s in excess of Medicare FFS, typically including reduced cost sharing, enhanced prescription drug benefits, care coordination, data analysis techniques to help identify member needs, complex case management, tools to guide members in their health care decisions, care management programs, wellness and prevention programs, and in some instances, a reduced monthly Part B premium. Most Medicare Advantage plans offer the prescription drug benefit under Part D as part of the basic plan, subject to cost sharing and other limitations. Medicare Advantage plans might charge beneficiaries monthly premiums and other copayments for Medicare-covered services or for certain extra benefits. Generally, Medicare-eligible individuals enroll in one of the company’s plan choices between October 15 and December 7 for coverage that begins on the following January 1. The company’s Medicare HMO and PPO plans, which cover Medicare-eligible individuals residing in certain counties, might eliminate or reduce coinsurance or the level of deductibles on many other medical services while seeking care from participating in-network providers or in emergency situations. Except in emergency situations or as specified by the plan, most HMO plans provide no out-of-network benefits. PPO plans carry an out-of network benefit that is subject to higher member cost-sharing. In some cases, these beneficiaries are required to pay a monthly premium to the HMO or PPO plan in addition to the monthly Part B premium they are required to pay the Medicare program. Most of the company’s Medicare PFFS plans are network-based products with in and out of network benefits due to a requirement that Medicare Advantage organizations establish adequate provider networks, except in geographic areas that CMS determines have fewer than two network-based Medicare Advantage plans. In these areas, the company offers Medicare PFFS plans that have no preferred network. Individuals in these plans pay the company a monthly premium to receive typical Medicare Advantage benefits along with the freedom to choose any health care provider that accepts individuals at rates equivalent to Medicare FFS payment rates. CMS uses monthly rates per person for each county to determine the fixed monthly payments per member to pay to health benefit plans. These rates are adjusted under CMS’ risk-adjustment model which uses health status indicators, or risk scores, to improve the accuracy of payment. The risk-adjustment model, which CMS implemented pursuant to the Balanced Budget Act of 1997 and the Benefits and Improvement Protection Act of 2000, generally pays more for members with predictably higher costs and uses principal hospital inpatient diagnoses, as well as diagnosis data from ambulatory treatment settings (hospital outpatient department and physician visits) to establish the risk-adjustment payments. Under the risk-adjustment methodology, all health benefit organizations must collect from providers and submit the necessary diagnosis code information to CMS within prescribed deadlines. As of December 31, 2015, the company provided health insurance coverage under CMS contracts to approximately 2,753,400 individual Medicare Advantage members, including approximately 587,400 members in Florida. The company’s HMO, PPO, and PFFS products covered under Medicare Advantage contracts with CMS are renewed generally for a calendar year term unless CMS notifies the company of its decision not to renew by May 1 of the calendar year in which the contract would end, or the company notifies CMS of its decision not to renew by the first Monday in June of the calendar year in which the contract would end. All material contracts between the company and CMS relating to its Medicare Advantage products have been renewed for 2016, and all of its product offerings filed with CMS for 2016 have been approved. Individual Medicare Stand-Alone Prescription Drug Products The company offers prescription drug plans (PDPs) under Medicare Part D, including a PDP offering co-branded with Wal-Mart Stores, Inc., or the Humana-Walmart plan. The company’s PDP offerings consist of plans offering basic coverage with be
humana inc (HUM:New York Consolidated)
500 West Main Street
Louisville, KY 40202
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