2019 Allwell Dual Medicare (HMO SNP) H0908: 001

Transcription

1 2019 Allwell Dual Medicare (HMO SNP) H0908: 001 Adams, Allen, Ashtabula, Auglaize, Brown, Butler, Carroll, Champaign, Clark, Clermont, Clinton, Columbiana, Coshocton, Crawford, Cuyahoga, Defiance, Delaware, Erie, Fayette, Fulton, Geauga, Greene, Guernsey, Hamilton, Hancock, Hardin, Harrison, Henry, Highland, Hocking, Holmes, Huron, Lake, Logan, Lorain, Lucas, Madison, Mahoning, Medina, Meigs, Mercer, Miami, Montgomery, Morgan, Morrow, Noble, Ottawa, Paulding, Perry, Pickaway, Pike, Portage, Preble, Putnam, Sandusky, Seneca, Shelby, Stark, Summit, Trumbull, Tuscarawas, Van Wert, Vinton, Warren, Wayne, Williams, Wood, and Wyandot Counties, OH H0908_19_8106SB_001_M Accepted

2 This booklet provides you with a summary of what we cover and the cost-sharing responsibilities. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please call us at the number listed on the last page, and ask for the Evidence of Coverage (EOC), or you may access the EOC on our website at allwell.buckeyehealthplan.com. You are eligible to enroll in Allwell Dual Medicare (HMO SNP) if: You are entitled to Medicare Part A and enrolled in Medicare Part B. Members must continue to pay their Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. You must be a United States citizen, or are lawfully present in the United States and permanently reside in the service area of the plan (in other words, your permanent residence is within the Allwell Dual Medicare (HMO SNP) service area counties). Our service area includes the following counties in Ohio: Adams, Allen, Ashtabula, Auglaize, Brown, Butler, Carroll, Champaign, Clark, Clermont, Clinton, Columbiana, Coshocton, Crawford, Cuyahoga, Defiance, Delaware, Erie, Fayette, Fulton, Geauga, Greene, Guernsey, Hamilton, Hancock, Hardin, Harrison, Henry, Highland, Hocking, Holmes, Huron, Lake, Logan, Lorain, Lucas, Madison, Mahoning, Medina, Meigs, Mercer, Miami, Montgomery, Morgan, Morrow, Noble, Ottawa, Paulding, Perry, Pickaway, Pike, Portage, Preble, Putnam, Sandusky, Seneca, Shelby, Stark, Summit, Trumbull, Tuscarawas, Van Wert, Vinton, Warren, Wayne, Williams, Wood, and Wyandot. You do not have end-stage renal disease (ESRD). (Exceptions may apply for individuals who develop ESRD while enrolled in an Allwell commercial or group health plan, or a Medicaid plan.) For Allwell Dual Medicare (HMO SNP), you must also be enrolled in the Ohio Medicaid plan. Premiums, copays, coinsurance, and deductibles may vary based on your Medicaid eligibility category and/or the level of Extra Help you receive. Your Part B premium is paid by the State of Ohio for full-dual enrollees. Please contact the plan for further details. The Allwell Dual Medicare (HMO SNP) plan gives you access to our network of highly skilled medical providers in your area. You can look forward to choosing a primary care provider (PCP) to work with you and coordinate your care. You can ask for a current provider directory or, for an up-to-date list of network providers, visit allwell.buckeyehealthplan.com. (Please note that, except for emergency care, urgently needed care when you are out of the network, out-of-area dialysis services, and cases in which our plan authorizes use of out-of-network providers, if you obtain medical care from out-of-plan providers, neither Medicare nor Allwell Dual Medicare (HMO SNP) will be responsible for the costs.) This Allwell Dual Medicare (HMO SNP) plan also includes Part D coverage, which provides you with the ease of having both your medical and prescription drug needs coordinated through a single convenient source.

3 Summary of Benefits JANUARY 1, DECEMBER 31, 2019 Benefits Allwell Dual Medicare (HMO SNP) H0908: 001 Premiums / Copays / Coinsurance Premiums, copays, coinsurance, and deductibles may vary based on your Medicaid eligibility category and/or the level of Extra Help you receive. Monthly Plan Premium You pay up to $32.90 based on your level of Medicaid eligibility (You must continue to pay your Medicare Part B premium, if not otherwise paid for by Medicaid or another third party.) Deductible $0 -$183 deductible for covered medical services. $183 is the 2018 Part B deductible. This amount may change for $50 deductible for Part D prescription drugs (applies to drugs on Tiers 2, 3, 4 and 5) Maximum Out-of-Pocket Responsibility (does not include prescription drugs) $3,400 annually This is the most you will pay in copays and coinsurance for medical services for the year. Inpatient Hospital Coverage* Outpatient Hospital* Doctor Visits* Preventive Care* (e.g. flu vaccine, diabetic screening) Emergency Care Urgently Needed Services In 2018, the amounts for each benefit period were: $0 or, $1,340 hospital deductible for each benefit period. $0 copay for days 1 through 60 $335 copay per day for days 61 through 90 $670 copay per day per lifetime reserve days (may change in 2019) Outpatient Hospital (includes ambulatory surgical center and observation services): 0% or 20% coinsurance per visit Primary Care: 0% or 20% coinsurance per visit Specialist: 0% or 20% coinsurance per visit $0 copay for most Medicare-covered preventive services Other preventive services are available. 0% or 20% coinsurance (up to $120) per visit You do not have to pay the copay if admitted to the hospital immediately. 0% or 20% coinsurance (up to a maximum of $65) per visit

4 Benefits Allwell Dual Medicare (HMO SNP) H0908: 001 Premiums / Copays / Coinsurance Diagnostic Services/Labs/ Imaging* Hearing Services Dental Services Lab services: 0% or 20% coinsurance Diagnostic tests and procedures: 0% or 20% coinsurance Outpatient X-ray services: 0% or 20% coinsurance Diagnostic Radiological services: 0% or 20% coinsurance Hearing exam (Medicare-covered): 0% or 20% coinsurance Routine hearing exam: $0 copay (1 every calendar year) Hearing aid: $0 copay (2 hearing aids every year) Dental services (Medicare-covered): 0% or 20% coinsurance per visit Preventive Dental Services: $0 copay (including oral exams, cleanings, and X-rays) Comprehensive dental services: $0 copay (including diagnostic and restorative services, endodontics, periodontics, extractions, prosthodontics, and other oral and maxillofacial surgery) There is a maximum allowance of $1,000 every calendar year; it applies to all comprehensive dental benefits. Vision Services Vision exam (Medicare-covered): 0% or 20% coinsurance per visit Routine eye exam: $0 copay per visit (up to 1 every calendar year) Routine eyewear: up to $200 allowance every year Mental Health Services* Individual and group therapy: 0% or 20% coinsurance per visit Skilled Nursing Facility * In 2018, the amounts for each benefit period were $0 or: $0 copay per day, days 1 through 20 $ copay per day, days 21 through 100 (may change for 2019) Physical Therapy* Ambulance* 0% or 20% coinsurance per visit 0% or 20% coinsurance (per one-way trip) Transportation* Medicare Part B Drugs* $0 copay for each one-way trip Up to 48 one-way trips to plan-approved locations (up to 30 miles each one way per trip) each calendar year. Chemotherapy drugs: 0% or 20% coinsurance Other Part B drugs: 0% or 20% coinsurance

5 Deductible Phase Part D Prescription Drugs $50 deductible (Deductible does not apply to Tiers 1, and 6.) Initial Coverage Phase (after you pay your Part D deductible, if applicable) Tier 1: Preferred Generic $0 copay Standard Retail Rx 30-day supply $0 copay Tier 2: Generic $20 copay $60 copay Tier 3: Preferred Brand $47 copay $141 copay Tier 4: Non-Preferred $100 copay $300 copay Drug Tier 5: Specialty 32% coinsurance Not available Tier 6: Select Care Drugs $0 copay Important Info: $0 copay Mail-Order Rx 90-day supply Cost-sharing may change depending on the level of help you receive, the pharmacy you choose (such as Standard Retail, Mail- Order, Long-Term Care or Home Infusion) and when you enter another of the four phases of the Part D benefit. For more information about the costs for Long-Term Supply, Home Infusion, or additional pharmacy-specific cost-sharing and the phases of the benefit, please call us or access our EOC online. Low income subsidy (LIS) is extra help you receive from Medicare. To find out if you qualify, visit Medicare.gov or call Member Services at (TTY: 711). Medicaid has no copayments on Medications Refer to preferred drug formulary. Some over the counter drugs are covered with written prescription. Medication that is not listed requires a prior authorization. Some drugs have limitations on age, dosage or maximum quantities.

6 Additional Covered Benefits Benefits Allwell Dual Medicare (HMO SNP) H0908: 001 Premiums / Copays / Coinsurance Over-the-Counter (OTC) Items Meals* $0 copay ($80 allowance per month for items available via mail order) Please visit the plan s website to see the list of covered over-thecounter items. $0 copay Plan covers home-delivered meals (up to 2 meals per day for 14 days) following discharge from an inpatient facility or skilled nursing facility provided the meals are medically necessary and ordered by a physician or practitioner. Chiropractic Care* Chiropractic services (Medicare-covered): 0% or 20% coinsurance per visit Medical Equipment/ Durable Medical Equipment (e.g., wheelchairs, oxygen): 0% or Supplies* 20% coinsurance Prosthetics (e.g., braces, artificial limbs): 0% or 20% coinsurance Diabetic supplies: 0% or 20% coinsurance Foot Care* Foot exams and treatment (Medicare-covered): 0% or 20 (Podiatry Services) coinsurance Wellness Programs Fitness program: $0 copay 24-hour nurse advice line: $0 copay Coverage for one Personal Emergency Medical Response Device per lifetime and monthly fee For a detailed list of wellness program benefits offered, please refer to the EOC.

7 Comprehensive Written Statement for Prospective Enrollees The benefits described in the Premium and Benefit section of the Summary of Benefits are covered by our Medicare Advantage plan. For each benefit listed, you can see what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. Coverage of the benefits described in this Summary of Benefits depends upon your level of Medicaid eligibility. No matter what your level of Medicaid eligibility is, Buckeye Health Plan Medicaid will cover the benefits described in Benefit section of the Summary of Benefits. If you have questions about your Medicaid eligibility and what benefits you are entitled to, call Ohio Department of Medicaid toll-free at Our source of information for Medicaid benefits All Medicaid covered services are subject to change at any time. For the most current Ohio Medicaid coverage information, please visit or call Member Services for assistance. A detailed explanation of Ohio Medicaid benefits can be found in the OH Summary of Services online at Benefit Ambulance Description If you are having a medical emergency, call 911 for an ambulance. If you need assistance in getting to routine health care services (such as appointments with your doctor or regularly scheduled treatments) that are covered by Medicaid, contact your county department of job & family services. If you need non emergency transport by ambulance or wheelchair van, call the Medicaid Consumer Hotline at for a list of providers in your area. (Note: Medicare covers certain non- emergency trips by ambulance.) Chiropractic Care Dental Services $0 copay for Medicaid-covered services. 30 visits every 12 months for children younger than age 21; 15 visits every 12 months for adults older than age 21 $0 copay for Medicaid-covered services. Dental Check-ups and Cleaning: Once every 6 months for children and once every 12 months for adults $3 per dental visit Extractions and Fillings: Services performed as needed $3 per dental visit Dentures and Partial Plates: Must be prior authorized. They may be replaced every 8 years. $3 per dental visit Braces: Services must have pre-authorization. $3 per dental visit

8 Dermatology (Skin) Services Doctor s Office Visits Emergency Care Family Planning Visits and Services Hearing Services Home Health Care Lab Testing and X-rays Long-term Home and Community Care Options or Waiver Services Outpatient Rehabilitation Must be medically necessary and related to a disease or condition. Up to 24 visits every 12 months with additional visits for specified conditions $0 copay for Medicaid-covered services. Covered as needed and when medically necessary. Some hospital services require prior authorization. Your doctor will get this before your hospital stay. $3 copay for Medicaid non- emergency services obtained in a hospital emergency room. Otherwise, there are no member costs for Medicaid- covered services. Visits and services are covered as needed. $0 copay for Medicaidcovered services. One conventional hearing aid every four years; one digital or programmable hearing aid every five years $0 copay for Medicaid-covered services. Part-time health care in your home. A home health visit is less than or equal to 4 hours. Nursing, nurse aide, and skilled physical, occupational, and speech therapy services must be medically necessary and ordered by your doctor after a face-toface encounter is documented within 6-months. There are defined service limits. $0 copay for Medicaid-covered services. Annual chest x-rays for long-term care facility residents. Medically necessary services that are ordered by a physician are covered, as well as mammograms. $0 copay for Medicaid-covered services. If you need long-term care but want to stay in your home, you may be able to do so through one of the home and community-based services waiver programs. Your Medicaid caseworker will determine a Patient Liability amount based on your income excluding certain deductions. $0 copay for these Medicaid-covered services: Speech Therapy: 30 visits for speech/language pathology and audiology services combined every 12 months, prior authorization needed for additional visits Physical Therapy: 30 visits for physical and occupational therapy combined every 12 months, prior authorization needed for additional visits Occupational Therapy: 30 visits forphysical and occupational therapy combined every 12 months, prior authorization needed for additional visits

9 Outpatient Surgery Covered as needed and when medically necessary. Some hospital services require prior authorization. Your doctor will get this before your hospital stay. $3 copay for Medicaid non- emergency services obtained in a hospital emergency room. Otherwise, there are no member costs for Medicaid-covered services. Pre-natal and Postpartum Doctor Visits Ultrasounds Childbirth Classes Labor & Delivery Hospital Stay Health Care for Baby Preventive Services All pregnancy related services are covered. Services include: education, care coordination, counseling, high risk monitoring, nurse midwife services, preconception care, prenatal care, ultrasounds, prenatal risk assessment, delivery, and transportation $0 copay for Medicaid-covered services Mammogram: Contact the Ohio Department of Medicaid for more information. $0 copay for Medicaid-covered services Prostate (Cancer) Tests: For men, once a year starting at age 50 $0 copay for Medicaid- covered services Pap Smears and Pelvic Exams: Once a year for women ages 18 and older and sexually active adolescents $0 copay for Medicaid- covered services Private Duty Nursing (PDN) Physical exam required for job placements: Exam is covered if not offered free of charge by employer. $0 copay for Medicaid-covered services Continuous nursing care in your home. A PDN visit is more than 4 hours and less than or equal to 12 hours. PDN nursing must be prior authorized by Ohio Department of Medicaid, medically necessary and ordered by your doctor after a face-to-face encounter is documented within 6-months. There are defined service limits. $0 copay for Medicaid-covered services.

10 Transportation If you are having a medical emergency, call 911 for an ambulance. If you need assistance in getting to routine health care services (such as appointments with your doctor or regularly scheduled treatments) that are covered by Medicaid, contact your county department of job & family services. If you need non-emergency transport by ambulance or wheelchair van, call the Medicaid Consumer Hotline at for a list of providers in your area. (Note: Medicare covers certain non emergency trips by ambulance.) $0 copay for Medicaid-covered services. Vision Services Regular Eye Exams: If you are years old: once every 24 months. If you are 20 years old or younger, or 60 years old or older: once every 12 months. $2 per routine exam. Eye Glasses: If you are years old: one pair every 24 months. If you are 20 years old or younger, or 60 years old or older: one pair every 12 months. $1 per eye glass fitting. Contact Lenses, Tinted Lenses, Prosthetic Eye, and Low-Vision Aids: These items must be prior authorized and be medically necessary. $0 copay for Medicaid-covered services Prescription Drug Coverage Medicaid only covers drugs that are excluded from Medicare Part D coverage such as: Vitamins (except potassium, prenatal vitamins and fluoride) Cough suppressants Over the Counter (OTC) drugs that do not have a Medicare Part D-covered equivalent $2 copay for most brand name non-generic prescriptions $3 copay for prescriptions that require prior authorization.

11 Section 1557 Non-Discrimination Language Notice of Non-Discrimination Allwell complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Allwell does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Allwell: Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Allwell s Member Services telephone number listed for your state on the Member Services Telephone Numbers by State Chart. From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. If you believe that Allwell has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by calling the number in the chart below and telling them you need help filing a grievance; Allwell s Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Offce for Civil Rights, electronically through the Offce for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, (TTY: ). Complaint forms are available at Member Services Telephone Numbers by State Chart State Telephone Number and Plan Type Arizona / (HMO and HMO SNP) (TTY: 711) Arkansas (HMO) (TTY: 711) Florida (HMO); (HMO SNP) (TTY: 711) Georgia (HMO); (HMO SNP) (TTY: 711) Illinois (HMO) (TTY: 711) Indiana (HMO and PPO); (HMO SNP) (TTY: 711) Kansas (HMO); (HMO SNP) (TTY: 711) Louisiana (HMO) (TTY: 711) Mississippi (HMO); (HMO SNP) (TTY: 711) Missouri (HMO); (HMO SNP) (TTY: 711) New Mexico (HMO SNP) (TTY: 711) Ohio (HMO); (HMO SNP) (TTY: 711) Pennsylvania (HMO); (HMO SNP) (TTY: 711) South Carolina (HMO and HMO SNP) (TTY: 711) Texas (HMO); (HMO SNP) (TTY: 711) Wisconsin (HMO SNP) (TTY: 711) ALL_19_8450FLY_C_ACCEPTED_

12 Section 1557 Non-Discrimination Language Multi-Language Interpreter Services

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14 Allwell is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Allwell depends on contract renewal. FLY020520ZK00 (8/18)

15 For more information, please contact: Allwell Dual Medicare (HMO SNP) 4349 Easton Way, Suite 300 Columbus, OH allwell.buckeyehealthplan.com Current members should call: (TTY: 711) Prospective members should call: (TTY: 711) From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call This plan is available to anyone who has both Medical Assistance from the State and Medicare. You must continue to pay your Medicare Part B premium. However, for full-dual beneficiaries, the State will cover your Part B premium as long as you retain your Medicaid eligibility. This information is not a complete description of benefits. Call (TTY: 711) for more information. Coinsurance is the percentage you pay of the total cost of certain medical and prescription drug services. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. This document is available in other formats such as Braille, large print or audio. Allwell is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Allwell depends on contract renewal. SBS020692EK00 (6/18)