ODS. Healthcare from your head to your toes.

PERS ODS Advantage PPORX (PPO) premium

The PERS ODS Advantage PPORX premium includes coverage for both medical services and prescription drug coverage. If you have questions about your premiums, address changes, plan changes or enrollment please contact the PERS Health Insurance Program.

In addition to your monthly PERS premium you must continue to pay your Medicare Part B premium if not otherwise paid for under Medicaid or by another third party.

Part D IRMAA
Part D-IRMAA stands for the Income Related Monthly Adjustment Amount for Part D and this is mandated by the Affordable Care Act to help fund the Medicare Part D Trust Fund. It started on January 1, 2011. Part D-IRMAA is a set amount paid to the government in addition to and separate from the plan premium. As a reminder, this is not paid to the plan. The Part D-IRMAA is required to be paid by those who have Part D coverage and higher income.

Part D-IRMAA is determined each year by the Social Security Administration using the Modified Adjusted Gross Income as reported on, generally, two-year old tax data from the IRS. If an individual is assessed a Part D-IRMAA, SSA notifies the person around the end of November. Individuals who are newly enrolled in Part D will be notified soon after their enrollment takes effect. For example, if you have someone who does not have Part D coverage and during the annual election period they decide to join a plan and they have Part D coverage effective January 1, SSA will send the notice that they have to pay the Part D-IRMAA after their enrollment into the Part D plan. Generally, for individuals who already have Part D coverage, they will receive an annual notice provided their income level stays high enough and that notice will be sent around the end of November. This notice, sent by SSA, includes information on how to appeal the Part D-IRMAA assessment by requesting a reconsideration if that individual believes they are assessed an incorrect amount. These notices also provide information about requesting a new decision when individuals have a life-changing event such as marriage, divorce, if they become widowed, or they stop working. If you are disenrolled because you didn’t pay your Part D IRMAA you can request reinstatement for a "good cause".

PERS ODS Advantage PPORX Monthly Plan Premium reduction for People who get Extra Help from Medicare to Help Pay for their Prescription Drug Costs

If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our plan.

This table shows you how much your monthly plan premium will be reduced if you get extra help.

Your level of extra help	The amount of extra help you will receive each month*
100 percent	$31.10*
75 percent	$23.30*
50 percent	$15.60*
25 percent	$7.80*

*You must continue to pay your Medicare Part B premium each month (if not paid under Medicaid or a third party).

Low-income subsidy
If you are receiving extra help from Medicare to pay for your prescription drugs and you will qualify for the same amount of help next year, the table below tells you how your prescription costs will change.

If you paid this much in 2011	You will pay this much in 2012
$0 deductible	$0 deductible
$1.10 for generics and brands that are treated as generics	$1.10 for generics and brands that are treated as generics
$3.30 for brand-name drugs	$3.30 for brand-name drugs
$2.50 for generics and brands that are treated as generics	$2.60 for generics and brands that are treated as generics
$6.30 for brand-name drugs	$6.50 for brand-name drugs
15 percent coinsurance for all drugs	15 percent coinsurance for all drugs

You may receive a letter from Medicare or the Social Security Administration about your eligibility for extra help in 2012. Read this important information carefully. If you don't know what level of extra help you qualify for, you can call 800-MEDICARE (800-633-4227, TTY/TDD: 877-486-2048). Representatives are available 24 hours a day, seven days a week.

If you aren't getting extra help, you can see if you qualify by calling:

The Social Security Administration at 800-772-1213 (TTY/TDD: 800-325-0778 between 7 a.m. and 7 p.m., Seven days a week)
Your state Medicaid office
800-MEDICARE (800-633-4227, TTY/TDD: 877-486-2048)

If you have any questions, please contact member services.

Best available evidence (BAE)
Beneficiaries are "deemed" eligible for a low-income subsidy (LIS) if they are full-benefit Medicare/Medicaid-eligible, partial dual eligible, are receiving Social Security Income (SSI) or have applied and been awarded LIS by the Social Security Administration. There is a new process for assisting individuals who do not have the required pieces of evidence but claim to be eligible for LIS. If you do not have the required evidence called "best available evidence" (BAE) and believe you are LIS-eligible, please call member services.

For more information, visit the section of the Centers for Medicare and Medicaid Services website regarding the BAE policy.