2019 Benefits-At-A-Glance
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1 2019 Benefits-At-A-Glance MolinaHealthcare.com/Duals Molina Dual Options Medicare-Medicaid Plan South Carolina
2 2019 Benefits-At-A-Glance Molina Dual Options Monthly Premium Monthly Premium Services/Coverage Medical and Hospital Benefits Doctor Visits Visits to treat an injury or illness Wellness visits, such as a physical; includes annual wellness visit every 12 months Specialist care Care to keep you from getting sick, such as flu shots Welcome to Medicare preventive visit (one time only) Medical Tests Lab tests, such as blood work (authorization rules may apply; outpatient lab services do not require prior authorization) X-rays or other pictures, such as CAT scans (authorization rules may apply; outpatient X-ray services do not require prior authorization) Screening tests, such as tests to check for cancer (authorization rules may apply) Therapy After a Stroke or Accident Occupational, physical, or speech therapy (authorization rules may apply) Chiropractic services (only for manual manipulation for certain approved conditions) Emergency Room Services You may get covered emergency medical care whenever you need it, anywhere in the United States or its territories, without prior authorization. Not covered outside the U.S. and its territories except under limited circumstances. Contact plan for details. Ambulance Services Prior Authorization rules may apply for non-emergency Ambulance services. Authorization is not required for emergency transportation. Urgent Care You may get urgent care services whenever you need it, anywhere in the United States or its territories, without prior authorization. Not covered outside the U.S. and its territories except under limited circumstances. Contact plan for details. Hospital Care (authorization rules may apply) Hospital stay Doctor or surgeon care Rehabilitation Services Medical Equipment for Home Care Authorization rules may apply. You must talk to your provider and get a referral for specialized supplies. You Pay
3 Medical and Hospital Benefits (Continued) Skilled Nursing Care You must talk to your provider and get a referral. Medicare-covered stays (for example, rehabilitation) and Healthy Connections Medicaid-covered stays (for example, long term skilled nursing facility stays) require prior authorization. Eye Care Treatment for eye injuries or diseases Initial replacement of lens due to cataract surgery Dental Care (authorization rules may apply) Emergency medical procedures by oral surgeons Dental procedures related to organ transplants, cancer, joint replacement, heart valve replacement, and trauma Foot Care/Podiatry Services Hearing/Auditory Services Includes hearing screening exam to diagnose and treat hearing and balance issues Chronic Conditions, Such as Diabetes or Heart Disease Services to help manage your disease; includes self-management training and disease management program for diabetics Diabetes supplies and services; includes diabetic monitoring supplies and therapeutic shoes or inserts (authorization rules may apply) Cardiac and pulmonary rehabilitation services Mental Health Mental or behavioral health services: Outpatient group or individual therapy visit Partial hospitalization (authorization rules may apply) Long-term services: Impatient mental health care (authorization rules may apply) Substance Abuse Services Outpatient group or individual therapy visit Durable Medical Equipment Wheelchairs, Crutches, IV infusion pumps, Oxygen equipment and supplies, Nebulizers and Walkers (authorization rules may apply; you must talk to your provider and get a referral) Prosthetic Devices (authorization rules may apply)
4 Medical and Hospital Benefits (Continued) Home Services (authorization rules may apply) Meals brought to your home: Up to 2 meals every day 1 Homemaker services, such as cleaning or housekeeping 1 2 Changes to your home, such as ramps and wheelchair access (environmental modifications benefit has a $7,500 lifetime limit) 1 Personal care services (you may be able to choose your own aide) 1 2 Home health care services; includes incontinence supplies (the amount and frequency are based on medical necessity) Adult day services or other support services 2 Nursing Home Care You must talk to your provider and get a referral. Authorization rules may apply. You must contribute toward the cost of this service when your income is more than an allowable amount. This contribution, known as the patient pay amount, is required only for those living in a nursing home. You will not need to pay if you are in the nursing home for short-term rehabilitation. These services are available only if your need for long-term care has been determined by Healthy Connections Medicaid. Respite Care Respite care may be available based on your situation and availability of provider. The type of care you are qualified to get will depend on your situation. Authorization rules may apply. 2 Palliative Care Care for advanced illness or life-threatening injury (you must talk to your provider and get a referral; authorization rules may apply) Family Planning Services Family planning supplies are covered only with a prescription Family planning lab and diagnostic tests Treatment for sexually transmitted infections (STIs) Prescription Drugs and Over-the-Counter (OTC) Items Generic and Brand Name Drugs There may be limitations on the types of drugs covered. A 90 day supply is available at a retail and mail order pharmacy at no additional cost. There may be certain drugs that are limited to a 31-day supply. Some drugs have quantity limits. Non-Medicare Prescriptions/Over-the-Counter (OTC) Drugs There may be limitations on the types of drugs covered. Over-the-Counter (OTC) Items You get $75 every 3 months, with carry over, for non-prescription OTC products like vitamins, sunscreen, pain relievers, cough/cold medicine, and bandages. Allowance expires at the end of the calendar year. or amount based on income for a 31-day supply 1 Long Term Services and Supports (LTSS) are offered to all plan members as medically necessary. 2 You must talk to your provider and get a referral.
5 Prescription Drugs and Over-the-Counter (OTC) Items (Continued) Medicare Part B Prescription Drugs Authorization rules may apply. Part B drugs include drugs given by your doctor in his or her office, some oral cancer drugs, and some drugs used with certain medical equipment. Additional Benefits Education and Wellness Programs End Stage Renal Disease Services Hearing Services Routine hearing exam: Up to 1 every year Hearing aid fitting/evaluation: Up to 1 every 2 years Hearing aids: Plan pays up to $1,000 every 2 years for hearing aids Infusion Services Nursing Home Transition Services Preventive Services Services Provided at Federally Qualified Health Centers Targeted Case Management Telemedicine Vision Services One routine eye exam per year Up to $150 every 2 years for eyeglasses (frames and lenses) Exam to diagnose and treat diseases and conditions of the eye Molina Dual Options Medicare-Medicaid Plan is a health plan that contracts with both Medicare and South Carolina Healthy Connections Medicaid to provide benefits of both programs to enrollees. Product offered by Molina Healthcare of South Carolina, Inc., a wholly owned subsidiary of Molina Healthcare, Inc. You can get this document for free in other formats, such as large print, braille, or audio. Call (855) , TTY/TDD: 711, 7 days a week, 8 a.m. to 8 p.m., local time. The call is free. This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. For information on Molina Dual Options Medicare-Medicaid Plan and other options for your health care, call South Carolina Healthy Connections Choices Customer Service Center at (877) , TTY (877) , from Monday Friday, 8 a.m. to 6 p.m., or visit H2533_19_16930_40_SCMMPBAAG Approved 1/28/2019
6 Learn more. Contact us today. Call (855) , TTY/TDD days a week, 8 a.m. to 8 p.m., local time MolinaHealthcare.com/Duals MMP0119
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