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| HeartLine Plus Backgrounder HeartLine Plus is a program designed around the prescription and health management needs for South Dakota residents who are eligible for Medicare and who have cardiac care and/or stroke needs. The Medicare Prescription Drug Improvement and Modernization Act of 2003 set forth a new national prescription program, referred to as Part D, for Medicare-eligible beneficiaries. It was designed primarily to help seniors save money on the cost of their prescription drugs and to safeguard against unforeseen drug costs as they trend upward. Unlike other programs, HeartLine Plus not only includes prescription drug coverage but also provides beneficiaries with complete health care coverage access to the widest physician, pharmacy and hospital network in South Dakota. In addition, beneficiaries will have access to best practice guidelines for medical therapy, coordinated care management, a personal health advisor and community services and disease management assistance. Experts agree that proper disease management offers a more integrated approach to delivering healthcare so that better outcomes and quality of care are achieved for patients. It supports the physician-patient relationship and plan of care and empowers patients to self-manage their overall health. DAKOTACARE will begin making this program available on November 15, 2005, through a partnership with QMed, a clinical information management company, specializing in physician support and patient health promotion services. Executive Summary of Benefits HeartLine Plus is unique because it’s exclusively designed to meet the needs of South Dakotans who have a heart condition or had had a stroke, are on Medicare and spend $3,000 or more a year in prescription medications. Medicare’s changes give beneficiaries access to a pharmacy benefit. Each enrollee will pay a monthly Part D premium, along with the current Part A and B fees. However, if you spend over $2,250 a year, the Standard Medicare Part D will not reimburse any fees until costs exceed $5,100. HeartLine Plus from DAKOTACARE is designed to cover enrollees that fall into the Part D gap. The plan uses a preferred list of drugs, or a formulary, to meet patient needs at a lower cost. Generic and brand name drugs have low co-pays and no deductibles. In addition, HeartLine Plus offers benefits for emergency care, skilled nursing facilities, outpatient rehabilitation, doctor office visits, inpatient hospital care and outpatient services or surgeries. For more information, go to heartline.dakotacare.com. Backgrounder In 1986, the physicians of South Dakota banded together to address the rising concerns of America’s healthcare system. They aimed to provide patient services at reasonable costs through a health maintenance organization without the hassle of unnecessary paper work and red tape. With one strong voice, these pioneers developed the health care plan of the South Dakota Medical Association, providing coverage, stable rates and simplified claims processing. Moreover, a dedicated staff and high level of physician participation laid the groundwork for what DAKOTACARE has become today: an organization that provides stability in healthcare and helps patients maintain control of their own healthcare. DAKOTACARE, rated B+ (Very Good) by A.M. Best, is proudly entering its 20th year of operation and is South Dakota’s largest and only statewide HMO, serving over 110,000 members. The network includes 98% of the state’s physicians and pharmacies, all South Dakota hospitals, and many other types of providers such as psychologists, chiropractors, optometrists, and surgical centers. The company also incorporated DAKOTACARE Administrative Services, Inc. (DAS), a wholly owned subsidiary, to provide third party administration services to members residing in South Dakota, as well as Illinois, Iowa, Kansas, Minnesota, Nebraska, North Dakota, Tennessee, Wisconsin and Wyoming. DAKOTACARE and its subsidiaries have over $34 million in total statutory assets and a statutory net worth of over $18 million with annual combined revenues in excess of $90 million. DAKOTACARE employs 130 in Sioux Falls at the corporate headquarters and in its Webster, SD, service center. 9/05 HeartLine Plus FAQs Who can participate in the HeartLine Plus program? Any resident of South Dakota who is eligible for Medicare and has one of the following conditions: coronary artery disease (CAD); congestive heart failure (CHF); or a previous stroke; can join the plan. When can beneficiaries join? Seniors can enroll in the HeartLine Plus program beginning November 15, 2005, for coverage beginning January 1, 2006. What are the benefits of HeartLine Plus? HeartLine Plus is an “all in one coverage plan” making it easier for beneficiaries to have one contact and one plan to deal with their all of their health care needs. HeartLine Plus beneficiaries will have access to the largest managed care plan, pharmacy and hospital network in How can family and other caregivers derive benefit? HeartLine Plus uses evidence based medicine keyed to the specific needs of each beneficiary combined with best practice guidelines for medical therapy. Health Care Professionals will be available 24 hours a day. In addition, the enrollee will have a personal health advisor to assist them with any of their medical concerns. How can eligible beneficiaries enroll? Why is this plan being offered now? The 2003 Medicare reform act created Medicare Advantage Special Needs Plans, which allow patients with chronic conditions to participate in Medicare Advantage Plans with generous drug coverage. It was designed primarily to help Medicare beneficiaries save money on the cost of their prescriptions and also have coverage that is specific to dealing with their special needs. Does this affect other coverage plans? HeartLine Plus members receive all of the benefits that the Original Medicare plan offers with additional benefits, which may change from year to year. HeartLine does provide both supplemental coverage (fills the gaps in Part A & B) and Part D prescription drugs. Medicare Part D FAQ's What is the Medicare drug coverage? It’s insurance provided by private companies that were approved by Medicare. Coverage begins January 1, 2006, and Medicare’s elderly and disabled beneficiaries are eligible. Do I have to join? No. It’s a voluntary benefit. However, if you are eligible now it is advisable to purchase a basic plan to secure the lower premiums and avoid the higher rates in the future. May 15, 2006, is the last day you can enroll in a Part D prescription drug plan without a late enrollment fee, unless you qualify for an exception. What if I already have drug coverage through my former employer or union? You should first contact your plan to find out how your coverage will be affected by the new Medicare prescription drug benefit. Be advised, if you drop your retiree or union drug coverage, you might not be able to rejoin. Your plan will notify you about whether your coverage is changing because of the new Medicare coverage and whether it provides equal or better coverage than a Medicare plan. How can I get Medicare drug coverage? You can get the new coverage in several ways: through Medicare managed plans known as “Medicare Advantage” plans, like HeartLine Plus, or by enrolling in a privately run prescription drug plan. How much will it cost? Premiums and co-pays will vary, but most beneficiaries will pay an average monthly premium of $32 and a $250 deductible. Once those are paid, Medicare then pays 75% of drug purchase costs up to $2,250, while beneficiaries pay only 25%. The standard Part D program requires individuals to pay 100% of their prescription costs between $2,250 and $5,100. (This “donut hole” is covered for patients who are enrolled in HeartLine Plus.) Medicare then pays 95% of all costs that exceed $5,100. What drugs will be covered? All plans will cover at least two drugs in each medication class, including brand name and generic drugs. You should check if your prescription drugs are covered and what co-pays they will charge in the new plans. In addition, you should find out which drug plans the pharmacies in your area use to make sure it is convenient for you. What expenses count toward the deductibles? It’s important to note that drugs not on the plan’s formulary, will not be counted toward the Part D deductibles—either the $250 basic or the $3,600 annual out-of-pocket limits. Be sure to clarify which drugs will and will not be included in the deductibles. |