2019 Summary of Benefits UMHA DUAL Plan (HMO-SNP)
|
|
- Clarissa Robbins
- 5 years ago
- Views:
Transcription
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
2 THIS PAGE INTENTIONALLY LEFT BLANK
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.
2018 Summary of Benefits Eon Deluxe (HMO SNP) GEORGIA / SOUTH CAROLINA
2018 Summary of Eon Deluxe (HMO SNP) GEORGIA / SOUTH CAROLINA For more information, call 1-844-895-8643 Y0122_0172 Accepted DSNP This page intentionally left blank 2018 Summary of Eon Deluxe (HMO SNP)
More informationSummary Of Benefits. WASHINGTON Pierce and Snohomish
Summary Of Benefits WASHINGTON Pierce and Snohomish 2018 Molina Medicare Choice (HMO SNP) (800) 665-1029, TTY/TDD 711 7 days a week, 8 a.m. 8 p.m. local time H5823_18_1099_0007_WAChoSB Accepted 9/26/2017
More informationFirst Look: Plan Benefit Filings
July 30, 2014 First Look: Plan Filings Maryland and Washington, D.C. 1 Disclaimers MedStar does not currently have a contract with CMS for the State of MD nor any special needs plans in Washington, D.C.
More informationSummary Of Benefits. Molina Medicare Options Plus (HMO SNP) (866) , TTY/TDD days a week, 8 a.m. 8 p.m. local time
Summary Of Benefits OHIO Brown, Butler, Clark, Clermont, Clinton, Columbiana, Delaware, Fairfield, Fayette, Franklin, Greene, Hamilton, Highland, Hocking, Lake, Madison, Miami, Montgomery, Morrow, Perry,
More informationSummary of Benefits 2018
SM Summary of Benefits 2018 bluecareplus.bcbst.com H3259_18_SB Accepted 08282017 This is a summary of drug and health services covered by BlueCare Plus (HMO SNP) SM health plan January 1, 2018 - December
More informationSummary Of Benefits. FLORIDA Broward, Hillsborough, Miami-Dade, Palm Beach, Pinellas, and Polk
Summary Of Benefits FLORIDA Broward, Hillsborough, Miami-Dade, Palm Beach, Pinellas, and Polk 2018 Molina Medicare Options Plus (HMO SNP) (866) 553-9494, TTY/TDD 711 7 days a week, 8 a.m. 8 p.m. local
More information2016 Summary of Benefits
2016 Summary of Benefits Health Net Jade (HMO SNP) Kern, Los Angeles and Orange counties, CA Benefits effective January 1, 2016 H0562 Health Net of California, Inc. H0562_2016_0175 CMS Accepted 09082015
More informationCorrection Notice. Health Partners Medicare Special Plan
Correction Notice Special Plan Following are corrections that apply to both the English and Spanish versions of the 2015 for Special (HMO SNP): Original Information Page 1, under the heading SECTIONS IN
More informationSummary of Benefits for Anthem MediBlue Dual Advantage (HMO SNP)
Summary of Benefits for Available in: Select Counties* in Maine *See Page 2 for a list of counties. Plan year: January 1, 2018 December 31, 2018 In this section, you ll learn about some of the benefits
More informationSummary of Benefits. New Mexico Bernalillo, Chaves, Dona Ana, Luna, McKinley, Otero, Sandoval, San Juan, Santa Fe, Sierra, Torrance and Valencia
Summary of Benefits New Mexico Bernalillo, Chaves, Dona Ana, Luna, McKinley, Otero, Sandoval, San Juan, Santa Fe, Sierra, Torrance and Valencia 2016 Molina Medicare Options Plus HMO SNP Member Services
More informationspecial needs plan (hmo snp) MEDICARE advantage plan summary of benefits Serving Members in Douglas & Klamath Counties
special needs plan (hmo snp) 2017 MEDICARE advantage plan summary of benefits Serving Members in Douglas & Klamath Counties Table of Contents About the Summary of Benefits... 2 Who Can Join?... 2 Which
More informationFor full details of services and costs for each plan, please consult the Evidence of Coverage at GeisingerGold.com or call us for more information.
This Summary of Benefits contains 2018 plan information for: Geisinger Gold Secure Rx (HMO SNP) For full details of services and costs for each plan, please consult the Evidence of Coverage at GeisingerGold.com
More informationINTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 SUMMARY OF BENEFITS
INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 SUMMARY OF BENEFITS January 1, 2015 - December 31, 2015 CARE1ST HEALTH PLAN California: Fresno, Merced, Stanislaus and San Joaquin Counties H5928_15_029_SB_CTCA_2
More informationSelect Summary YOU HAVE CHOICES ABOUT HOW TO GET YOUR MEDICARE BENEFITS TIPS FOR COMPARING YOUR MEDICARE CHOICES
INTRODUCTION TO THE SUMMARY OF BENEFITS FOR January 1, 2015 - December 31, 2015 Central Alabama and Mobile Area SECTION I INTRODUCTION TO THE SUMMARY OF BENEFITS This booklet gives you a summary of what
More informationOF BENEFITS. Cigna-HealthSpring TotalCare (HMO SNP) H Cigna H3949_15_19921 Accepted
agesummary OF BENEFITS Cover erage Cigna-HealthSpring TotalCare (HMO SNP) H3949-009 2014 Cigna H3949_15_19921 Accepted SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS You have choices about how to get
More informationSummary Of Benefits. NEW MEXICO Bernalillo, Chaves, Dona Ana, Luna, McKinley, Otero, San Juan, Sandoval, Santa Fe, Sierra, Torrance, and Valencia
Summary Of Benefits NEW MEXICO Bernalillo, Chaves, Dona Ana, Luna, McKinley, Otero, San Juan, Sandoval, Santa Fe, Sierra, Torrance, and Valencia 2018 Molina Medicare Options Plus (HMO SNP) (866) 440-0127,
More information2018 CareOregon Advantage Plus (HMO-POS SNP) Summary of Benefits
2018 CareOregon Advantage Plus (HMO-POS SNP) Summary of Benefits For Oregon counties: Clackamas, Clatsop, Columbia, Jackson, Josephine, Multnomah, Tillamook, Washington and Yamhill H5859_1099_CO_1018 CMS
More informationOur service area includes these counties in: Florida: Broward, Miami-Dade.
2018 SUMMARY OF BENEFITS Overview of your plan Preferred Medicare Assist (HMO SNP) H1045-012 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer Service
More informationJanuary 1, 2015 December 31, Maintenance Organization (HMO) offered by HEALTHNOW NEW YORK INC. with a Medicare contract)
BLUECROSS BLUESHIELD SENIOR BLUE 601 (HMO), BLUECROSS BLUESHIELD SENIOR BLUE HMO SELECT (HMO) AND BLUECROSS BLUESHIELD SENIOR BLUE HMO 651 PARTD (HMO) (a Medicare Advantage Health Maintenance Organization
More informationInformation for Dual-Eligible Members with Secondary Coverage through California Regular Medi-Cal (Fee-for-Service)
Information for Dual-Eligible Members with Secondary Coverage through California January 1, 2015 December 31, 2015 Los Angeles County This publication is a supplement to the 2015 Evidence of Coverage and
More informationExtra Value Summary YOU HAVE CHOICES ABOUT HOW TO GET YOUR MEDICARE BENEFITS TIPS FOR COMPARING YOUR MEDICARE CHOICES
INTRODUCTION TO THE SUMMARY OF BENEFITS FOR January 1, 2016 - December 31, 2016 Central Alabama and Mobile Area SECTION I INTRODUCTION TO THE SUMMARY OF BENEFITS This booklet gives you a summary of what
More informationKeystone First VIP Choice (HMO-SNP) 2018 Summary of Benefits
Keystone First VIP Choice (HMO-SNP) 2018 Summary of Benefits Y0093_SOB_2497 _ACCEPTED_09052017 January 1, 2018- December 31, 2018 Summary of Benefits This booklet gives you a summary of what we cover
More information2019 Summary of Benefits
2019 Summary of Benefits H6345 This is a summary of drug and health services covered by January 1, 2019 - December 31, 2019. is Medicare Advantage HMO Plan (HMO stands for Health Maintenance Organization)
More informationSummary Of Benefits. CALIFORNIA Imperial, Los Angeles, Riverside (partial), San Bernardino (partial), and San Diego
Summary Of Benefits CALIFORNIA Imperial, Los Angeles, Riverside (partial), San Bernardino (partial), and San Diego 2018 Molina Medicare Options Plus (HMO SNP) (800) 665-0898, TTY/TDD 711 7 days a week,
More informationSummary of Benefits. New York: Bronx, Kings, New York, Queens and Richmond Counties
Summary of Benefits New York: Bronx, Kings, New York, Queens and Richmond Counties January 1, 2006 - December 31, 2006 You ve earned the right to live life on your own terms. And that includes the right
More information2017 Summary of Benefits
H5209 004_DSB9 23 16 File & Use 10/14/2016 DHS Approved 10 7 2016 This is a summary of drug and health services covered by Care Wisconsin Medicare Dual Advantage Plan (HMO SNP) January 1, 2017 to December
More information2019 Summary of Benefits
2019 Summary of Benefits H7511 This is a summary of drug and health services covered by Great Plains Medicare Advantage (HMO SNP) January 1, 2019 - December 31, 2019. is Medicare Advantage HMO Plan (HMO
More informationMEDICARE CARE1ST DUAL PLUS PLAN SUMMARY OF BENEFITS.
ine 1-800-544-0088 www.care1st.com CARE1ST DUAL PLUS PLAN SUMMARY OF BENEFITS MEDICARE 2009 COUNTIES: LOS ANGELES - ORANGE - SAN BERNARDINO - SAN DIEGO H5928_09_004_SNP_SB 10/2008 Section I Introduction
More informationOur service area includes the following county in: Delaware: New Castle.
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Dual Complete (HMO SNP) H3113-011 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer
More informationSummary of Benefits Report SENIOR CARE PLUS: VALUE BASIC PLAN (HMO)-009 January 1, 2015 December 31, 2015 WASHOE COUNTY, NEVADA
SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare).
More information2009 BENEFIT HIGHLIGHTS HEALTH NET PEARL HAWAII OPTION 1
2009 BENEFIT HIGHLIGHTS HEALTH NET PEARL HAWAII OPTION 1 Hawaii, Honolulu, Kalawao, Kauai and Maui counties MEDICAL COVERAGE Monthly Plan Premium $0 Calendar Year Out-Of-Pocket Maximum1 $1,200 Inpatient
More informationOur 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
More informationFREEDOM BLUE PPO R CO 307 9/06. Freedom Blue PPO SM Summary of Benefits and Other Value Added Services
FREEDOM BLUE PPO R9943 2007 CO 307 9/06 Freedom Blue PPO SM Summary of Benefits and Other Value Added Services Introduction to Summary of Benefits for Freedom Blue January 1, 2007 - December 31, 2007 California
More informationSUMMARY OF BENEFITS. Cigna-HealthSpring. Advantage SMS (HMO) H January 1, December 31, Cigna H4407_16_32690 Accepted
SUMMARY OF BENEFITS January 1, 2016 - December 31, 2016 Cigna-HealthSpring Advantage SMS (HMO) H4407-011 2015 Cigna H4407_16_32690 Accepted SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS This booklet
More information2018 SUMMARY OF BENEFITS
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Senior Care Options (HMO SNP) H2226-001 Look inside to learn more about the plan and the health and drug services it covers. Call Customer
More informationOur 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.
More informationOur 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
More informationSummary of Benefits. Texas Bexar, Cameron, Collin, Dallas, El Paso, Harris, Hidalgo and Webb
Summary of Benefits Texas Bexar, Cameron, Collin, Dallas, El Paso, Harris, Hidalgo and Webb 2016 Molina Medicare Options Plus HMO SNP Member Services (866) 440-0012, TTY/TDD 711 7 days a week, 8 a.m. -
More informationSummary of Benefits. January 1, 2018 December 31, Providence Medicare Dual Plus (HMO SNP)
Summary of Benefits January 1, 2018 December 31, 2018 Providence Medicare Dual Plus (HMO SNP) This plan is available in Clackamas, Multnomah and Washington counties in Oregon for members who are eligible
More informationOur service area includes these counties in: Texas: Aransas, Kleberg, Nueces, San Patricio.
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Dual Complete Focus (HMO SNP) H4527-004 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer
More information2019 Summary of Benefits
2019 Summary of Benefits H6351 This is a summary of drug and health services covered by January 1, 2019 - December 31, 2019. is Medicare Advantage HMO Plan (HMO stands for Health Maintenance Organization)
More informationSignal Advantage HMO (HMO) Summary of Benefits
Signal Advantage HMO (HMO) Summary of Benefits January 1, 2016 December 31, 2016 The provider network may change at any time. You will receive notice when necessary. This information is available for free
More informationSummary of benefits Health Net. seniority plus green. Benefits effective January 1, 2009 H0562 Medicare Advantage HMO
2009 Health Net Summary of benefits Los Angeles, Orange, Riverside and San Bernardino counties s effective January 1, 2009 H0562 Medicare Advantage HMO Material ID H0562-09-0041 CMS Approval 9/08 Section
More informationSummary of Benefits for Simply Level (HMO SNP)
Summary of Benefits for Available in: Hernando, Hillsborough, Pasco and Pinellas Counties Plan year: January 1, 2018 December 31, 2018 In this section, you ll learn about some of the benefits and services
More informationSummary Of Benefits. IDAHO Ada, Bannock, Bingham, Bonner, Bonneville, Canyon, Kootenai, Nez Perce, and Twin Falls
Summary Of Benefits IDAHO Ada, Bannock, Bingham, Bonner, Bonneville, Canyon, Kootenai, Nez Perce, and Twin Falls 2018 Molina Medicare Options Plus (HMO SNP) (844) 239-4913, TTY/TDD 711 7 days a week, 8
More informationPROFESSIONAL SERVICES INPATIENT HOSPITAL SERVICES OUTPATIENT FACILITY SERVICES
PROFESSIONAL SERVICES PCP office visits Specialist office visits Annual physical exam/preventive care Physical, Speech & Occupational Therapy Cardiac/Pulmonary Rehab Flu & Pneumonia Vaccinations Diagnostic
More informationOur service area includes these counties in:
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Nursing Home Plan (HMO SNP) H5253-042 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer
More information2018 Summary of Benefits
2018 Summary of MVP Health Plan, Inc. (HMO-POS) (HMO-POS) (HMO-POS) H3305: Plan 022, Plan 021 and Plan 020 This is a summary of drug and health services covered by MVP Health Plan January 1, 2018 - December
More information2018 Summary of Benefits
2018 Summary of Benefits H5209-004_MDASB 9-13-17 Accepted 9/18/2018 DHS Approved 09/13/2017 This is a summary of drug and health services covered by Care Wisconsin Medicare Dual Advantage Plan (HMO SNP)
More informationY0021_H4754_MRK1427_CMS File and Use PacificSource Community Health Plans, Inc. is a health plan with a Medicare contract
Y0021_H4754_MRK1427_CMS File and Use 08262012 PacificSource Community Health Plans, Inc. is a health plan with a Medicare contract Section I - Introduction to Summary of s Thank you for your interest in.
More informationFreedom Blue PPO SM Summary of Benefits
Freedom Blue PPO SM Summary of Benefits R9943-206-CO-308 10/05 Introduction to the Summary of Benefits for Freedom Blue PPO Plan January 1, 2006 - December 31, 2006 California YOU HAVE CHOICES IN YOUR
More informationOur service area includes these counties in:
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Dual Complete ONE (HMO SNP) H3113-012 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer
More informationPROFESSIONAL SERVICES. 1199SEIU VIP Premier (HMO) Medicare INPATIENT HOSPITAL SERVICES. 1199SEIU VIP Premier (HMO) Medicare
PROFESSIONAL SERVICES PCP office visits Specialist office visits Annual physical exam/preventive care Physical, speech & occupational therapy Flu and pneumonia vaccinations Diagnostic services including
More informationGet More Than. Original Medicare. Summary of Benefits MA Special Needs Plan (HMO SNP) 014. H5826_MA_193_2016_v_01_SB014 Accepted.
Get More Than Original Medicare Offered by 2016 Summary of Benefits MA Special Needs Plan (HMO SNP) 014 H5826_MA_193_2016_v_01_SB014 Accepted Section I Introduction to the Summary of Benefits for Community
More informationSchedule of Benefits
Schedule of Benefits ANTHEM Small Business Health Options Program (SHOP) This is a brief schedule of benefits. Refer to your Anthem Certificate of Coverage (Booklet) for complete details on benefits, conditions,
More informationHMO Basic (HMO) / HMO 40 (HMO) / HMO 20 (HMO) Summary of Benefits
/ / Summary of Benefits January 1, 2015 December 31, 2015 Call toll-free 1-800-965-4022 8 a.m. to 8 p.m. daily October 1 to February 15 and 8 a.m. to 8 p.m. weekdays the rest of the year. TTY/TDD 711 HealthAllianceMedicare.org
More informationBlueMedicare Complete (HMO SNP) H ,064
2018 Summary of (HMO SNP) H1026-063,064 Broward and Miami-Dade HMO coverage is offered by Health Options, Inc., DBA Florida Blue HMO, an affiliate of Blue Cross and Blue Shield of Florida, Inc. These companies
More informationSummary of Benefits. Tufts Medicare Preferred HMO PLANS Tufts Medicare Preferred HMO GIC
Tufts Medicare Preferred HMO PLANS 2018 Summary of Benefits Tufts Medicare Preferred HMO GIC The benefit information provided is a summary of what we cover and what you pay. It does not list every service
More information2015 Summary of Benefits
2015 Summary of Benefits Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) Los Angeles County, CA H3237_2015_0291 CMS Accepted 09082014 Health Net Cal MediConnect Summary of Benefits! This is a
More informationMyHPN Solutions HMO Gold 7
MyHPN Solutions HMO Gold 7 HIOS ID: 95865NV0030074 Attachment A Benefit Schedule Calendar Year Deductible (CYD): $3,000 of EME per Member and $6,000 of EME per family. The Calendar Year Out of Pocket Maximum
More informationSummary of Benefits [Silver Access+ HMO 1750/55 OffEx] [Silver Local Access+ HMO 1750/55 OffEx]
Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits [Silver Access+ HMO 1750/55 OffEx] [Silver Local Access+ HMO 1750/55 OffEx] Group Plan HMO Benefit
More informationVIVA MEDICARE Select (HMO)
INTRODUCTION TO THE SUMMARY OF BENEFITS FOR VIVA MEDICARE January 1, 2014 - December 31, 2014 Central Alabama and Mobile Area Thank you for your interest in. Our plan is offered by Viva Health, Inc., which
More informationSummary of Benefits for SmartValue Classic (PFFS)
Summary of Benefits for SmartValue Classic (PFFS) Available in Select Counties in Nevada A health plan with a Medicare contract. Rocky Mountain Hospital and Medical Service, Inc. has contracted with the
More informationOur service area includes the following county in: Florida: Miami-Dade.
2018 SUMMARY OF BENEFITS Overview of your plan Medica HealthCare Plans MedicareMax (HMO) H5420-001 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer
More informationVNSNY CHOICE. Monthly Premium, Deductible, and Limits on how much you pay for Covered Services
Medicare Advantage-Classic Program (HMO): The Medicare Classic service area includes the following counties in New York: Albany, Bronx, Kings (Brooklyn), Nassau, New York, Queens, Rensselaer, Richmond
More informationInformation for Dual-Eligible Members with Secondary Coverage through California Regular Medi-Cal (Fee-for-Service)
Information for Dual-Eligible Members with Secondary Coverage through California January 1, 2011 December 31, 2011 Los Angeles County This publication is a supplement to the 2011 Positive (HMO SNP) Evidence
More informationHealthPartners Freedom Plan (Cost) 2011 Medical Summary of Benefits Wisconsin
HealthPartners Freedom Plan 2011 Medical Summary of Benefits Wisconsin HealthPartners Wisconsin Freedom Plan I HealthPartners Wisconsin Freedom Plan II 420421 (10/10) H2462_SB WI_151 CMS Approved 10/5/10
More informationSummary of Benefits. for Blue Medicare Access Value SM (Regional PPO) Available in Ohio
Summary of Benefits for SM Available in Ohio Anthem Blue Cross and Blue Shield is a Health plan with a Medicare contract.anthem Insurance Companies, Inc. (AICI) is the legal entity that has contracted
More informationSummary of Benefits Advantra Freedom PEBTF
Advantra Freedom is a Medicare Advantage Private Fee-For-Service (PFFS) Plan. This Summary of Benefits tells you some features of our Plan. It doesn't list every service that we cover or list every limitation
More informationSummary of Benefits Platinum Trio HMO 0/25 OffEx
Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits Platinum Trio HMO 0/25 OffEx Group Plan HMO Benefit Plan This Summary of Benefits shows the amount
More informationSummary of Benefits Empire MediBlue Dual Advantage (HMO SNP) Plan year:
Summary of Benefits for Empire MediBlue Dual Advantage (HMO SNP) Available in: New York City* Area *See Page 2 for a list of counties. Plan year: January 1, 2017 December 31, 2017 In this section, you
More informationSummary of Benefits For Advantage Health NY - SNP (HMO SNP)
Summary of Benefits For Advantage Health NY - SNP January 1, 2014 December 31, 2014 Summary of Benefits, H2773-003 Advantage Health NY - SNP H2773_QHPNY0658 Accepted Advantage Health NY - SNP 1 SECTION
More informationSummary of Benefits Fidelis Dual Advantage (HMO SNP) and Dual Advantage Flex Plan (HMO SNP) January 1, 2018 December 31, 2018 CMS Contract #H3328
Summary of Benefits (HMO SNP) and Dual Advantage Flex Plan (HMO SNP) January 1, 2018 December 31, 2018 CMS Contract #H3328 Thank you for your interest in Plans. Our plans are offered by The New York State
More informationMedicare Plus Blue SM Group PPO. Summary of Benefits. Michigan Public School Employees Retirement System
2018 Medicare Plus Blue SM Group Summary of Benefits January 1, 2018 December 31, 2018 Michigan Public School Employees Retirement System www.bcbsm.com/mpsers This information is a summary document and
More informationSummary of Benefits Platinum Full PPO 0/10 OffEx
Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits Platinum Full PPO 0/10 OffEx Group Plan PPO Benefit Plan This Summary of Benefits shows the amount
More informationOur service area includes these counties in:
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Dual Complete (HMO SNP) H7464-001 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer
More informationSUMMARY OF BENEFITS 2009
HEALTH NET VIOLET OPTION 1, HEALTH NET VIOLET OPTION 2, HEALTH NET SAGE, AND HEALTH NET AQUA SUMMARY OF BENEFITS 2009 Southern Oregon Douglas, Jackson, and Josephine Counties, Oregon Benefits effective
More informationEXCLUSIVE CARE SUMMARY OF COVERED BENEFITS Select Medicare Eligible Supplement Plan
2018 EXCLUSIVE CARE SUMMARY OF COVERED BENEFITS Select Medicare Eligible Supplement Plan Summary Table of Benefits Select Medicare Supplement Plan PLAN REIMBURSEMENT METHOD DEDUCTIBLE - Individual Medicare
More informationSUMMARY OF BENEFITS. Advantage (HMO) H
SUMMARY OF BENEFITS January 1, 2017 - December 31, 2017 Cigna-HealthSpring Advantage (HMO) H4513-009 Our service area includes the following counties in Texas: Angelina, Brazoria, Cameron, Chambers, Fort
More informationOur service area includes these counties in:
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Dual Complete (HMO SNP) H5253-041 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer
More information2012 Summary of Benefits
2012 Summary of Benefits San Francisco County, CA Benefits effective January 1, 2012 H0562 Health Net of California, Inc. Material ID # H0562_2012_0055 CMS Approved 08122011 SECTION I Introduction to
More informationSelect Summ ary. VIVA MEDICARE Plus Select (HMO) INTRODUCTION TO THE SUMMARY OF BENEFITS FOR. You have choices in your health care.
INTRODUCTION TO THE SUMMARY OF BENEFITS FOR VIVA MEDICARE Plus January 1, 2013 - December 31, 2013 Central Alabama and Mobile Area Thank you for your interest in. Our plan is offered by Viva Health, Inc./,
More information2019 Health Net Seniority Plus Amber I (HMO SNP) H0562: 055 Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco
2019 Health Net Seniority Plus Amber I (HMO SNP) H0562: 055 Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco and Tulare Counties, CA H0562_19_7837SB_055_M_Accepted
More informationSummary of Benefits. for Anthem Medicare Preferred Premier (PPO)
Summary of Benefits for Available in Androscoggin, Cumberland, Franklin, Hancock, Kennebec, Lincoln, Oxford, Penobscot, Piscataquis, Sagadahoc, Somerset, Waldo, and Washington Counties, ME Anthem Blue
More informationGold Access+ HMO 500/35 OffEx
An Independent Member of the Blue Shield Association Gold Access+ HMO 500/35 OffEx Benefit Summary (For groups 1 to 100) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective
More informationSchedule of Benefits-EPO
Schedule of Benefits-EPO [Plan Information] [Health Plan:] [Ambetter Balanced Care 3 (2018)-Standard Silver On Exchange Plan] [Primary Member:] [John Doe] [Member ID:] [01213456] [Date of Birth:] [08/12/62]
More informationExplorer Plan (HMO-POS) SunSaver Plan (HMO-POS)
January 1, 2015 December 31, 2015 Explorer Plan SunSaver Plan SECTION I INTRODUCTION This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list
More informationPlatinum Trio ACO HMO 0/20 OffEx
Platinum Trio ACO HMO 0/20 OffEx Benefit Summary (For groups 1 to 100) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2017 THIS MATRIX IS INTENDED TO
More information$100 Hospital Ambulatory Surgical Center (ASC) Specialist: $30/visit Chiropractic (Medicare-covered) Podiatry (Medicare-covered)
2009 BENEFIT HIGHLIGHTS HEALTH NET PEARL NEW YORK OPTION 1 Albany, Broome, Cayuga, Chenango, Erie, Franklin, Genessee, Herkimer, Lewis, Livingston, Madison, Monroe, Montgomery, Oneida, Onondaga, Ontario,
More informationBlue Shield Gold 80 HMO
Blue Shield Gold 80 HMO Uniform Health Plan Benefits and Coverage Matrix Blue Shield of California Effective January 1, 2017 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND
More information2018 Summary of Benefits. HMO Plan REHP H3907
2018 Summary of Benefits HMO Plan REHP H3907 UPMC for Life HMO Plan (HMO) REHP SUMMARY OF BENEFITS January 1, 2018 December 31, 2018 This Summary of Benefits booklet gives you a summary of what UPMC for
More informationExplorer Plan (HMO-POS) SunSaver Plan (HMO-POS)
January 1, 2016 December 31, 2016 Explorer Plan SunSaver Plan SECTION I INTRODUCTION This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list
More informationOur service area includes these counties in: North Carolina: Durham, Wake.
2018 SUMMARY OF BENEFITS Overview of your plan AARP MedicareComplete (HMO) H5253-039 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer Service or go
More informationBlue Shield Gold 80 HMO 0/30 + Child Dental INF
Blue Shield Gold 80 HMO 0/30 + Child Dental INF Benefit Summary (For groups 1 to 100) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2017 THIS MATRIX
More informationH1463-HMO 20 (HMO) HMO 20 (HMO) / HMO 20Rx (HMO) Summary of Benefits
H1463- / Summary of Benefits January 1, 2014 December 31, 2014 Call us 8 a.m. to 8 p.m. daily Toll-free 1-800-965-4022 TTY/TDD 1-800-526-0844 www.healthalliancemedicare.org med-hmo20sob-0713 H1463_14_8837
More informationAnnual Notice of Changes for 2017
Network PlatinumPlus (PPO) offered by Network Health Insurance Corporation Annual Notice of Changes for 2017 You are currently enrolled as a member of Network PlatinumPlus. Next year, there will be some
More informationBenefits and Premiums are effective January 01, 2018 through December 31, 2018 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA HEALTH PLANS INC.
Benefits and Premiums are effective January 01, 2018 through December 31, 2018 PLAN FEATURES Network Providers Annual Maximum Out-of-Pocket Amount $2,500 The maximum out-of-pocket limit applies to all
More informationTrue Blue Special Needs Plan (HMO SNP)
True Blue Special Needs Plan (HMO SNP) 2012 Summary of Benefits You think about finding the perfect health insurance plan. We think about providing you with seamless service and affordable benefits. Serving
More informationClassic Plan (HMO-POS) Value Plan (HMO) Rewards Plan (HMO)
January 1, 2016 December 31, 2016 Classic Plan Value Plan Rewards Plan SECTION I INTRODUCTION This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover
More information2013 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
More information