Yakima Guidebook by Health Alliance

Northwest, Yakima

Medicare Made for You 2022 Medicare Advantage + Prescription Drug Coverage Guide

Washington: Yakima

How to Enroll Online

Broker

Go to HealthAlliance.org/Medicare to get started.

If you attend a seminar, the person presenting can schedule an appointment to help you enroll.

By Phone Call (877) 642-3331 (TTY 711), daily from 8 a.m. to 8 p.m. local time. Voicemail is used on holidays and weekends from April 1 to September 30.

After You Enroll

Fill out and mail us the enrollment form in the back of this guide. You can also download it from HealthAlliance.org/Medicare.

If you enroll in a Medicare Advantage plan during the Annual Enrollment Period, your coverage will begin January 1, 2022. In the meantime, we’ll mail you your member materials and your member ID card, which you’ll use instead of your red, white and blue Medicare card at the doctor, hospital and pharmacy starting January 1.

Mail to:

Meet us in our local office.

Health Alliance Northwest Application Processing Center 3310 Fields South Dr. Champaign, IL 61822

Stop by our office for a visit. We look forward to meeting you.

By Mail

1701 Creekside Loop Suite 100 Yakima, WA 98902

Contents Welcome to Medicare Your Network Your Providers Your Pharmacy Coverage Stages of Pharmacy Coverage Your Team Your Travel Your Perks and Programs Your Health at Your Fingertips Your Protection: Appeals and Grievances Enrollment Your Plan HMO Plans POS Plans

2021 Washington Service Area

Service Area San Juan

Clallam

Island

Whatcom Skagit Okanogan

Jefferson

Snohomish

Ferry

Pend Oreille

Stevens

Kitsap

Chelan

Mason King

Douglas

Grays Harbor

Pacific Wahkiakum

Thurston

Pierce

Lincoln

Kittitas Grant

Lewis

Spokane

Adams

Cowlitz Yakima

Whitman

Skamania

Franklin

Clark Klickitat

Benton

Garfield Columbia

Walla Walla

Asotin

Welcome to Medicare made for you. When you become a member, you get a health plan made with you in mind – access to doctors you trust, perks you deserve and local customer service reps always ready to help. And we strive to make these plans affordable for you. Use this guide to find the plan that’s made for you. Plus, compare plan options and key benefits all in one place with the 2022 Key Medicare Advantage Benefits guide.

Your Health Alliance Northwest TM Plan Options: SignalAdvantage HMO (HMO)

SignalAdvantage POS Rx (HMO-POS)

SignalAdvanage HMO Rx (HMO)

SignalAdvantage POS Rx Plus (HMO-POS)

SignalAdvantage HMO Basic Rx (HMO) SignalAdvantage HMO Rx Plus (HMO)

Your Network You should have access to healthcare that inspires you to thrive, so we partnered with Yakima Valley Memorial – a health system focused on helping you achieve health in new ways. And together, we brought a Medicare Advantage plan to the community with an office right in Yakima.

When your doctor and health plan are on the same team working toward the same goal, you get programs and benefits made for you that help you achieve health and thrive.

Your Providers Check out the list below to see some of our providers. Go to HealthAlliance.org/Medicare for a full list. Community Health of Central Washington Washington • Family Medicine • Highland Clinic • Naches Medical Clinic • Kadlec Regional Medical Center & Clinics

Pacific Vascular

• Central

Kadlec Regional Medical Center & Clinics Mid-Valley Community Clinic • Sunnyside

Prosser Memorial Health City Clinic • Prosser Memorial Hospital • Prosser Clinic • Prosser Memorial Grandview Clinic • Prosser Women’s Health Clinic • Prosser Specialty Clinic • Benton

Swofford – Halma Clinic • Sunnyside

Virginia Mason Medical Center — Seattle and Clinics

Yakima Valley Memorial Lower Valley Specialty Center Yakima Medical Clinic

• Hospital

Weaver Family Medicine – Sunnyside Yakima Valley Memorial Family of Services • Apple Valley Family Medicine • Cascade Surgical Partners • Family Medicine of Yakima • Generations OB/GYN • Healthy Now — Convenient Care Clinics — all locations • Lakeview • Memorial Cornerstone Medicine • Memorial Outpatient Psychiatric Services • Memorial Sleep Specialists • Memorial Valley Imaging • North Star Lodge • Ohana • Orthopedics Northwest • Pacific Crest Family Medicine • Selah Family Medicine • Water’s Edge Pain Institute • Yakima Valley Memorial Hospital — all departments • Yakima Ear Nose and Throat • Yakima Endocrinology Associates • Yakima Gastroenterology Associates • Yakima Valley Memorial Heart & Vascular • Yakima Lung and Asthma Center • Yakima Podiatry Associates • Yakima Urology Associates • Yakima Vascular Associates • Zillah Family Medicine

Yakima Neighborhood Health Services – Yakima • Granger • Neighborhood Connections • Sunnyside

We don’t require a referral, but your doctor might. When your doctor directs you to another provider, it’s called a referral. We don’t require this, but your doctor might. Check with your doctor before you see a specialist or other provider to make sure you’ve taken

the proper steps. If we don’t have an in-network specialist to treat your specific condition, we’ll help you find one. And you’ll still pay the in-network cost if you get prior authorization from us.

Your Pharmacy Coverage Plans with pharmacy coverage built in help you keep all your coverage in one place and help you save with special programs and discounts made for you.

Pharmacy Basics

Benefits

Drug Formulary A formulary is the list of drugs we cover. You can find it at HealthAlliance.org/Medicare or in the back of this guide. (Generally, we only cover drugs that are listed.)

No Rx Deductible Unlike many other Medicare Advantage plans, our Part D plans have no pharmacy deductible. $2 Tier 1 Generics Get Tier 1 generic drugs for $2 at any in-network pharmacy.

Pharmacy Network You must use an in-network pharmacy to get covered drugs unless it’s an emergency. For a list of in-network pharmacies, view our pharmacy directory at HealthAlliance.org/Medicare, or request a copy using the card in the back of this guide.

Drug Compare Tool See how much you’ll pay each month and how much you could save by switching to a pharmacy with lower prescription costs or by taking a lower-cost drug.

Savings for Members Without Part D Our Medicare Advantage members without Part D coverage get help paying for their prescription drug costs by showing their health plan ID card.

You can check costs at different pharmacies and see the differences in costs between retail (pickup) or mail order (delivery of a 90-day supply). You can also estimate your total annual drug costs.

Late Enrollment Penalty If you don’t enroll in a prescription drug (Part D) plan when you’re first eligible, you may have to pay a penalty for enrolling later. That penalty will increase for every month you didn’t have prescription coverage. You can’t be enrolled in a Medicare Advantage HMO or HMO-POS plan and a stand-alone prescription drug plan (PDP) at the same time.

90-Day Supply Options Limit your trips to the pharmacy with two convenient options. With our mail-order benefit, you can get a 90-day supply of your drugs delivered directly to you for two copays. If you prefer to get your drugs at a retail pharmacy, you can visit any in-network pharmacy and get a 90-day supply for three copays. Medication Therapy Management If you take multiple medications, this program can help you use them safely and effectively.

Extra Help

You might be able to get help to pay for your prescription drug premiums and costs through the Extra Help program. To see if you qualify, call one of the following: • (800)

MEDICARE (800-633-4227), 24 hours a day, seven days a week (TTY 877-486-2048). • The Social Security Administration at (800) 772-1213, 7 a.m. to 7 p.m., Monday through Friday (TTY 800-325-0778). • The state’s Medicaid office.

Stages of Pharmacy Coverage There are three pharmacy coverage stages, but most people stay in the initial coverage stage.

Most people stay in this range. $4,430 Few people reach this stage. $7,050 Even fewer people reach this stage.

Initial Coverage You pay the following until the amount you pay plus the amount we pay reaches $4,430:

Alliance Northwest plan, you’ll continue to pay your copay for Tier 1 medications until your out-ofpocket expenses reach $7,050.

• Tier

Coverage Gap Also known as the “donut hole,” this stage begins when the amount you pay plus the amount we pay for your prescription drugs reaches $4,430. Here, you pay the following until you reach $7,050:

1: $2. 2: $15. • Tier 3: $47. • Tier 4: 50%. • Tier 5: 33%. • Tier

Coverage Through the Gap If your total prescription spend adds up to $4,430, you’ll reach the coverage gap. With your Health

• 25% • 25%

for covered generic drugs. for covered brand-name drugs.

Catastrophic Coverage This stage begins when your out-of-pocket drug costs reach $7,050. Here, we pay for most of your drug costs for the rest of the year, while you pay the greater of the following: • 5%

of the cost. or • $3.95 for covered generic drugs (including brand-name drugs treated as generic) and $9.85 for covered brand-name drugs.

Your Team Your plan is made for more than when you’re sick. It’s made to help you stay healthy in the first place, so you have a team of health coaches, care coordinators and more to help you with both.

Care Coordinators Whether you’d like to speak to a dietitian, want to quit smoking or need help understanding a recent diagnosis, we have teams to help you achieve your goals or get you back on track. Connect to a team of providers, like nurse practitioners, social workers, health coaches, dietitians, pharmacists and more, who work with your doctor to make sure you have the resources you need to stay healthy or work through your medical issues. The care coordination team reaches out to offer these services, but you can also request them if you’d like this personalized help.

Health Coaching Health coaches are your health partners. They’ll help you reach your health goals in the following areas and more:

Set and reach health and wellness goals.

Find helpful resources.

Understand and manage health issues, like diabetes and asthma.

Care for yourself to help prevent illness and hospital stays.

Coordinate your care when you have complicated health conditions.

Use your health benefits to save money.

• Nutrition. • Weight • Staying

loss. active.

Breck Obermeyer Community Liaison Health Alliance Northwest

Your Community We like to get out and meet the entire community. We’ll be at health fairs, senior expos and other events ready to educate and talk with you and others throughout the area. Led by our team of liaisons, we’re excited to get to know you.

Your Travel No matter where sickness or injury strikes – even if you’re traveling – you’re covered for emergency care, urgent care (also called convenient care or a walk-in clinic) or an ambulance at the in-network cost-share amount. You’re also covered at the in-network cost-share if you’re admitted to a hospital through the emergency department. POS plans offer out-of-network coverage for routine care, including physical therapy or doctor’s visits. With an HMO, out-of-network routine care won’t be covered, but some services, like physical therapy, might be covered if deemed medically necessary for you to be able to return home. How You’re Covered your ankle while hiking? Your emergency care is covered both in and out of network, and so is any emergency surgery you need as a result. • Need routine physical therapy? You’re covered on a POS plan, but you may have to pay more for being out of network. With an HMO plan, you only have coverage when seeing an in-network provider. • Take a tumble and need physical therapy in order to return home? You’re covered both in and out of network if deemed medically necessary. • Come down with a cold or flu? Urgent care (also called convenient care or a walk-in clinic) is covered at the in-network level regardless of where you get your care. • Need a routine physical? With an HMO plan, you only have coverage when seeing an in-network provider.

Assist America® Have peace of mind whenever you travel 100 miles or more from home. With doctors, nurses and emergency medical technicians on staff, help is just a phone call away, 24 hours a day and 365 days a year. Assist America can connect you to prompt medical attention and help make sure you’re admitted to reliable hospitals when needed. Plus, it can even help in some situations that aren’t health-related.

• Break

If you have questions about other situations, give us a call.

Here are just some of its many features: • Prescription

assistance if you need medication or left your prescription behind. • Compassionate visit from someone close to you if you need to be hospitalized for more than a week. • Emergency medical evacuation. • Lost luggage assistance. • Interpreter and legal referrals.

All Assist America benefits apply on all of our Medicare Advantage plans, but when you’re out of network, our HMO plans cover only emergency and urgent care. Assist America will not pay you back for ambulance and other services you arrange on your own. In a lifethreatening emergency, always call the ambulance right away. There is no added cost for the service itself, but there could still be a cost with any medical care. Other conditions and exclusions may apply.

Your Perks and Programs Your plan is made with plenty of extras to help you with your health goals.

Be Fit Get paid back for a variety of fitness activities. You choose how you want to work out, and we pay you back up to $360 a year. Activities include the following and more: • Fitness

class fees. memberships. • Online fitness subscriptions. • Weight loss subscriptions. • Ski memberships. • Rowing. • Golf. • Bowling. • Tennis. • Pickleball. • Recreational league fees. • Pool exercise classes. • 5K/10K race fees. • Gym

If your fees are more than $360 a year, you pay the difference. If they’re less, we pay you back the amount you paid. Be Fit doesn’t cover fitness trackers, personal trainers or personal equipment.

Dental Coverage We cover up to $1,000 a year for use on dental services, like cleanings, X-rays and more (copayment applies; see the Summary of Benefits for specific copayment amounts). You pay the dentist and then send us the receipt. If your dentist submits the claim for you, you don’t need to send us the receipt. (SignalAdvantage HMO Basic RX has a $750 limit.)

Disease Management Programs Get connected to resources, motivation, support and reminders to help you manage the following and more:

• Asthma. • Diabetes. • High

blood pressure. heart failure. • Migraines. • Congestive

Hearing Benefit Through TruHearing®, you can get one routine hearing exam for a $45 copay and lowered rates on up to two TruHearing hearing aids per year when you see a TruHearing provider.

Nurse Advice Line Get 24/7 answers to your health questions, like whether you need to set up an appointment or see a doctor right away.

Preventive Care Focus on preventing sickness and catching problems before they get worse with these services and more: • Yearly

wellness visit. screenings, like mammograms or colorectal cancer screenings. • Flu shot. • Routine

Quit For Life® Get help ending your tobacco use with: • One-on-one

coaching from a quit coach. plan made just for you. • Helpful tools, like Text2Quit. • Web Coach®, an online learning and support community. • Quit

Virtual Health Coverage Get care when and where you need it with virtual health coverage. If you need to interact with your primary care provider (PCP) or specialist over the phone or online, you’re covered through the telehealth benefit. You don’t even need to leave the comfort of your home. You can also get care for common conditions like allergies, cold, flu and pink eye from anywhere you have phone or internet connection in the U.S. Whether at home or traveling, you can talk to a board certified doctor or counselor by phone or secure video through the Hally® app or hally.com at any time of the day, any day of the year.

Vision Get access to vision services beyond what Original Medicare covers, including a routine vision exam with an in-network provider.

Wellness Rewards Take steps toward better health while working your way toward a $50 gift card. Have a yearly wellness visit or physical, plus complete two other activities outlined at HealthAlliance.org/Perks/Wellness-Rewards, to qualify for your $50 gift card.

Your Health at Your Fingertips Find helpful tools at hally.com. Get access to plenty of resources to help you stay healthy with no login required at hally.com. You’ll find: • Classes

on exercise, cooking and caring for your conditions. • Hally blog. • Hally Healthcast, a monthly podcast focused on health and wellness.

Access secure member information. Get secure, instant access to your coverage by logging in to the Hally app or on hally.com. Manage your health plan and get the care you need anytime, anywhere. • See

all your account activities in one place. your virtual ID card. • Search for doctors and other resources. • Quickly connect with a doctor over virtual visits. • Get cost estimates. • Check claims status. • Access

Visit the App Store or Google Play to download.

App Store is a service mark of Apple Inc., registered in the U.S. and other countries. Google Play and the Google Play logo are trademarks of Google LLC.

Your Protection: Appeals and Grievances Medicare Advantage plans offer safeguards to make sure you’re treated fairly and have the chance to voice your opinion if you think you’ve been mistreated. Appeal This is a type of complaint you can file if you disagree with the plan’s decision to not cover healthcare services you’re trying to get or have already gotten. You must file an appeal in writing within 60 days of the decision or as soon as you can.

Grievance This is a type of complaint you can make about your plan. Some examples are poor quality of care, bad customer service or feeling like an employee is encouraging you to leave the plan. You can file a grievance by calling our Member Services department within 60 days of the event or as soon as you can.

Enrollment Timelines and Requirements The Centers for Medicare & Medicaid Services (CMS) sets certain times during the year when you can enroll in a Medicare Advantage or prescription drug plan.

Timelines and Requirements Annual Enrollment Period From October 15 to December 7, you can enroll in Medicare Advantage or a stand-alone prescription drug plan, or you can switch plans. If you enroll during this period, your coverage begins January 1 of the following year. Initial Enrollment Period You have a seven-month initial enrollment period to enroll in Original Medicare, Medicare Advantage or a prescription drug plan. It starts three months before the month you turn 65, includes the month of your 65th birthday and ends three months after the month you turn 65. you enroll one to three months before your 65th birthday, your coverage begins the first day of the month you turn 65. • If you enroll during your birth month, your coverage begins the first day of the following month. • If you enroll one to three months after the month you turn 65, your coverage begins the first day of the month after you enroll.

Special Enrollment Period You can enroll in a new plan or change your plan in certain situations. Examples include: • Permanent

address change. of coverage due to employment change. • Becoming eligible for a low-income subsidy. • Loss

To be eligible for our plans, you must:

• If

Open Enrollment Period From January 1 to March 31, you can switch to Original Medicare and/or join a stand-alone prescription drug plan.

• Have

Medicare Parts A and B and live in the service area. • Continue to pay your Medicare Part B premium if not otherwise paid for by Social Security or another third party.

Enrollment in a plan will automatically disenroll you from any other Medicare Advantage plan. But it won’t automatically disenroll you from a Medicare Supplement plan. You must contact that plan to disenroll.

Your Enrollment Process How to Enroll

After You Enroll

Online Go to HealthAlliance.org/Medicare to get started.

By Phone Call (877) 642-3331 (TTY 711), daily from 8 a.m. to 8 p.m. local time. Voicemail is used on holidays and weekends from April 1 to September 30. By Mail Fill out and mail us the enrollment form in the back of this guide. You can also download it from HealthAlliance.org/Medicare. Mail to: Health Alliance Northwest Application Processing Center 3310 Fields South Dr. Champaign, IL 61822 Broker If you attend a seminar, the person presenting can schedule an appointment to help you enroll.

Meet us in our local office. Stop by our office for a face-to-face visit. We look forward to meeting you. 1701 Creekside Loop Suite 100 Yakima, WA 98902

Your Plan You deserve coverage that fits your lifestyle, so we offer plans made for your needs. Does staying in network or having lower monthly premiums give you peace of mind? You might prefer a health maintenance organization (HMO) plan:

• Do

• Comfort

of having an in-network primary care provider (PCP) to oversee all your care. • Must see doctors in our large provider network but can go out of network for emergency and urgent care. • Focus on strong doctor-patient relationships and familiarity with your provider network. Find an overview of your plan options and benefits made for you in our 2022 Key Medicare Advantage Benefits guide.

you travel often or like having freedom to see doctors in and out of network? You might prefer a point of service (POS) plan:

of having an in-network PCP to oversee all your care. • Flexibility to see out-of-network providers but may save money by staying in network. • Balance between security and freedom.

HMO Plans Our HMO plans give you access to a network of respected doctors.

We offer the following HMO plan options: SignalAdvantage HMO (HMO) SignalAdvantage HMO Rx (HMO) SignalAdvantage HMO Basic Rx (HMO) SignalAdvantage HMO Rx Plus (HMO)

Start Plan Information Here

POS Plans POS plans are made to give you the comfort of having a primary care provider with the freedom to see out-of-network providers.

We offer the following POS plan options: SignalAdvantage POS Rx (HMO-POS) SignalAdvantage POS Rx Plus (HMO-POS)

Health Alliance Northwest™ Yakima Star Ratings Click on the link below to view the most up-to-date star ratings for your service area. 2021 Health Alliance Yakima Star Ratings 2022 Health Alliance Yakima Star Ratings (Available Mid-October 2021)

Health Alliance Northwest is a Medicare Advantage Organization with a Medicare contract. Enrollment in Health Alliance Northwest depends on contract renewal. Every year, Medicare evaluates plans based on a 5-star rating system. MDMKNW22-WAYstarrtgissuu-0921 | H3471_22_101990_M