2019 Summary of Benefits UMHA DUAL Plan (HMO-SNP)

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1 2019 Summary of Benefits UMHA DUAL Plan (HMO-SNP) Call (TTY:711) 8 am - 8 pm, 7 days a week from 10/1-3/31 8 am - 8 pm, Monday - Friday from 4/1-9/30 H8854_19_ _002_OE_M CMS Accepted: 08/18/2018

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3 2019 Summary of Benefits UMHA DUAL (HMO-SNP) This is a summary of drug and health services covered by University of Maryland Health Advantage UMHA DUAL from January 1, 2019 December 31, UMHA Dual is a Medicare Advantage HMO-SNP plan with a Medicare contract. Enrollment in the Plan depends on contract renewal. The benefit information provided does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the Evidence of Coverage. To join UMHA DUAL you must be entitled to Medicare Part A, be enrolled in Medicare Part B, have Medical Assistance from the State of Maryland, and live in our service area. Our service area includes the following counties in Maryland: Anne Arundel, Baltimore, Baltimore City, Caroline, Carroll, Cecil, Charles, Dorchester, Harford, Howard, Kent, Montgomery, Prince George s, Queen Anne s, and Talbot. Except in emergency situations, if you use the providers that are not in our network, we may not pay for these services. For coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at or get a copy by calling MEDICARE ( ). TTY users should call This document is available in other formats such as Braille or large print. For more information, please call us at (TTY users should call 711), or visit us at

4 UMHA DUAL (HMO-SNP)* PLAN HIGHLIGHTS Monthly Premium: $0 Doctor Visits: $0 PCP / $0 Specialist Generic Prescriptions: As low as $0 Dental Care: Preventive, Comprehensive & Dentures Vision Services: $175 allowance towards eyewear every year Hearing Services: Up to $750 allowance every year for hearing aids Over-the-Counter (OTC) Items: $110 monthly allowance Transportation: 36 one-way trips per year Meals: for up to 18 meals postdischarge from inpatient stay Routine Foot Care (Podiatry Services) for 6 visits per year Routine Chiropractic Care for 4 visits per year Health & Wellness: for 1 at-home fitness kit per quarter 24/7 Nurse Hotline

5 UMHA DUAL (HMO-SNP) Summary of Benefits UMHA DUAL/HEALTH * Monthly Plan Premium $0 Deductible Part C (Medical) $0 Maximum Out-of- Pocket (MOOP) $6,700 annually This is the most you pay for copays, coninsurance, and other costs for medical services for the year Inpatient Hospital Days 1-5: $0 per day Coverage 1 Days 6-90: $0 per day Outpatient Hospital Ambulatory surgical center: Coverage 1 Outpatient hospital: These copays apply to surgical procedures only Doctor Visits Primary Care Physician visit: Specialist visit: Preventive Care Emergency Care Urgently Needed Services Diagnostic Tests, Lab and Radiology Services, and X-Rays 1 Diagnostic radiology services (such as MRIs, CT scans): 0% coinsurance Diagnostic test and procedures: 0% coinsurance Lab services: Outpatient x-rays: Therapeutic radiology services (such as radiation treatment for cancer): 0% coinsurance Hearing Services 1 Exam to diagnose and treat hearing and balance issues: Routine hearing exam (for up to 1 every year): 1 fitting and evaluation with 3 follow up visits within the first year from date of initial fitting: Our plan pays up to $750 every year for hearing aids 1 May require prior authorization *If your Medicaid status changes from Full Benefit Dual Eligible (FBDE) or Qualified Medicare Beneficiary (QMB), your copays and coinsurances will increase to 20% of the total cost for your medical benefits and 25% of the total cost of your Part D prescription drugs.

6 UMHA DUAL (HMO-SNP) Summary of Benefits UMHA DUAL/HEALTH * Dental Services Preventive Dental Services: Oral exams: every 6 months Comprehensive oral exam: every 3 years Prophylaxis: every 6 months Fluoride treatment: every 6 months Palliative treatment: 3 every year Comprehensive Dental Services: Coverage limit is $1,500 every year. Member is responsible for all costs over the $1,500 annual maximum. for the following: Restorative services: 1 restoration per tooth once every 24 months not to exceed 6 surfaces per year. Endodontics: 1 per lifetime, per patient, per tooth Crowns: once per tooth per 5 years Extractions: 1 extraction per tooth Periodontics: 1 per quadrant of scaling every 36 months Periodontal maintenance: once every 3 months Dentures: once every 5 years Denture repairs: once every 12 months Denture relines/rebase: once every 36 months Denture adjustments: 2 per year, not included under $1,500 dental limit Vision Services Exam to diagnose and treat diseases and the conditions of the eye including Glaucoma Screening: 0% coinsurance Medicare-Covered Eyewear- Medicare pays for one pair of sunglasses or contact lenses after cataract surgery: 0% coinsurance Routine eye exam: 1 exam every year for the $175 allowance towards eyewear every year. Includes contact lenses, eyeglass frames and lenses 1 May require prior authorization Bitewing x-ray: once per year Panoramic x-ray: once every 3 years Vertical bitewing x-ray: once every 3 years Intraoral imaging: once every 3 years *If your Medicaid status changes from Full Benefit Dual Eligible (FBDE) or Qualified Medicare Beneficiary (QMB), your copays and coinsurances will increase to 20% of the total cost for your medical benefits and 25% of the total cost of your Part D prescription drugs.

7 UMHA DUAL (HMO-SNP) Summary of Benefits Mental Health Services 1 Inpatient: Days 1-5: $0 per day Days 6-90: $0 per day UMHA DUAL/HEALTH * Outpatient: Group therapy visit: Individual therapy visit: Skilled Nursing Facility Days 1-20: $0 per day (SNF) 1 Days : $0 per day Physical Therapy 1 Ambulance 1 Transportation Medicare Part B Drugs 1 for 36 one-way trips per year UMHA DUAL / PRESCRIPTION DRUG * Deductible Initial Coverage Period (90-day supply available retail or mail order) Does not apply For generic drugs (including brand drugs treated as generic), either: / $1.25 copay / $3.40 copay For all other drugs, either: / $3.80 copay / $8.50 copay Catastrophic Coverage For generic drugs (including brand drugs treated as generic), you pay the greater of 5% of the cost, or $ May require prior authorization For all other drugs, you pay the greater of 5% of the cost, or $8.50 *If your Medicaid status changes from Full Benefit Dual Eligible (FBDE) or Qualified Medicare Beneficiary (QMB), your copays and coinsurances will increase to 20% of the total cost for your medical benefits and 25% of the total cost of your Part D prescription drugs.

8 UMHA DUAL (HMO SNP) Summary of Benefits UMHA DUAL / ADDITIONAL HEALTH * Chiropractic Care 1 Medicare covered visit- Manual manipulation of the spine to correct subluxation: 0% coinsurance Routine Visit- Manual manipulation of the spine for the treatment of neuromusculoskeletal disorders of the spine, neck, and/or lower back. Limited to 4 visits per year: 0% coinsurance Foot Care (Podiatry Medicare Covered Services: Services) 1 Routine Foot Care: 6 visits per year Meals 1 Up to 18 meals post-discharge from inpatient stay: Outpatient Rehabilitation 1 Durable Medical Equipment 1 Over-the-Counter (OTC) Items Health & Wellness Program Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions over a period of up to 36 weeks): 0% coinsurance Occupational therapy visit: Speech and language therapy visit: 0% coinsurance 24/7 Nursing Hotline Member receives $110 allowance monthly through UMHA OTC catalog One (1) at-home fitness kit per quarter, limited to four (4) kits per year: Home Health Care 1 1 May require prior authorization *If your Medicaid status changes from Full Benefit Dual Eligible (FBDE) or Qualified Medicare Beneficiary (QMB), your copays and coinsurances will increase to 20% of the total cost for your medical benefits and 25% of the total cost of your Part D prescription drugs.

9 UMHA DUAL (HMO SNP) Statement of Maryland Medical Assistance (Medicaid) Benefits and Cost-Sharing Eligibility The UMHA Dual plan is available to anyone with both Medicare Parts A and B and who receives Medical Assistance from the state Medicaid program to cover Medicare cost-sharing. UMHA Dual members with Full Benefit Dual Eligible (FBDE) and Qualified Medicare Beneficiary (QMB) are covered by the state Medicaid program for their Medicare cost sharing. Cost Sharing and Protection for Members In the UMHA Dual plan, the state Medicaid program pays the cost sharing for Medicare-covered medical services you receive. You pay no cost sharing for the Medicare-covered benefits described in the Covered Medical and Hospital Benefits section of this Summary of Benefits. You will pay small copayments for prescriptions covered under the Medicare Part D prescription drug benefit. When you receive covered health care services, the network provider should bill UMHA Dual first and then Maryland Medical Assistance second. Network providers are not permitted to balance bill you for services that are covered by both UMHA Dual and Medicaid. If you receive care from a non-network provider, the provider may not understand UMHA Dual or these billing rules. If you receive a bill from a provider for Medicare-covered services, please notify Member Services so we can help you. Please see chapter 7, Asking us to pay our share of a bill you have received for covered medical services or drugs, of your UMHA Dual Evidence of Coverage. for more information. The benefits described below are covered by Maryland Medical Assistance (Medicaid). The benefits described in the Covered Medical and Hospital Benefits section of the Summary of Benefits are covered by Medicare. For each benefit listed below, you can see what Maryland Medical Assistance covers and what our plan covers. What you pay for these covered services may depend on your level of Medicaid eligibility.

10 UMHA DUAL (HMO SNP) Maryland Medical Assistance (Medicaid) Program Benefits Depending on your Medicaid category, you may have to make a small co-payment when you receive your medical care, but Medicaid will pay most or all of the bill. MARYLAND MEDICAID UMHA DUAL Ambulance Services Ambulatory Surgical Services Dental Services Medicaid covers certain emergency dental care for adults. Preventive dental care, fillings and oral surgery for children. Ambulatory Surgical Center: Preventive Dental Services: Oral Exams: every 6 months Bitewing x-ray: once Comprehensive oral exam: per year every 3 years Panoramic x-ray: once Prophylaxis: every 6 months every 3 years Fluoride treatment: every 6 Vertical bitewing x-ray: months once every 3 years Palliative treatment: 3 every Intraoral imaging: year once every 3 years 1 May require prior authorization

11 UMHA DUAL (HMO SNP) Maryland Medical Assistance (Medicaid) Program Benefits Depending on your Medicaid category, you may have to make a small co-payment when you receive your medical care, but Medicaid will pay most or all of the bill. MARYLAND MEDICAID UMHA DUAL Dental Services Diagnostic Tests, Lab and Radiology Services, and X-Rays Medicaid covers certain emergency dental care for adults. Preventive dental care, fillings and oral surgery for children. *Not covered: portable X-ray services; services provided in facilities not meeting the definition of an independent laboratory or X-ray. Comprehensive Dental Services: Coverage limit is $1,500 every year. Member is responsible for all costs over $1,500 annual maximum. for the following: Restorative services: 1 restoration per tooth once every 24 months not to exceed 6 surfaces per year Endodontics (1 per lifetime, per patient, per tooth) Crowns once per tooth per 5 years Extractions (1 extraction per tooth) Periodontics (1 per quadrant of scaling every 36 months) Periodontal maintenance (once every 3 months) Prosthodontics (dental plates: either upper, lower, or partial, or any combination, once every 5 years) Denture repairs (once every 12 months) Dental relines/rebase (once every 36 months) Denture adjustments (2 per year, not included under $1,500 dental limit) Diagnostic radiology services (such as MRIs, CT scans): 0% coinsurance Diagnostic test and procedures: 0% coinsurance Lab services: Outpatient x-rays: Therapeutic radiology services (such as radiation treatment for cancer): 0% coinsurance

12 UMHA DUAL (HMO SNP) Maryland Medical Assistance (Medicaid) Program Benefits Depending on your Medicaid category, you may have to make a small co-payment when you receive your medical care, but Medicaid will pay most or all of the bill. MARYLAND MEDICAID UMHA DUAL Doctor Visits Home Health Services (Includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.) Hospice Services *Not covered: social services, chore services, meals on wheels, audiology services. Primary Care Physician visit: Specialist visit: You pay nothing for hospice care from a Medicare certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. Inpatient Hospital Coverage (Includes Substance Abuse and Rehabilitation Services) *Available to Members certified as being terminally ill and having a medical prognosis of life expectancy of six (6) months or less. Days 1-5: $0 per day Days 6-90: $0 per day

13 UMHA DUAL (HMO SNP) Maryland Medical Assistance (Medicaid) Program Benefits Depending on your Medicaid category, you may have to make a small co-payment when you receive your medical care, but Medicaid will pay most or all of the bill. MARYLAND MEDICAID UMHA DUAL Durable Medical Equipment Mental Health Services Outpatient Hospital Coverage Podiatry Services (Foot Care) 0% coinsurance Inpatient: Days 1-5: $0 per day Days 6-90: $0 per day Outpatient Group therapy visit: Individual therapy visit: Outpatient hospital: Medicare Covered Services: Routine Foot Care: 6 visits per year *Not covered: services for flatfoot; subluxation; routine foot care, supportive devices; vitamin B-12 injections.

14 UMHA DUAL (HMO SNP) Maryland Medical Assistance (Medicaid) Program Benefits Depending on your Medicaid category, you may have to make a small co-payment when you receive your medical care, but Medicaid will pay most or all of the bill. MARYLAND MEDICAID UMHA DUAL Prescription Drugs Initial Coverage Period: For generic drugs (including brand drugs treated as generic), either: / $1.25 copay/ $3.40 copay For all other drugs, either: $0 copay/ $3.80 copay/ $8.50 copay Catastrophic Coverage: For generic drugs (including brand drugs treated as generic), you pay the greater of 5% of the cost, or $3.40 For all other drugs, you pay the greater of 5% of the cost, or $8.50

15 UMHA DUAL (HMO SNP) Maryland Medical Assistance (Medicaid) Program Benefits Depending on your Medicaid category, you may have to make a small co-payment when you receive your medical care, but Medicaid will pay most or all of the bill. MARYLAND MEDICAID UMHA DUAL Skilled Nursing Facility (SNF) Transportation (Non- Emergency) Vision Services Medicaid covers NET emergency transportation as medically necessary. Medically necessary diagnostic services may be covered. Services may only be covered if performed for medical reasons and not for refractive purposes for members twenty-one (21) years of age or older. Days 1-20: $0 per day Days : $0 per day for 36 one-way trips per year Exam to diagnose and treat diseases and the conditions of the eye including Glaucoma Screening: 0% coinsurance Medicare-Covered Eye Wear 0% coinsurance Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery Routine eye exam: 1 exam every year for the $175 allowance towards eyewear every year. Includes contact lenses, eyeglass frames and lenses.

16 You can access the Evidence of Coverage (EOC), which provides a full listing of our plan s benefits and services, on our website at or by calling the telephone number listed below. You may view our plan s Provider Directory at our website at Find-a-Doctor. You can see our plan s Pharmacy Directory at our website at org/find-a-medication-pharmacy. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website at Pharmacy , (TTY:711) Hours of Operation: October 1 March 31: 8 am 8 pm, 7 days a week April 1 September 30 8 am 8 pm, Monday - Friday This information is not a complete description of benefits. Call (TTY: 711) for more information. *If Medicaid status changes from Full Benefit Dual Eligible (FBDE) or Qualified Medicare Beneficiary (QMB), your copays and coinsurances will increase to 20% of the total cost of the service and 25% of the total cost of the Part D drug. *If your Medicaid status changes from Full Benefit Dual Eligible (FBDE) or Qualified Medicare Beneficiary (QMB), your copays and coinsurances will increase to 20% of the total cost for your medical benefits and 25% of the total cost of your Part D prescription drugs.

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