First Choice VIP Care PLUS MMP Benefits
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1 First Choice VIP Care PLUS MMP Benefits
2 First Choice VIP Care PLUS covers all Original Medicare and Healthy Connections Medicaid Medical Benefits Medicare Parts A and B benefits Medicare Part D prescription drug benefits Healthy Connections Medicaid benefits Long Term Services and Supports (LTSS) benefits for the: Community Choices Waiver HIV/AIDS Waiver and Mechanical Ventilator Dependent Waiver First Choice VIP Care Plus does not charge deductible, coinsurance, or a copayment for Original Medicare and Healthy Connections Medicaid Medical Benefits to the member, except for some Medicaid only covered services. 2
3 Benefits Medicare vs. Medicaid: Which Program Pays for What Service? PLAN NAME MEDICARE PARTS A & B MEDICARE PART D HEALTHY CONNECTIONS MEDICAID Medicaid South Carolina Department of Health and Human Services NA NA Medicare Fee for Service or Medicare Advantage (MAPD) Not applicable for non-dual Medicare beneficiaries FFS for dual eligible beneficiaries First Choice VIP Care Plus Medicare Medicaid Plan 3
4 Benefits Medicare Part A and B Benefits * ** Ambulance Services Cardiac and Pulmonary Rehabilitation Services Catastrophic Coverage Chiropractic Care Dental Services Diabetes Program and Supplies Diagnostic Tests, X-Rays, Lab Services, and Radiology Services Doctor Office Visits Durable Medical Equipment Emergency Care Hearing Services Home Health Care Hospice - Initial Consultation Inpatient Hospital Care Inpatient Mental Health Care Out-of Network Catastrophic Coverage Out-of-Network Initial Coverage Outpatient Mental Health Care Outpatient Rehabilitation Outpatient Services/Surgery Outpatient Substance Abuse Care Pharmacy LTC Pharmacy Mail Order Prescriptions Out-of-Network catastrophic Prescriptions Outpatient Prescription Drugs Podiatry Preventive Services and Wellness/Education Prosthetic Devices Skilled Nursing Facility Urgent Care *Exceptions may apply, see provider manual for full list of benefits. ** Prior authorization may be required. 4
5 Benefits Medicaid Benefits * ** Adult Day Health Transportation Skilled Nursing Facility Home Health Services Durable Medical Equipment Prosthetics/Medical Supplies Family Planning Personal Care Services (Personal Care I and II) Private Duty Nursing Institution for Mental Disease Pharmacy Services Dialysis for End-Stage Renal Disease (ESRD) Medicaid Targeted Case Management Health Education Behavioral Health Services (Rehabilitative Behavioral Health) Outpatient Mental Health Services (Community mental health services) Infusion Centers/Services Nursing Home Transition Services (Home Again) Tele-psychiatry *Exceptions may apply, see provider manual for full list of benefits. ** Prior authorization may be required. 5
6 Carved Out Medicare and Medicaid Benefit Covered by Medicaid Fee for Service: Non-Emergency Medical Transportation Services. Adult Dental. Covered by Medicare Fee for Service: Hospice Services. 6
7 Long Term Services and Supports (LTSS) Benefits
8 What are Long Term Services and Supports (LTSS)? Long Term Services and Supports (LTSS) are services and supports for persons with chronic illnesses/functional limitations which have the primary purpose of supporting the person s ability to live or work in the setting of his/her choice. Examples include: Assistance with bathing. Assistance with dressing and other basic activities of daily life. Support for everyday tasks such as laundry, shopping, and transportation. Managed Long Term Services and Supports (MLTSS) refers to the delivery of long term services and supports through capitated Medicaid managed care programs. Increasing numbers of states are using MLTSS as a strategy for expanding homeand community-based services, promoting community inclusion, ensuring quality and increasing efficiency. 8
9 What are Medicaid Waivers? Waivers are the state specific Medicaid programs that allow for long term services and supports to be provided outside of nursing homes. Waivers may also be referred to as: 1915 waivers (for the Social Security Act) Home and community based services (HCBS) waivers Waiver services/programs And by any number of other state-specific names Healthy Connections Prime will include three of the nine South Carolina waiver programs; Community Choices, HIV/AIDS, and Mechanical Ventilator Dependent waivers. 9
10 Katie Beckett and her parents History of the Waiver Program Shaped by a Movement 10
11 She is the child who inspired the waiver programs. At 5 months old she was confined to a hospital for almost three years due to contracting encephalitis and needing the aid of a ventilator to breathe for most of the day. Who Is Katie Beckett? After exhausting private insurance benefits, Medicaid picked up, but would only cover services within the hospital. Her parents wanted her home and the doctors agreed. Federal officials refused to make an exception, but Ronald Reagan was told about the family and he changed the Medicaid rules. Katie was able to go home and, despite the odds, lived to age 34 due in part to being able to live a pretty normal life at home. 11
12 The name waiver comes from the fact that the federal government "waives" Medical Assistance/ Medicaid rules for institutional care to allow for states to use the same funds to provide these supports and services for people in their homes or in their own communities. Birth of the Waiver Programs 12
13 Adult Day Health Care. Case Management. Personal Care (I and II). Adult Care Home Services. Adult Companion Care. Adult Day Health Care Transportation. Attendant Care. Community Residential Personal Assistance (CRPA). Home Accessibility Adaptations. Home delivered meals. Nursing Home Transition Service. Personal Emergency Response System. Specialized Medical Equipment and Supplies. Telemonitoring. Benefits Community Choices Waiver 13
14 Case Management. Personal Care (I and II). Benefits- HIV/Aids Waiver Prescription Drugs, except drugs furnished to participants who are eligible for Medicare Part D benefits. Adult Companion Care. Attendant Care Services. Home Accessibility Adaptations. Home Delivered Meals. Private Duty Nursing. Specialized Medical Equipment and Supplies. 14
15 Personal Care (I and II). Respite. Prescription Drugs, except drugs furnished to participants who are eligible for Medicare Part D benefits. Attendant Care. Home Accessibility Adaptations. Personal Emergency Response System. Pest Control. Private Duty Nursing. Specialized Medical Equipment and Supplies. Benefits- Mechanical Ventilator Dependent Waiver 15
16 Incontinence Supplies Oral Nutritional Supplements Miscellaneous Supplies and Equipment Other Benefits/ Services Flexible Benefits - members who are in the application process for one of the three (3) waiver programs listed above may be eligible for waiver-like services during that time period, if the First Choice VIP Care Plus Care Coordinator determines that the services are necessary to avoid or delay nursing home placement as identified through an assessment conducted by the care coordinator or by physician recommendation/order. Members referred by First Choice VIP Care Plus and accepted in to a waiver program will not be placed on a waiting list. 16
17 If your office identifies a patient who is a member of First Choice VIP Care Plus that you believe can benefit from these types of long term service and supports please contact our Care Management Department at Identifying Patients with These Needs 17
18 Non-covered Benefits / Services First Choice VIP Care Plus will refer members to local resources for services that are not covered by First Choice VIP Care Plus, such as supportive, affordable housing, and other social services that maximize community integration, as appropriate. Providers may contact the First Choice VIP Care Plus Care Management team at for assistance with coordination of noncovered services. 18
19 Benefits 24/7/365 Nurse Line If members are unable to reach their PCP s office, registered nurses are available 24/7days to assist members through the Nurse toll-free Call Line. First Choice VIP Care Nurse Call Line: Please encourage our members to take advantage of this option. 19
20 Interpretation Services Free language services for First Choice VIP Care Plus members anywhere, anytime. Call Provider/Member Services OR the 24 Hour Nurse Help Line 1-(855) to be connected. 20
21
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PROFESSIONAL SERVICES PCP office visits Specialist office visits Annual physical exam/preventive care Physical, Speech & Occupational Therapy Cardiac/Pulmonary Rehab Flu & Pneumonia Vaccinations Diagnostic
Our service area includes Florida.
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Dual Complete RP ONE (Regional PPO SNP) R7444-013 Look inside to learn more about the health services and drug coverages the plan provides.
Anthem Blue Cross Effective: January 1, 2017 Your Plan: University of California High Option Supplement to Medicare
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2012 Summary of Benefits
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2018 SUMMARY OF BENEFITS
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Summary of benefits Health Net. seniority plus green. Benefits effective January 1, 2009 H0562 Medicare Advantage HMO
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Summary of Benefits. Available in Delaware, Nassau, and Rockland Counties, NY
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MEDICARE By Peter G. Pan
Wendell K. Kimura Acting Director Research (808) 587-0666 Revisor (808) 587-0670 Fax (808) 587-0681 LEGISLATIVE REFERENCE BUREAU State of Hawaii State Capitol Honolulu, Hawaii 96813 No. 02-13 October 7,
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2019 Health Net Seniority Plus Amber I (HMO SNP) H0562: 055 Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco
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Our service area includes these counties in: Arizona: Apache, Coconino, Maricopa, Mohave, Navajo, Pinal, Yavapai.
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Dual Complete ONE (HMO SNP) H0321-004 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer
2013 SUMMARY OF BENEFITS Brand New Day HMO D Special Needs Plan (SNP) (For Members with Medicare & Medi-Cal)
2013 SUMMARY OF BENEFITS Brand New Day HMO D Special Needs Plan (SNP) (For Members with Medicare & Medi-Cal) H0838_2013SB_024_File & Use: Contract#H0838 SECTION I - INTRODUCTION TO SUMMARY
Our service area includes these counties in:
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Dual Complete (HMO SNP) H0432-009 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer