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Your Benefit Options

The Health Options Program provides medical, prescription drug and dental benefits for Medicare-eligible individuals through Medicare Supplement plans or Medicare Advantage plans. The Health Options Program also offers medical and prescription drug benefits for non-Medicare-eligible individuals. You may find this decision guide helpful in electing coverage under the Health Options Program. Read on for more details about each of the options.

If You Are Medicare-Eligible

The HOP Medical Plan

If you keep Original Medicare, you can supplement it by enrolling in the HOP Medical Plan. This Plan covers many of the deductibles, coinsurance and other expenses that you are required to pay under Original Medicare. In addition:

  • You have the freedom to use virtually any health care provider (doctor or hospital) you want.
  • You pay nothing for covered hospital and medical expenses, except for $10 per physician visit or $15 per specialist visit.
  • You’re covered anywhere in the United States and abroad when you are traveling.
  • You can add prescription drug coverage by enrolling in the Enhanced, Basic or Value Medicare Rx Option.
  • You can enroll in the option that includes the MetLife Dental Plan.
  • You have SilverSneakers® Fitness at no additional cost.

The Value Medical Plan

The Value Medical Plan is for retirees who want a low monthly premium and are willing to pay more out of pocket when obtaining services. It is designed to provide financial protection in the event of unexpected high-cost hospital and medical expenses. In addition:

  • You have the freedom to use virtually any health care provider (doctor or hospital) you want.
  • You pay a $300 per admission copay if you are admitted to the hospital, then the Plan pays 100% of Medicare's hospital deductible and daily copays.
  • The Value Medical Plan coverage for services provided abroad is limited to those covered by Medicare.
  • The Plan limits your share of the medical expenses after you pay Medicare's annual deductible ($185 in 2019). For example, when you visit a physician and you've already met your deductible, you pay 20% of the Medicare-approved cost of the visit, up to a maximum of $20.
  • You can add prescription drug coverage by enrolling in the Enhanced, Basic or Value Medicare Rx Option.
  • You can enroll in the option that includes the MetLife Dental Plan.
  • Unlike the HOP Medical Plan, the Value Medical Plan does not provide any additional coverage if you exhaust your Medicare benefits, nor does it include a SilverSneakers membership.

The Enhanced, Basic and Value Medicare Rx Options

The Enhanced, Basic and Value Medicare Rx Options are Medicare prescription drug (Part D) plans designed specifically for HOP Medical Plan and Value Medical Plan participants and their eligible dependents. You can choose a Medicare prescription drug option with or without enrolling in the HOP Medical Plan or the Value Medical Plan. However, if you choose a prescription drug plan on a standalone basis (without a Medicare Supplement plan), you will not be eligible for Premium Assistance.

  • Enhanced Medicare Rx Option: You have no deductible and pay the least of the three options for certain medications, such as for brand-name drugs in Initial Coverage. The Enhanced Medicare Rx Option also covers certain medications not covered at all under the Basic Medicare Rx Option, the Value Medicare Rx Option or Medicare prescription drug programs offered by commercial carriers.
  • Basic Medicare Rx Option: Like the Enhanced Medicare Rx Option, the Basic Medicare Rx Option has no deductible, but provides a lower level of coverage than the Enhanced Medicare Rx Option for certain medications.
  • Value Medicare Rx Option: The Value Medicare Rx Option is for retirees who are willing to pay Medicare's annual prescription drug deductible for a lower monthly premium. It is designed to provide financial protection in the event of unexpected high-cost prescription drug expenses. After you meet the annual deductible, you pay 25% of the cost of any medication in Initial Coverage.

MetLife Dental Plan

When you become eligible for Medicare, you and your spouse, if he or she is also Medicare-eligible, can enroll in the MetLife Dental Plan if you enroll in either the HOP Medical Plan or the Value Medical Plan. The MetLife Dental Plan is not available on a standalone basis or with a Medicare Advantage plan.

If you do not enroll in the Dental Plan when you are first eligible or if you enroll but choose to drop your coverage at a later date, you will not be able to re-enroll in dental coverage in the future, unless you experience a Qualifying Event.

Learn more about the MetLife Dental Plan here.

Medicare Advantage Plans

You can choose a Medicare Advantage plan (also known as a Medicare Part C plan) instead of Original Medicare and the HOP Medical Plan or the Value Medical Plan.

  • A Medicare Advantage plan combines medical and prescription drug benefits in a single program. You cannot enroll for medical coverage without prescription drug coverage, or vice versa. Therefore, if you choose this option, you cannot enroll in any other Medicare prescription drug plan.
  • Medicare Advantage plans available through the Health Options Program are offered by Highmark, Aetna, Independence BlueCross, Capital BlueCross and UPMC. These insurance companies have contracted with the federal government to provide Medicare benefits. Each insurance company sets its own benefits and member rates.
  • In addition, since each Medicare Advantage plan serves only certain areas, the plans available to you depend on where you live. If you enroll in a Medicare Advantage plan, you must use its network of providers to receive maximum benefits.

If You Are Not Medicare-Eligible

The HOP Pre-65 Medical Plan

The HOP Pre-65 Medical Plan covers hospital, surgical, and medical services and offers an option for prescription drug coverage:

  • Except for a free physical exam each year that requires no deductible, you must meet a $1,500 annual deductible before the Plan pays benefits.
  • Once you meet the deductible, you pay 25% of the cost for network providers and 40% of the cost for out-of-network providers.
  • If your annual out-of-pocket spending reaches $5,500 in a calendar year, the Plan will pay 100% of your covered medical expenses for the rest of the year, up to a $300,000 annual maximum benefit.
  • The Plan also includes a fitness benefit through the SilverSneakers® Fitness Program.

You can elect to enroll in the HOP Pre-65 Medical Plan with or without prescription drug coverage, but you cannot enroll for prescription drug coverage only. If you choose prescription drug coverage, you must meet a $350 annual deductible (separate from the medical deductible). Once you meet the deductible, you pay 50% of the cost for most generic and brand-name drugs that you purchase either at a local network pharmacy or by mail.

  • Please note the following Click here for an overview of the benefits for pre-65 participants, and the type of coverage available.

The Pre-65 Managed Care Plans

You have an option to enroll in a Pre-65 Managed Care Plan instead of the HOP Pre-65 Medical Plan. The Pre-65 Managed Care Plans provide benefits designed especially for the Health Options Program and include both medical and prescription drug coverage. You must use a provider in the MCO's network to receive the maximum benefit. See the regional Managed Care Plan guides for descriptions of the Managed Care Plans available where you live, the benefits they provide and their rates.

An Overview of Plan Options

Below is a general overivew of the plan options. Use the Coverage and Premium lookup tool to find out which plans are available where you live and their premiums.

Plan options
If You Are Medicare-eligible,
you can choose to enroll in:
If you are not eligible for Medicare,
you can choose to enroll in:
  • HOP Medical Plan only
  • HOP Medical Plan with Enhanced Rx Option
  • HOP Medical Plan with Basic Rx Option
  • HOP Medical Plan with MetLife Dental Plan
  • HOP Medical Plan with Enhanced Rx Option and MetLife Dental Plan
  • HOP Medical Plan with Basic Rx Option and MetLife Dental Plan
  • Enhanced Medicare Rx Option*
  • Basic Medicare Rx Option*
  • Value Medical Plan only
  • Value Medical Plan with Value Rx Option
  • Value Medical Plan with MetLife Dental Plan
  • Value Medical Plan with Value Rx Plan and MetLife Dental Plan
  • Value Medicare Rx Option**
  • A Managed Care Plan (Medicare Advantage Plan)
  • HOP Pre-65 Medical Plan only (no prescription drug coverage)
  • HOP Pre-65 Medical Plan with prescription drug coverage
  • A Pre-65 Managed Care Plan

* Can be combined with the Value Medical Plan.
** Can be combined with the HOP Medical Plan.

 

Last updated: August 1, 2019