Affinity Medicare Solutions (HMO-SNP) Affinity Medicare Ultimate (HMO-SNP) SUMMARY OF BENEFITS EFFECTIVE JANUARY 1, 2015 THROUGH DECEMBER 31, 2015

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1 Solutions (HMO-SNP) Ultimate (HMO-SNP) 2015 SUMMARY OF BENEFITS EFFECTIVE JANUARY 1, 2015 THROUGH DECEMBER 31, 2015

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3 SUMMARY OF BENEFITS Ultimate (HMO-SNP) and (HMO-SNP) Solutions January 1, 2015 December 31, 2015 (Medicare Advantage Health Maintenance Organization (HMO) offered by AFFINITY HEALTH PLAN, INC. with a Medicare contract) 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 every limitation or exclusion. To get a complete list of services we cover, call us and ask for the Evidence of Coverage. 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). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Affinity Medicare Ultimate (HMO-SNP) and Solutions (HMO-SNP). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what Ultimate (HMO-SNP) and Solutions (HMO-SNP).covers and what you pay. If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on 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 Sections in this booklet Things to Know About Ultimate (HMO-SNP) and Solutions (HMO-SNP). Monthly Premium, Deductible, and Limits on How Much You Pay for Services Medical and Hospital Benefits Prescription Drug Benefits This document is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call us at TTY users should call Things to Know About Ultimate (HMO-SNP) and Solutions (HMO-SNP). Hours of Operation From October 1, 2014 to February 14, 2015 you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. From February 15, 2015 to September 30, 2015 you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time. Ultimate (HMO-SNP) and Affinity Medicare Solutions (HMO-SNP) Phone Numbers and Website H5991_SBDSNP_15 Accepted 1

4 If you are a member of this plan, call toll-free TTY users should call If you are not a member of this plan, call toll-free Our website: Who can join? To join Ultimate (HMO-SNP) or Solutions (HMO-SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and the New York State Medicaid Program, and live in our service area. Our service area includes the following counties in New York: Bronx, Kings, Nassau, New York, Orange, Queens, Richmond, Rockland, Suffolk, and Westchester. Which doctors, hospitals, and pharmacies can I use? Ultimate (HMO-SNP) or Affinity Medicare Solutions (HMO-SNP) has a network of doctors, hospitals, pharmacies, and other providers. If you use providers that are not in our network, the plan may not pay for these services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan s provider and pharmacy directory at our website Or, call us and we will send you a copy of the provider and pharmacy directories. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers and more. Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, Or call us, and we will send you a copy of the formulary. How will I determine my drug costs? Our plan groups each medication into one of five tiers. You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug s tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage. 2

5 SUMMARY OF BENEFITS FOR Ultimate (HMO SNP) and (HMO SNP) Solutions January 1, 2015 December 31, 2015 New York City (5 Boroughs), Nassau, Suffolk, Orange, Rockland and Westchester Counties H5991 Ultimate (HMO SNP) Solutions (HMO SNP) MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is the monthly premium? $0 per month. $36.90 per month. In addition, you must keep paying your Medicare Part B premium. How much is the deductible? This plan does not have a deductible. This plan does not have a deductible for chemotherapy and other drugs administered in your doctor s office (Part B drugs). This plan does not have a deductible for Part D prescription drugs. This plan does not have a deductible. This plan does not have a deductible for chemotherapy and other drugs administered in your doctor s office (Part B drugs). This plan does not have a deductible for Part D prescription drugs. Is there any limit on how much I will pay for my covered services? Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. In this plan, you may pay nothing for Medicare-covered services, depending on your level of New York State Medicaid eligibility. Refer to the Medicare & You handbook for Medicare-covered services. For New York State Medicaid-covered services, refer to the Medicaid Coverage section in this document. Your yearly limit(s) in this plan: $3,400 for services you receive from in-network providers. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. In this plan, you may pay nothing for Medicare-covered services, depending on your level of New York State Medicaid eligibility. Refer to the Medicare & You handbook for Medicare-covered services. For New York State Medicaid covered services, refer to the Medicaid Coverage section in this document. Your yearly limit(s) in this plan: $3,400 for services you receive from in-network providers. 3

6 Ultimate (HMO SNP) Solutions (HMO SNP) Is there any limit on how much I will pay for my covered services? (continued) If you reach the limit on out-of-pocket costs, you will keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and costsharing for your Part D prescription drugs. If you reach the limit on out-of-pocket costs, you will keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and costsharing for your Part D prescription drugs. Is there a limit on how much the plan will pay? Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. COVERED MEDICAL AND HOSPITAL BENEFITS NOTE: SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION. SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR. OUTPATIENT CARE AND SERVICES Acupuncture and Other Alternative Therapies For up to 12 Acupuncture visits every year: For up to Acupuncture 12 visits every year: Ambulance 1 $0 or $25 copay Chiropractic Care Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $0 or $15 copay 4

7 Ultimate (HMO SNP) Solutions (HMO SNP) Dental Services Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): Plan does not cover Preventive dental services: The Plan offers up to $425 per year for comprehensive dental benefit coverage Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): Preventive dental services: Cleaning (for up to 1 every six months): Dental x-ray(s) (for up to 1 every year): Oral exam (for up to 1 every six months): Plan offers up to $425 per year for comprehensive dental benefit coverage Diabetes Supplies and Services Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts: Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts: 5

8 Ultimate (HMO SNP) Solutions (HMO SNP) Diagnostic Tests, Lab and Radiology Services, and X-Rays 1 Diagnostic radiology services (such as MRIs, CT scans): Diagnostic tests and procedures: Lab services: Outpatient x-rays: Therapeutic radiology services (such as radiation treatment for cancer): Authorization required for PET scans, MRI, MRA and Cardiac CT. No authorization required for routine Lab services. Diagnostic radiology services (such as MRIs, CT scans): $0 or $25 copay Diagnostic tests and procedures: Lab services: Outpatient x-rays: $0 or $25 copay Therapeutic radiology services (such as radiation treatment for cancer): $0 or $25 copay Authorization required for PET scans, MRI, MRA and Cardiac CT. No authorization required for routine Lab services. Doctor s Office Visits Primary care physician visit: Specialist visit: Primary care physician visit: Specialist visit: $0 or $20 copay Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Authorization required for all DME rentals and DME purchases exceeding $1,000. 0% or 20% of the cost Authorization required for all DME rentals and DME purchases exceeding $1,000. Emergency Care $0 or $65 copay If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. See the Inpatient Hospital Care section of this booklet for other costs. 6

9 Ultimate (HMO SNP) Solutions (HMO SNP) Foot Care (podiatry services) Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: Routine foot care (for up to 4 visits every year): $10 copay Foot exams and treatment if you have diabetes-related nerve damage and/ or meet certain conditions: $0 or $15 copay Routine foot care (for up to 4 visits every year): $10 copay Hearing Services Exam to diagnose and treat hearing and balance issues: Routine hearing exam: Hearing aid fitting/evaluation: Hearing aid: Our plan pays up to $750 every year for hearing aids. Exam to diagnose and treat hearing and balance issues: Routine hearing exam (for up to 1 every year): Hearing aid fitting/evaluation (for up to 1 every year): Hearing aid: Our plan pays up to $350 every year for hearing aids. Home Health Care 1 Mental Health Care 1 Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. 7

10 Ultimate (HMO SNP) Solutions (HMO SNP) Mental Health Care 1 (continued) Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. Outpatient group therapy visit: Outpatient individual therapy visit: Authorization is required after 20 Outpatient Individual Non-Physician therapy visits. Authorization required after 20 Outpatient Individual psychiatric therapy visits. Authorization required after the first 20 Partial Hospitalization visits Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. $0 or $200 copay per stay Outpatient group therapy visit: $0 or $20 copay Outpatient individual therapy visit: $0 or $20 copay Authorization required after 20 Outpatient Individual Non-Physician therapy visits. Authorization is required after 20 Outpatient Individual psychiatric therapy visits. Authorization required after the first 20 Partial Hospitalization visits Outpatient Rehabilitation 1 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions, up to 36 weeks): Occupational therapy visit: Physical therapy and speech and language therapy visit: Authorization is required after a combined total of 20 Physical Therapy and/or Speech-Language Pathology visits. Authorization required after the first 10 occupational therapy visits Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions, up to 36 weeks): $0 or $10 copay Occupational therapy visit: $0 or $15 copay Physical therapy and speech and language therapy visit: $0 or $15 copay Authorization is required after a combined total of 20 Physical Therapy and/or Speech-Language Pathology visits. Authorization required after the first 10 occupational therapy visits 8

11 Ultimate (HMO SNP) Solutions (HMO SNP) Outpatient Substance Abuse 1 Group therapy visit: Individual therapy visit: Authorization required after 20 visits Group therapy visit: $0 or $20 copay Individual therapy visit: $0 or $20 copay Authorization required after 20 visits Outpatient Surgery 1 Ambulatory surgical center: Outpatient hospital: Authorization required only for hospital-based ambulatory surgery and sterilization procedures Ambulatory surgical center: $0 or $100 copay Outpatient hospital: $0 or $0-100 copay, depending on the service Authorization required only for hospital-based ambulatory surgery and sterilization procedures Over-the-Counter Items Please visit our website to see our list of covered over-the-counter items. Monthly benefit of up to $65 per month. Month-to-month balance carry-over does NOT apply. OTC items covered by the benefit are limited to items that are consistent with CMS guidance in the most recent version of Chapter 4 of the Medicare Managed Care Manual. Not Prosthetic Devices (braces, artificial limbs, etc.) 1 Prosthetic devices: Related medical supplies: Authorization is required for Prosthetics/Medical Supplies exceeding $1,000 in cost. Prosthetic devices: 0% or 20% of the cost Related medical supplies: Authorization is required for Prosthetics/Medical Supplies exceeding $1,000 in cost. 9

12 Ultimate (HMO SNP) Solutions (HMO SNP) Renal Dialysis Transportation Not covered Non-emergency Transportation benefit is limited to 12 round-trips per year within Affinity s service area. Transportation services are limited to use for health-related purposed only, and must be to and from planapproved health services and/or providers. Advance notice is required to schedule appointments. Urgent Care $0 or $20 copay Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing Routine eye exam (for up to 1 every year): Contact lenses: Eyeglasses (frames and lenses): Eyeglasses or contact lenses after cataract surgery: Our plan pays up to $200 every year for contact lenses and eyeglasses (frames and lenses). Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing Routine eye exam (for up to 1 every year): Contact lenses: Eyeglasses (frames and lenses): Eyeglasses or contact lenses after cataract surgery: Our plan pays up to $200 every year for contact lenses and eyeglasses (frames and lenses). 10

13 Ultimate (HMO SNP) Solutions (HMO SNP) Preventive Care Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) 11

14 Ultimate (HMO SNP) Solutions (HMO SNP) Preventive Care (continued) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Any additional preventive services approved by Medicare during the contract year will be covered. Annual physical exam: Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Any additional preventive services approved by Medicare during the contract year will be covered. Annual physical exam: Hospice for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. INPATIENT CARE Inpatient Hospital Care 1 Our plan covers an unlimited number of days for an inpatient hospital stay. Our plan covers an unlimited number of days for an inpatient hospital stay. $0 or $250 copay per stay per day for days 91 and beyond Inpatient Mental Health Care For inpatient mental health care, see the Mental Health Care section of this booklet. For inpatient mental health care, see the Mental Health Care section of this booklet. Skilled Nursing Facility (SNF) 1 Our plan covers up to 100 days in a SNF. Our plan covers up to 100 days in a SNF. per day for days 1 through 20 $0 or $75 copay per day for days 21 through

15 NOTES

16 Ultimate (HMO SNP) PRESCRIPTION DRUG BENEFITS How much do I pay? For Part B drugs such as chemotherapy drugs 1 : Other Part B drugs 1 : Initial Coverage Our plan does not have a deductible for Part D prescription drugs. You pay the following: You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing Tier One-month supply Two-month supply Three-month supply Tier 1 (Preferred Generic) $0 $0 $0 Tier 2 (Non-Preferred Generic) 14

17 Solutions (HMO SNP) For Part B drugs such as chemotherapy drugs 1 : 0% or 10% of the cost Other Part B drugs 1 : 0% or 10% of the cost Our plan does not have a deductible for Part D prescription drugs. You pay the following: You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing Tier One-month supply Two-month supply Three-month supply Tier 1 (Preferred Generic) $0 $0 $0 Tier 2 (Non-Preferred Generic) 15

18 Ultimate (HMO SNP) PRESCRIPTION DRUG BENEFITS Initial Coverage (continued) Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Generic) 16

19 Solutions (HMO SNP) PRESCRIPTION DRUG BENEFITS Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Generic) 17

20 Ultimate (HMO SNP) PRESCRIPTION DRUG BENEFITS Initial Coverage (continued) Tier 5 (Specialty Tier) Not Offered Not Offered Standard Mail Order Cost-Sharing Tier Three-month supply Tier 1 (Preferred Generic) $0 18

21 Solutions (HMO SNP) PRESCRIPTION DRUG BENEFITS Tier 5 (Specialty Tier) Not Offered Not Offered Standard Mail Order Cost-Sharing Tier Three-month supply Tier 1 (Preferred Generic) $0 19

22 Ultimate (HMO SNP) PRESCRIPTION DRUG BENEFITS Tier 2 (Non-Preferred Generic) Tier 3 (Preferred Brand) 20

23 Solutions (HMO SNP) PRESCRIPTION DRUG BENEFITS Tier 2 (Non-Preferred Generic) Tier 3 (Preferred Brand) 21

24 Ultimate (HMO SNP) PRESCRIPTION DRUG BENEFITS Tier 4 (Non-Preferred Brand) If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. Catastrophic Coverage 22

25 Solutions (HMO SNP) PRESCRIPTION DRUG BENEFITS Tier 4 (Non-Preferred Brand) If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay nothing for all drugs. 23

26 NOTES

27 SUMMARY OF MEDICAID-COVERED BENEFITS The benefits described below are covered by Medicaid. The benefits described in the Medical and Hospital Benefits section of the Summary of Benefits are covered by Medicare. For each benefit listed below, you can see what New York State Medicaid covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. Coverage of the benefits described below depends upon your level of Medicaid eligibility. Benefits marked with an asterisk * may not be available to all enrollees No matter what your level of Medicaid eligibility is, Ultimate or Solutions will cover the benefits described in the Medical and Hospital Benefits (Section II: Summary of Benefits). Your Medicare copayments can be billed to Medicaid Fee For Service, however your final cost share may differ based on your level of Medicaid eligibility. If you have questions about your Medicaid eligibility and what benefits you are entitled to call: Medicaid Benefit Description Medicaid Fee For Service Ultimate Solutions Inpatient Hospital Care Including Substance Abuse and Rehabilitation Services. Up to 365 days per year (366 days for leap year). Medicare-covered services covered by Plan. Medicare-covered services covered by Plan. $0 or $250 copay for each Medicare-covered hospital stay.* Inpatient Mental Health Medically necessary care, including days in excess of the Medicare 190-day lifetime maximum. Medicare-covered services covered by the Plan, up to 90 days in a Psychiatric Hospital in a lifetime. Days beyond 90 can be billed to Medicaid Fee For Service. Medicare-covered services covered by the Plan, up to 90 days in a Psychiatric Hospital in a lifetime. $0 or $200 copay for each Medicare-covered hospital stay.* If you have Medicaid, days beyond 90 can be billed to Medicaid Fee For Service. 25

28 Medicaid Benefit Description Medicaid Fee For Service Ultimate Solutions Skilled Nursing Facility Medicare covered care provided in a skilled nursing facility. No prior hospital stay required. Days in excess of 100 per benefit period also covered. Plan covers up to 100 days for each benefit period. No prior hospital stay is required. Plan covers up to 100 days for each benefit period. No prior hospital stay is required. For Medicare-covered SNF stays $0 or $75* Days 1-20: $0 copay per day. Days : $75 copay per day.* Home Health Medically necessary intermittent skilled nursing care, home health aide services and rehabilitation services. Also includes non-medicare covered home health services (e.g., home health aide services with nursing supervision to medically unstable individuals). Medicare-covered home health visits covered by the Plan. Medicare-covered home health visits covered by the Plan. 26

29 Medicaid Benefit Description Medicaid Fee For Service Ultimate Solutions Private Duty Nursing Not covered. Not covered. Medically necessary private duty nursing services can be provided through an approved certified home health agency, or a private practitioner. Nursing services may be intermittent, part-time or continuous and must be provided in an enrollee s home in accordance with the ordering physician, registered physician assistant or certified nurse practitioner s written treatment plan. Private duty nursing services may be accessed by using your Medicaid Fee For Service Benefits. If you have Medicaid, private duty nursing services may be accessed by using your Medicaid Fee For Service Benefits. Outpatient Mental Health Individual and group therapy visits. Enrollee must be able to self-refer for one assessment from a network provider in a twelve (12) month period. Medicare-covered individual or group therapy home health visits covered by the Plan. Medicare-covered individual or group therapy home health visits are covered by the Plan. $0 or $20 copay for each Medicare-covered individual or group therapy visit.* 27

30 Medicaid Benefit Description Medicaid Fee For Service Ultimate Solutions Outpatient Substance Abuse Individual and group therapy visits. Enrollee must be able to self-refer for one assessment from a network provider in a twelve (12) month period. Medicare-covered individual or group therapy visits covered by the Plan. Medicare-covered individual or group therapy visits covered by the Plan. $0 or $20 copay for each Medicare-covered individual or group therapy visit.* Durable Medical Equipment (DME) Medicaid covered durable medical equipment, including devices and equipment other than medical/ surgical supplies, enteral formula, and prosthetic or orthotic appliances having the following characteristics: Medicare-covered items covered by the Plan. Medicare-covered items covered by the Plan. 0% or 20% of the cost for Medicare-covered items.* can withstand repeated use for a protracted period of time; are primarily and customarily used for medical purposes; are generally not useful to a person in the absence of illness or injury and; are usually fitted, designed or fashioned for a particular individual s use. Must be ordered by a qualified practitioner. No homebound prerequisite and including non- Medicare DME covered by Medicaid (e.g. tub stool; grab bars). 28

31 Medicaid Benefit Description Medicaid Fee For Service Ultimate Solutions Prosthetics Medicaid covered prosthetics, orthotics and orthopedic footwear. by plan including deductibles, copays and coinsurances. Medicare-covered items covered by Plan. 0% or 20% of the cost for Medicare-covered items.* Doctor Office Visits $0 copay for each primary care doctor visit for Medicare-covered benefits.* $0 copay for the cost of each in-area, network urgent care Medicarecovered visit.* $0 or $10 copay for each specialist visit for Medicare-covered benefits.* $0 copay for each primary care doctor visit for Medicare-covered benefits.* $0 or $20 copay for each specialist visit for Medicare-covered benefits.* Outpatient Services/ Surgery $0 copay for each Medicare-covered ambulatory surgical center visit.* $0 or $100 copay for each Medicare-covered ambulatory surgical center visit.* $0 copay for each Medicare-covered outpatient hospital facility visit.* $0 or $100 copay for each Medicare-covered outpatient hospital facility visit.* 29

32 Medicaid Benefit Description Medicaid Fee For Service Ultimate Solutions Outpatient Rehabilitation Services Occupational, Physical and Speech therapies are limited to twenty (20) visits per therapy per year, except for children under age 21, unless you have been determined to be developmentally disabled by the Office for People with Developmental Disabilities, or if you have a traumatic brain injury. $0 or $10 copay for Medicare-covered Occupational Therapy visits.* $0 or $10 copay for Medicare-covered Physical and/or Speech and Language Therapy visits.* $0 or $15 copay for Medicare-covered Occupational Therapy visits.* $0 or $15 copay for Medicare-covered Physical and/or Speech and Language Therapy visits.* Ambulance Services $0 copay for Medicarecovered ambulance benefits.* $0 or $25 copay for Medicare- covered ambulance benefits.* Emergency Care $0 copay for Medicarecovered emergency room visits. $5,000 plan coverage limit for emergency services outside the U.S. every year. If you are admitted to the hospital within 24 hours for the same condition, you pay $0 for the emergency room visit. $0 or $65 copay for Medicare-covered emergency room visits.* $5,000 plan coverage limit for emergency services outside the U.S. every year. If you are admitted to the hospital within 24 hours for the same condition, you pay $0 for the emergency room visit. 30

33 Medicaid Benefit Description Medicaid Fee For Service Ultimate Solutions Urgent Care $0 copay for Medicarecovered urgent care visits.* If you are admitted to the hospital within 24 hours for the same condition, you pay $0 for the urgent care visit. $0 or $20 copay for Medicare-covered urgent care visits.* If you are admitted to the hospital within 24 hours for the same condition, you pay $0 for the urgent care visit. Dental Medicaid covered dental services including necessary preventive, prophylactic and other routine dental care, services and supplies and dental prosthetics to alleviate a serious health condition. Ambulatory or inpatient surgical dental services subject to prior authorization. Medicare-covered dental benefits covered by Plan. In general, preventive dental benefits (such as cleaning) are not covered. Plan covers up to $425 of comprehensive dental benefits. Medicare-covered dental benefits covered by Plan. The following preventive dental benefits are covered by Plan: Up to 1 oral exam every six months. Up to 1 cleaning every six months. Up to 1 dental X-ray every year Plan covers up to $425 of comprehensive dental benefits. 31

34 Medicaid Benefit Description Medicaid Fee For Service Ultimate Solutions Hearing Services Medicaid hearing services and products when medically necessary to alleviate disability caused by the loss or impairment of hearing. Services include hearing aid selecting, fitting, and dispensing; hearing aid checks following dispensing, conformity evaluations and hearing aid repairs; audiology services including examinations and testing, hearing aid evaluations and hearing aid prescriptions; and hearing aid products including hearing aids, ear molds, special fittings and replacement parts. Medicare-covered diagnostic hearing exams are covered by Plan. $0 copay for Medicarecovered diagnostic hearing exams. $0 copay for Routine hearing tests, and fittingevaluations for a hearing aid Hearing aids covered by Plan (up to $750 per ear per year). Medicare-covered diagnostic hearing exams are covered by Plan. $0 copay for Medicarecovered diagnostic hearing exams. $0 copay for Routine hearing tests, and fittingevaluations for a hearing aid Hearing aids covered by Plan (up to $350 per ear per year). 32

35 Medicaid Benefit Description Medicaid Fee For Service Ultimate Solutions Vision Care Services Services of optometrists, ophthalmologists and ophthalmic dispensers including eyeglasses, medically necessary contact lenses and poly- carbonate lenses, artificial eyes (stock or custom- made), low vision aids and low vision services. Coverage also includes the repair or replacement of parts. Coverage also includes examinations for diagnosis and treatment for visual defects and/or eye disease. Examinations for refraction are limited to every two (2) years unless otherwise justified as medically necessary. Eyeglasses do not require changing more frequently than every two (2) years unless medically necessary or unless the glasses are lost, damaged or destroyed. Diagnosis and treatment for diseases and conditions of the eye and one routine eye exam every year covered by Plan. Eyeglasses or contact lenses after cataract surgery covered by Plan. $0 copay Plan covers up to $200 for eye wear every year. Additional vision services may be accessed by using your Medicaid Fee For Service card. Diagnosis and treatment for diseases and conditions of the eye and one routine eye exam every year covered by Plan. Eyeglasses or contact lenses after cataract surgery covered by Plan. $0 copay Plan covers up to $200 for eye wear every year. If you have Medicaid, additional vision services may be accessed by using your Medicaid Fee For Service card. 33

36 Medicaid Benefit Description Medicaid Fee For Service Ultimate Solutions Diagnostic Tests, X-Rays, Lab Services and Radiology Services $0 copay for Medicarecovered: $0 or $25 copay for Medicare- covered* Lab services.* Lab services.* Diagnostic procedures and tests.* Diagnostic procedures and tests.* X-rays. X-rays. Diagnostic radiology services (not including X-rays).* Diagnostic radiology services (not including X-rays).* Therapeutic radiology services.* Therapeutic radiology services.* Bone Mass Measurement Colorectal Screening Exams at no cost to you at no cost to you Immunizations Medicaid covers Medicare deductibles, copays and coinsurances. at no cost to you Flu, Hepatitis B, and Pneumococcal vaccines covered at no cost to you. Copayment may apply for Part D Vaccines* 34

37 Medicaid Benefit Description Medicaid Fee For Service Ultimate Solutions Mammograms Medicaid covers Medicare deductibles, copays and coinsurances. at no cost to you at no cost to you Pap Smears and Pelvic Exams Medicaid covers Medicare deductibles, copays and coinsurances. Prostate Cancer Screening Medicaid covers Medicare deductibles, copays and coinsurances. at no cost to you at no cost to you Prescription Drugs Medicaid does not cover Part D covered drugs or copays. Medicaid Pharmacy Benefits allowed by State Law (select drug categories excluded from the Medicare Part D benefit). Certain Medical Supplies and Enteral Formula when not covered by Medicare. 35

38 Medicaid Benefit Description Medicaid Fee For Service Ultimate Solutions Over the Counter Drugs Certain over-the-counter medications are covered using your Medicaid benefit card. Up to $65 allowance every month for Medicare and plan-approved over thecounter items. Not Month-to-month balance carry-over does NOT apply Hospice Not Not Non-Emergency Transportation Transportation essential for an enrollee to obtain necessary medical care and services under the plan s benefits. Includes ambulette, invalid coach, taxicab, livery, public transportation, or other means appropriate to the enrollee s medical condition and a transportation attendant to accompany the enrollee, if necessary. Not. Transportation services may be accessed by using your Medicaid Fee For Service card. Up to 12 round-trips per year to plan-approved locations covered by the Plan. If you have Medicaid, additional transportation services may be accessed by using your Medicaid Fee For Service card. 36

39 Medicaid Benefit Description Medicaid Fee For Service Ultimate Solutions Out-of-Network Family Planning Services provided under the direct access provisions of the waiver. Not Not Personal Care Services Not Not Mental Health Services Services include up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. 90 days for an inpatient hospital stay. No Copay 60 lifetime reserve days.. No Copay Outpatient group therapy visit: No Copay Outpatient individual therapy visit: No Copay Authorization is required after 20 visits of Individual therapy and partial hospitalizations visits. Services include up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. 90 days for an inpatient hospital stay. $0 or $200 copay per stay* 60 lifetime reserve days. No Copay Outpatient group therapy visit: $0 or $20 copay* Outpatient individual therapy visit: $0 or $20 copay* Authorization is required after 20 visits of Individual therapy and partial hospitalizations visits 37

40 Medicaid Benefit Description Medicaid Fee For Service Ultimate Solutions Methadone Maintenance Treatment Programs (MMTP) Not Not Comprehensive Medicaid Case Management Not Not Directly Observed Therapy for Tuberculosis (TB) Disease Not Not AIDS Adult Day Health Care Not Not 38

41 Medicaid Benefit Description Medicaid Fee For Service Ultimate Solutions HIV COBRA Case Management Not Not Adult Day Health Care Not Not Personal Emergency Response Services (PERS) Not Not 39

INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 SUMMARY OF BENEFITS

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