitness, YMCA, and more.

• Enroll at multiple locations at any time.

• Reach and maintain a healthy body weight.

• Take fitness classes at convenient venues.

• Expand your circle of friends and enjoy social activities.

For participating locations visit www.silversneakers.com.

Travel Worldwide and Be Protected with Assist America®

Enjoy the protection of Assist America’s global emergency travel assistance services 24 hours a day, 365 days a year, for up to 90 days. This unique program immediately connects you to doctors, hospitals, pharmacies and other services when experiencing a medical emergency while traveling 100 miles or more away from your permanent residence or in another country.

Services include:

• Emergency medical evacuation and repatriation

• Prescription assistance

• Medical monitoring

• Interpreter and legal referrals

• Return of mortal remains

• Free mobile app and much more

For benefit details, visit www.assistamerica.com or call 1-800-872-1414.

More Plan Advantages for Presbyterian Members

SUMMARY OF BENEFITS

18

For more information about Presbyterian Medicare Advantage plans, please call us at the phone numbers below or visit us at www.phs.org/medicare.

Presbyterian Medicare Sales Consultants(505) 923-8458 or 1-800-347-4766 (TTY 711)

Hours: 8 a.m. to 8 p.m., 7 days a week (except holidays) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

Presbyterian Customer Service Center (for members)(505) 923-6060 or 1-800-797-5343 (TTY 711)

Hours: 8 a.m. to 8 p.m., 7 days a week from October 1 through March 31 and Monday to Friday (except holidays) from April 1 through September 30.

You can see our plan’s provider and pharmacy directory if you visit our website at www.phs.org/medicare and select Providers at the top of the page.

For coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week. TTY users should call 1-877-486-2048.

To learn how we safeguard your Protected Health Information and your rights, call us at (505) 923-6060 or 1-800-797-5343 (TTY 711) or visit www.phs.org/medicare and select Privacy Notice at the bottom of the page.

Out-of-network/non-contracted providers are under no obligation to treat Presbyterian Senior Care (HMO) members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

To get a complete list of services we cover, contact the plan or please refer to the Evidence of Coverage. You may easily download a copy of the Evidence of Coverage from our website, www.phs.org/medicare, and select For Members at the top of the page. You may also request a copy by calling customer service.

Presbyterian Senior Care (HMO) is a Medicare Advantage plan with a Medicare contract. Enrollment in the plan depends on contract renewal.

This information is not a complete description of benefits. Contact the plan for more information.

SUMMARY OF BENEFITS

19

A formulary is a list of drugs selected by Presbyterian Health Plan, Inc. which represents the prescription therapies believed to be a necessary part of a quality treatment program.

Drugs listed on the formulary are generally covered as long as the drug is medically necessary.

What if your drug is not on our formulary? • Call us and ask for a list of similar drugs that are covered. • You can ask us to make an exception to cover your drug. Generally, we will approve

your request for an exception as a Tier 5 drug if drugs on our formulary are not as effective at treating your condition.

Quantity limitations and restrictions may apply and are noted in the formulary with the following abbreviations:

PA = Prior AuthorizationQL = Quantity LimitsST = Step Therapy

For more information or to download the formulary drug list, visit www .phs .org/medicare and click Prescription Drugs.

GC = Gap CoverageLA = Limited AccessNDS = Non-Extended Day Supply

PRESCRIPTION DRUG FORMULARY

20

The enclosed list is an index by practitioner name, provider group name and pharmacy name in alphabetical order as of July 2020.

This listing is subject to change. Some providers and pharmacies may have been added or removed from our network after this listing was printed. We do not guarantee that each provider is accepting new patients.

Here are other ways to find your doctor .

• Call us – If you would like a copy of the full printed directory mailed to you, or need help finding your doctor, please call (505) 923-6060 or 1-800-797-5343 (TTY 711).

• Online – View our online directory at www .phs .org/medicare and select the Providers tab. Since our network providers can change daily, our online listing can help you find the most current information.

PROVIDERS AND PHARMACIES

21

New to Medicare

If you enroll… Your coverage begins…

1-3 months before your Part A and Part B effective date

The first day of the month of your Part A and Part B effective date

The month of your Part A and Part B effective date

The first day of the following month

1-3 months after your Part A and Part B effective date

The first day of the following month

Annual Enrollment PeriodOccurs every year, October 15 through December 7. Changes made during this time are effective January 1.

Medicare Advantage Open Enrollment Period (MA OEP)Occurs January 1 through March 31. This is your opportunity to change your Medicare Advantage plan. Individuals enrolled in Medicare Advantage plans can switch to:• Medicare Advantage with Part D• Medicare Advantage without Part D• Original Medicare (with or without a stand-alone Part D plan).

The effective date is the first of the following month following receipt of the enrollment request.

Special Election Period (Special Exceptions)• If you have Medicaid or Low Income Subsidy (LIS) you can enroll in, or disenroll from,

a Medicare Advantage plan once per calendar quarter during the first nine months of the year. It may not be used in the 4th quarter of the year (October-December).

• If you gain, lose, or have a change in your Medicaid or LIS-eligible status, you can enroll within three months of the change or notification of such a change, whichever is later.

• If you are moving into the service area, you can enroll during the month prior to your move, the month you move, and up to 2 months after you move.

• If you are leaving employer or union coverage, you can enroll up to 2 months after you lose coverage.

• If you involuntarily lost creditable drug coverage, you can enroll up to 2 months after you lose coverage.

• Other exceptions may apply.

GET ENROLLEDWhen You Can Enroll

22

Enroll online at www .phs .org/medicare

OR . . .

Complete the enclosed Individual Enrollment Request Form• Check which plan you want to enroll in.• If you and your spouse are enrolling, you’ll each need to complete

an enrollment form.• If you are enrolling in a plan with a monthly premium, select a payment option. • Read, sign and date the form. • Mail, fax or hand-deliver form to:

Mailing Address Presbyterian Health Plan, Inc. P.O. Box 27489 Albuquerque, NM 87125-7489FAX: (505) 923-5385

Street Address The Cooper Center 9521 San Mateo Blvd. NE Albuquerque, NM 87113

OR . . .

Contact a sales representative . Call (505) 923-8458 or 1-800-347-4766 (TTY 711), 8 a.m. to 8 p.m., seven days a week (except holidays) from October 1 through March 31, and Monday to Friday (except holidays) from April 1 through September 30.

Note: If you enroll in one of our plans and are already enrolled in a Medicare Advantage plan or a stand-alone Prescription Drug Plan, your current plan will automatically terminate when your plan with us becomes effective.

If you are currently enrolled in a Medicare Supplement plan, you will need to terminate that plan once you receive confirmation that your new enrollment with us was accepted by Medicare. Do not terminate your Medicare Supplemental coverage until your receive confirmation from our plan that your enrollment was accepted.

How to Enroll

GET ENROLLED


Who can use this form?People with Medicare who want to join a Medicare Advantage Plan

To join a plan, you must:

• Be a United States citizen or be lawfully present in the U.S.

• Live in the plan’s service area

Important: To join a Medicare Advantage Plan, you must also have both:

• Medicare Part A (Hospital Insurance)

• Medicare Part B (Medical Insurance)

When do I use this form?You can join a plan:

• Between October 15 – December 7 each year (for coverage starting January 1)

• Within 3 months of first getting Medicare

• In certain situations where you’re allowed to join or switch plans

Visit Medicare.gov to learn more about when you can sign up for a plan.

What do I need to complete this form?

• Your Medicare Number (the number on your red, white and blue Medicare card)

• Your permanent address and phone number

Note: You must complete all items in Section 1. The items in Section 2 are optional – you can’t be denied coverage because you don’t fill them out.

Reminders:

• If you want to join a plan during fall open enrollment (October 15 – December 7), the plan must get your completed form by December 7.

• Your plan will send you a bill for the plan’s premium. You can choose to sign up to have your premium payments deducted from your bank account or your monthly Social Security (or Railroad Retirement Board) benefit.

What happens next?Send your completed and signed form to:

Presbyterian Health Plan, Inc. P.O. Box 27489Albuquerque, NM 87125Fax: (505) 923-5385

Once we process your request to join, we contact you.

How do I get help with this form?Call Presbyterian Senior Care at (505) 923-6060 or 1-800-797-5343. TTY users can call 711.

Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

En español: Llame a Presbyterian Senior Care al (505) 923-6060 or 1-800-797-5343/TTY 711 o a Medicare gratis al 1-800-633-4227 y oprima el 2 para asistencia en español y un representante estará disponible para asistirle.

Y0055_MPC082016_Approved_M_08172020 Form Page 1 of 4

2021 Presbyterian Senior Care (HMO) Individual Enrollment Request Form

Section 1 – All fields on pages 1 and 2 are required (unless marked optional)

Select the plan you want to join:

Part D Drugs are included:

_____ Presbyterian Senior Care Plan 2 with Rx - $0 per month

_____ Presbyterian Senior Care Plan 3 with Rx - $120 per month

Part D Drugs are not included:

_____ Presbyterian Senior Care Plan 1- $0 per month

Optional Supplemental Benefit:_____ Comprehensive Dental - $19 per month

FIRST Name: LAST Name: Middle Initial:

Birth Date:( __ __ /__ __ /__ __ __ __ )(M M / D D / Y Y Y Y )

Sex: M F

Phone Number:( )

Email (optional):

Permanent Residence Street Address (Don’t enter a P.O. Box):

City: County: State: ZIP Code:

Mailing Address, if different from your permanent address (P.O. Box allowed):

City: County: State: ZIP Code:

Your Medicare information:

Medicare Number: __ __ __ __ - __ __ __ - __ __ __ __

Answer this important question:

Will you have other prescription drug coverage (like VA, TRICARE) in addition to Presbyterian Senior Care? Yes No

If yes, name of other coverage: __________________________________________________________

Member number for this coverage: _______________________________________________________

Group number for this coverage: _________________________________________________________





IMPORTANT – Read and sign below:

• I must keep both Hospital (Part A) and Medical (Part B) to stay in Presbyterian Senior Care.

• By joining this Medicare Advantage Plan, I acknowledge that Presbyterian Senior Care will share my information with Medicare, who may use it to track my enrollment, to make payments, and for other purposes allowed by Federal law that authorize the collection of this information (see Privacy Act Statement below).

• Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan.

• The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan.

• I understand that people with Medicare are generally not covered under Medicare while out of the country, except for limited coverage near the U.S. border.

• I understand that when my Presbyterian Senior Care coverage begins, I must get all of my medical and prescription drug benefits from Presbyterian Senior Care. Benefits and services provided by Presbyterian Senior Care and contained in my Presbyterian Senior Care “Evidence of Coverage” document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Presbyterian Senior Care will pay for benefits or services that are not covered.

• I understand that my signature (or the signature of the person legally authorized to act on my behalf) on this application means that I have read and understand the contents of this application. If signed by an authorized representative (as described above), this signature certifies that:

1) This person is authorized under State law to complete this enrollment, and

2) Documentation of this authority is available upon request by Medicare.

Signature: Today’s date:

If you’re the authorized representative, sign above and fill out these fields:

Name: Address:

Phone Number: Relationship to Enrollee:




Section 2 – All fields on this page are optionalAnswering these questions is your choice.

You can’t be denied coverage because you don’t fill them out.Select one if you want us to send you information in a language other than English.

Spanish Other ______________________________________

Select one if you want us to send you information in an accessible format.

Braille Large print Audio CDPlease contact Presbyterian Senior Care at (505) 923-6060 or 1-800-797-5343 if you need information in an accessible format other than what’s listed above. Our office hours are 8 a.m. to 8 p.m., seven days a week from October 1 to March 31, and Monday to Friday (except holidays) from April 1 through September 30. TTY users can call 711.

Do you work? Yes No Does your spouse work? Yes No

List your Primary Care Physician (PCP), clinic, or health center:

Paying your plan premiums

You can pay your plan premium (including any late enrollment penalty that you currently have or may owe) by mail, Electronic Funds Transfer (EFT) or credit card each month.

You can also choose to pay your premium by having it automatically taken out of your Social Security or Railroad Retirement Board (RRB) benefit each month. Please select a payment option:

Get a bill.

Electronic Funds transfer (EFT) from your bank account each month. Please enclose a VOIDED check or provide the following:

Account holder name: ________________________________________

Bank routing number: ______________________ Bank account number:______________________ Account type: Checking Saving

Credit Card. Please provide the following information:

Type of Card: ____________________________________

Name of Account holder as it appears on card: ___________________________________________

Account number: _________________________________ Expiration Date: _ _ / _ _ _ _ (MM/YYYY)

Automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check.

I get monthly benefits from: Social Security RRB

If you have to pay a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA), you must pay this extra amount in addition to your plan premium. The amount is usually taken out of your Social Security benefit, or you may get a bill from Medicare (or the RRB). DON’T pay Presbyterian Senior Care the Part D-IRMAA.



31

Sales Appointment Confirmation Form

GET ENROLLED

By signing this form, you are agreeing to a sales meeting with a sales agent to discuss the Presbyterian Senior Care (HMO), Presbyterian MediCare PPO and/or Presbyterian Dual Plus (D-SNP) Medicare Advantage Plans. The sales agent who will be discussing plan options with you is either employed or contracted by a Medicare health plan or prescription drug plan that is not the Federal government, and they may be compensated based on your enrollment in a plan.

You are not obligated to enroll in a plan and signing this form does NOT affect your current or future Medicare enrollment status, nor will it enroll you in a Medicare Advantage Plan, Prescription Drug Plan, or other Medicare plan.

Beneficiary name: _____________________________________________________________

Beneficiary signature: ___________________________ Date of appointment: __________

If you are the authorized representative, you must sign above and provide the following information:

Name: ___________________________ Address: ___________________________________

Phone number: ___________________ Relationship to beneficiary: ___________________

To be completed by Agent:

Agent name: ________________________________ Agent phone: ____________________

Agent’s signature: ____________________________ Date: ___________________________

This form is to be delivered to the Presbyterian Medicare Plans with completed Enrollment Form, if applicable.

Presbyterian Senior Care (HMO) and Presbyterian MediCare PPO are Medicare Advantage plans with a Medicare contract. Enrollment in Presbyterian Senior Care (HMO) or Presbyterian MediCare PPO depends on contract renewal.

Presbyterian Dual Plus is an HMO Special Needs Plan (SNP) with a Medicare contract and a contract with the State of New Mexico Human Services Department Medicaid program. Enrollment in Presbyterian Dual Plus (HMO D-SNP) depends on contract renewal.

Y0055_MPC091808_NM_C_09192018

33

Presbyterian Enrollment Receipt

To be completed if enrolling with a Licensed Agent .

Please use this as your Temporary Proof of Coverage until Medicare has confirmed your enrollment

and you receive your Presbyterian ID card. This receipt is not a guarantee of enrollment.

This copy is for your records only. Please do not resubmit enrollment.

Y0055_MPC072039_C_NSR_08042020

Applicant 1:

Name

Application Date

Proposed Effective Date

Plan Name

Plan Type

Applicant 2:

Name

Application Date

Proposed Effective Date

Plan Name

Plan Type

Call your Licensed Agent if you have any questions:

Licensed Agent Name and NPN Number

Licensed Agent Phone Number

If you have additional questions, you can call the Presbyterian Customer Service Center

toll-free at 1-855-465-7737 (TTY 711), 8 a .m . to 8 p .m ., seven days a week .

Please Note: Enrollment is subject to Medicare approval. If you do not receive your plan

verification within 14 days, please call customer service at (505) 923-7675 or 1-855-465-7737

(TTY 711).

Rx BIN: 610593

Rx PCN: PHPMEDD

Rx GRP: PHS

35

Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a customer service representative at 1-800-797-5343 or (505) 923-6060 (TTY 711)

Understanding the Benefits

Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services for which you routinely see a doctor. Visit www .phs .org/medicare or call 1-800-797-5343 or (505) 923-6060 (TTY 711) to view a copy of the EOC.

Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select a new doctor.

Review the pharmacy directory to make sure the pharmacy you use for any prescription medicine is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions.

Understanding Important Rules

In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month.

Benefits, premiums and/or copayments/co-insurance may change on January 1, 2022.

Except in emergency or urgent situations, we do not cover services by out-of-network providers (doctors who are not listed in the provider directory).

Pre-Enrollment Checklist

GET ENROLLED

36

Presbyterian Senior Care (HMO) is a Medicare Advantage plan with a Medicare contract. Enrollment in this plan depends on contract renewal.

1. You will first receive a letter from us notifying you we received your application. Once your application is approved, we’ll send you a confirmation letter verifying your enrollment.

2. A Member Identification (ID) card will arrive in the mail. Be sure to use this card when you seek services.

3. You will be invited to attend a New Member Education Session to learn more about your plan and get your questions answered.

4. You will receive in the mail a detailed handbook of your covered benefits and services called an Evidence of Coverage.

5. You will be asked to complete a health assessment so we can develop a care plan that is right for you.

What to Expect After Enrollment

GET ENROLLED

Presbyterian Customer Service Center (for members)

(505) 923-6060 or 1-800-797-5343 (TTY 711)

Hours: 8 a.m. to 8 p.m., seven days a week from October 1 through March 31 and Monday to Friday (except holidays) from April 1 through September 30.

Call the Presbyterian Customer Service Center if you need assistance in selecting a Primary Care Provider (PCP) .


Y0055_MPC072019_Accepted_M_07282020

Thank you for your interest in Presbyterian Medicare Advantage Plans. Presbyterian offers you the value that comes with our integrated system of physicians, hospitals and health plan – all working together to keep you healthy and provide new and innovative services.

Plan Highlights• More benefits than Original Medicare (Part A and Part B)

• Preventive dental benefit

• Coverage for emergency and urgent care anywhere in the world

• Routine acupuncture and chiropractic care

• Gym memberships included through SilverSneakers®

• A convenient and secure website to manage your plan online through myPRES

2021 ENROLLMENT GUIDE

Presbyterian MediCare PPO

2

ABOUT US . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Who We Are . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Our Integrated System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Easy Ways to Access Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Managing the Health of Our Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

MEDICARE BASICS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

SUMMARY OF BENEFITS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

PRESCRIPTION DRUG FORMULARY . . . . . . . . . . . . . . . . . . . . . . . . . . 19

PROVIDERS AND PHARMACIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

GET ENROLLED . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

When You Can Enroll . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

How to Enroll . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

Individual Enrollment Request Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Sales Appointment Confirmation Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Presbyterian Enrollment Receipt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Pre-Enrollment Checklist. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

What to Expect After Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

TABLE OF CONTENTS

Presbyterian complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (505) 923-5420, 1-855-592-7737 (TTY: 711).

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3

• Founded in New Mexico in 1908, Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system of nine hospitals, a medical group, and a health plan.

• Presbyterian’s health system serves one in three New Mexico residents in our clinics, hospitals and as members of our health plan.

• Owned by Presbyterian Healthcare Services, Presbyterian Health Plan, Inc. was formed in 1985 and now has more than 600,000 enrolled in Medicare Advantage, Medicaid, and Commercial/Individual plans.

Presbyterian by the Numbers

More than 13,000

employees – New Mexico’s largest private

employer

600,000 Presbyterian Health Plan members, which includes nearly 42,000 Medicare Advantage members

Nearly 900,000 individual customers (and counting)

112 years of serving

New Mexicans

9 hospitals in 7 communities

Who We Are

ABOUT US

More than 1,100 providers in

Presbyterian Medical Group

4

Our Integrated System

As part of an integrated healthcare system, Presbyterian offers patients throughout New Mexico access to dedicated primary care providers, as well as highly specialized care, including cancer care, heart and vascular care, and behavioral health

ABOUT US

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Residents in Albuquerque and Santa Fe don’t have to guess if a condition is an emergency because medical staff decide the level of care needed. Both urgent and emergency care are open 24 hours a day at two PRESNow locations in Albuquerque’s Northeast Heights and the Westside. In Santa Fe, the Presbyterian Santa Fe Medical Center at 4801 Beckner Rd. on Santa Fe’s south side now offers both options all day, every day.

24/7 Urgent and Emergency Care Under One Roof in Albuquerque and Santa Fe

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PresRN is a great starting point, giving you direct access to medical advice 24 hours a day, 7 days a week, including holidays. There is no charge to call our experienced registered nurses (RNs) for answers to your health or wellness questions. Call (505) 923-5573 or 1-800-887-9917.

MyChart is a secure, web-based portal allowing members with a Presbyterian Medical Group provider to send electronic messages to their care team, request prescription renewals, view medical records or test reports, and schedule office or telephone visits.

Video Visits offer a no-cost, convenient option to see a medical provider anytime – day or night – for non-emergency medical conditions via secure video through a smartphone, tablet or computer webcam. Online Visits are also available for patients who have visited a Presbyterian facility. Visit www .phs .org and select “Get Care Today .”

Primary care physicians can treat most health problems. They may be a general/family practice physician, internal medicine physician, gynecologist, physician assistant, or nurse practitioner.

Urgent care clinics provide care for minor illness and injuries that are not an emergency. For added convenience, Presbyterian now offers same-day, scheduled appointments.

Emergency rooms are for serious medical emergencies or injuries that require immediate medical attention.

Easy Ways to Access Care

ABOUT US

6

• Healthy Solutions Program – A Health Coach provides education and telephonic or video lifestyle coaching to assist you in managing your chronic condition for asthma, coronary artery disease, diabetes or hypertension.

• Case management – Nurses and social workers help you manage your complex medical needs and will help link you with appropriate providers that will work to keep you out of the hospital or emergency room.

• Utilization management reviews – Pre-service, urgent concurrent, and post-service reviews ensure you are receiving the most appropriate covered treatments and services for you.

• Complete Care Clinic – This program provides comprehensive primary care services for adults with chronic or complex illnesses and helps these patients access care and navigate the medical system. The clinic works closely with other programs such as Presbyterian Home Care, Hospital at Home, and Palliative Care.

• National Diabetes Prevention Program – This is a year-long program for eligible members that encourages lifestyle changes to prevent or delay Type 2 diabetes.

Managing the Health of Our Members

ABOUT US

7

Medicare is a federal health insurance program administered by the Centers for Medicare & Medicaid Services (CMS) that provides hospital and medical coverage. There are several parts to Medicare coverage, each with different benefits and costs.

Parts of Medicare

Part A Covers hospitalization, such as inpatient care, hospice care, and some home healthcare, skilled nursing home care and nursing home care. Most people do not have to pay premiums for Part A.

Part BCovers medical services such as doctor’s visits (including most doctor services while you’re in the hospital) and outpatient treatments, as well as medical services and supplies not covered under Part A. Most people pay premiums for Part B.

Part CCommonly called Medicare Advantage, these plans combine Part A and Part B. Part D may also be included as well as other benefits.

Part DPart D covers prescription drug costs and is available to individuals who have Part A, B or C. Joining a health plan that includes Part D prescription drug coverage is voluntary.

MEDICARE BASICS

8

Late Enrollment Penalties

• Part B – You may have to pay a late enrollment penalty for Part B if you do not enroll when you first become eligible and then enroll later.

• Part D – You may have to pay a late enrollment penalty if you had any period of 63 days or more without drug coverage that is as good as or better than Part D coverage. The penalty amount would be added to your Medicare Advantage plan premium for as long as you have Part D.

Income Related Monthly Adjusted Amounts (IRMAA)

• In 2020, your Part B and Part D premium may be higher if your income is above $87,000 a year as an individual. You will be notified if these amounts change in 2021.

Automatic Disenrollment

• Medicare beneficiaries cannot be enrolled in a Medicare Advantage plan and a stand-alone Medicare Part D prescription drug plan with another company at the same time. For example, if you enroll in a separate Part D plan, you will automatically be disenrolled from your Medicare Advantage plan.

What You Should Know

MEDICARE BASICS

9Y0055_MPC072034_Accepted_M_08212020

This is a summary of health and drug services

covered by Presbyterian MediCare PPO

January 1, 2021 to December 31, 2021.

To enroll in Presbyterian MediCare PPO:

• You must be entitled to Medicare Part A

and enrolled in Medicare Part B.

• You must live in New Mexico.

This plan covers services from either in-

network or out-of-network providers, as long

as the services are covered benefits and are

medically necessary. If you choose to receive

care from out-of-network providers, there will

likely be a higher out-of-pocket cost for you.

$0 copay for these valuable benefits and more!

• Basic dental services

• Hearing exam

• Video and online visits

• PresRN nurse advice line

• Lab services

• Diagnostic tests

• Foot care

• Diabetic test strips and lancets

2021 SUMMARY OF BENEFITSPresbyterian MediCare PPO


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Plan 1 In-Network

Plan 2 In-Network

Out-of- Network

Monthly Plan Premium (You must also continue to pay your Medicare Part B premium.)

$56 $188

Does not include

prescription drug coverage

Includes prescription

drug coverage

Deductible $0 $0 $0

Maximum Annual Out-of-Pocket Responsibility (This is the most you pay in a calendar year for covered medical and hospital services. It does not include prescription drugs.)

$6,700 $6,700

$10,000 Combined

In- and Out-of-Network Maximum

Inpatient Hospital Care* (per admission)• Days 1 – 5• Additional Days

$325 per day per admit

$0


$0


$0

Ambulatory Surgery Center / Outpatient Surgery*

$325 $325 20%

Doctor Visits (no referral required)• Primary Care• Specialists• Video Visits

$15$50$0

$15$50$0

$35$60$35

Preventive Care $0 $0 $35

Emergency Care (worldwide)(This copay is waived if admitted to the hospital.)

$90 $90 $90

Urgently Needed Services• In-network• Outside of United States

$15$90

$15$90

$65$90



SUMMARY OF BENEFITS

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Plan 1 In-Network

Plan 2 In-Network

Out-of- Network

Diagnostic Services/Labs/Imaging• Lab services• Diagnostic tests and procedures• Outpatient x-rays• Diagnostic radiology service* (such as CT, MRA, MRI, PET scans)

$0$0$20$300

$0$0$20$300

20%20%20%20%

Hearing Services (does not go toward maximum out-of-pocket responsibility)• Hearing exam• Hearing aid (from TruHearing)

$0$699 - $999

$0$699 - $999

$0Not covered

Dental Services• Medicare covered dental• Basic dental services

$50$0

$50$0

$60Fees vary

Vision Services• Annual routine exam $0 $0 $60• Diagnosis/treatment of diseases and conditions of eye $10 $10 $60

• Annual diabetic retinopathy screening

$0 $0 $60

• Eyeglasses or contact lenses after cataract surgery 20% 20% 25%

Mental Health Services

• Inpatient visit (Days 1 - 5)* – Additional days• Outpatient group therapy visit• Outpatient individual therapy visit

$325 per day per admission

$0$40$40


$0$40$40


$050%50%

Skilled Nursing Facility (SNF)*• Days 1 - 20• Days 21 - 100 (Our plan covers up to 100 days in a SNF.)






SUMMARY OF BENEFITS

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Plan 1 In-Network

Plan 2 In-Network

Out-of- Network

Rehabilitation Services• Cardiac and Pulmonary rehab (limited to 36 visits/year)• Occupational, Physical, and Speech and Language therapy visits

$0

$25

$0

$25

$35

$35

Ambulance (ground and air) $250 $250 $250

Routine Transportation Not covered Not covered Not covered

Medicare Part B Drugs* • Chemotherapy Drugs and other drugs administered by a medical professional• Purchased at a retail pharmacy

20%

$10

20%

$10

20%

20%

Foot Care (podiatry services)• Foot exams and treatment (Medicare covered)

$0 $0 $60

Medical Equipment/Supplies*• Durable Medical Equipment (e.g., wheelchairs, oxygen, continuous glucose monitors/ supplies)• Prosthetics (e.g., braces, artificial limbs)

20%

20%

20%

20%

25%

25%

Wellness Programs (e.g., fitness)

$0SilverSneakers® Fitness Program is included.

For participating locations visit www.silversneakers.com

Acupuncture • Medicare covered• Routine (limited to 25 visits/year)

$20$20

$20$20

$60$60

Chiropractic • To correct subluxation• Routine (limited to 25 visits/year)

$20$20

$20$20

$60$60

Home Health Care* $0 $0 $0

Kidney Dialysis 20% 20% 20%



SUMMARY OF BENEFITS

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Prescription drug coverage is a part of Plan 2.

Initial Coverage Initial coverage

limit $4,130; includes what both you and

your plan pay

Coverage Gap

Catastrophic Coverage

Part D Covered Drugs

30-day supply

90-day mail order(preferred)

Plan 2 Plan 2

Tier 1: Preferred Generic

$4 $8

25% generic

and brand

applies to all tiers

$3.70 or 5% for generics


You stay in this stage

for the rest of

the year.

Tier 2: Non- Preferred Generic

$10 $20

Tier 3: Preferred Brand

$45 $112.50

$9.20 or 5% for

brand names


Tier 4: Non- Preferred Brand

$95 $285

Tier 5: Specialty Drugs

25% NA

Catastrophic coverage begins after your out-of-pocket costs = $6,550

Prescription Drug Deductible All Tiers

Plan 2 $335


SUMMARY OF BENEFITS

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SUMMARY OF BENEFITS

Premium - Your premium for MediCare PPO Plan 2 will be reduced based on the LIS level you qualify for. The premium you will pay for MediCare PPO Plan 2 if you qualify for the 100% LIS level is $159.80.

Prescription drugs - If you qualify for Low-Income Subsidy (LIS), your prescription drug coverage gap (also known as the donut hole) in your drug coverage is eliminated. You also pay reduced copays for your Part D drugs.

LIS qualifying income levels for 20201 – To qualify, your annual income and resources / assets need to be at or below the following:Single Married

Annual Income1: $19,140 Annual Income1: $25,860

Resources / Assets2: $13,110 Resources / Assets2: $26,1601 Income limits may change in 2021.2 The house you live in, the car you drive, life insurance policies, and burial plots do not count toward the resource / asset limit. Contact Social Security for other income / resource exclusions.

Medicaid and Other Medicare Savings Programs (MSP)

Those who qualify for Extra Help may also qualify for Medicare Savings Programs that help pay Part A and/or Part B premiums. Medicaid programs may also lower your copays, depending on the level for which you qualify.

Extra Help / Low-Income Subsidy (LIS)

FIND OUT IF YOU QUALIFY FOR ASSISTANCEPresbyterian offers a personal service that helps you find out if you qualify for these money-saving programs. A trusted partner since 2006, My Advocate™, helps you apply for Extra Help / Low-Income Subsidy and Medicare Savings Programs.

Call My Advocate™ at 1-866-851-0324.

You also have the option to contact:• 1-800-Medicare (1-800-633-4227), 24 hours a day, seven days a week

(TTY 1-877-486-2048)• Social Security, 1-800-772-1213 (TTY 1-800-325-0778)• NM State Human Services Department, 1-888-997-2583 (TTY 1-855-227

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