2019 Allwell Dual Medicare (HMO SNP) H2134:001 Bernalillo, Cibola, Sandoval, and Valencia counties, NM

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1 2019 Allwell Dual Medicare (HMO SNP) H2134:001 Bernalillo, Cibola, Sandoval, and Valencia counties, NM H2134_19_7971SB_001_M Accepted

2 This booklet provides you with a summary of what we cover and the cost-sharing responsibilities. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please call us at the number listed on the last page and ask for the Evidence of Coverage (EOC), or you may access the EOC on our website at allwell.westernskycommunitycare.com You are eligible to enroll in Allwell Dual Medicare (HMO SNP) if: You are entitled to Medicare Part A and enrolled in Medicare Part B. Members must continue to pay their Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. You must be a United States citizen, or are lawfully present in the United States and permanently reside in the service area of the plan (in other words, your permanent residence is within the Allwell Dual Medicare (HMO SNP) service area county). Our service area includes the following counties in New Mexico: Bernalillo, Cibola, Sandoval, and Valencia. You do not have end-stage renal disease (ESRD). (Exceptions may apply for individuals who develop ESRD while enrolled in an Allwell commercial or group health plan, or a Medicaid plan.) For Allwell Dual Medicare (HMO SNP), you must also be enrolled in the New Mexico Medicaid plan. Premiums, copays, coinsurance, and deductibles may vary based on your Medicaid eligibility category and/or the level of Extra Help you receive. Your Part B premium is paid by the State of New Mexico for full-dual enrollees. Please contact the plan for further details. For Allwell Dual Medicare (HMO SNP), you must also be enrolled in the New Mexico Medicaid plan. Premiums, copays, coinsurance, and deductibles may vary based on your Medicaid eligibility category and/or the level of Extra Help you receive. Your Part B premium is paid by the State of New Mexico for full-dual enrollees. Please contact the plan for further details. The Allwell Dual Medicare (HMO SNP) plan gives you access to our network of highly skilled medical providers in your area. You can look forward to choosing a primary care provider (PCP) to work with you and coordinate your care. You can ask for a current provider directory or, for an up-to-date list of network providers, visit allwell.westernskycommunitycare.com. (Please note that, except for emergency care, urgently needed care when you are out of the network, out-of-area dialysis services, and cases in which our plan authorizes use of out-of-network providers, if you obtain medical care from out-of-plan providers, neither Medicare nor Allwell Dual Medicare (HMO SNP) will be responsible for the costs.) This Allwell Dual Medicare (HMO SNP) plan also includes Part D coverage, which provides you with the ease of having both your medical and prescription drug needs coordinated through a single convenient source.

3 Summary of Benefits JANUARY 1, DECEMBER 31, 2019 Benefits Allwell Dual Medicare (HMO SNP) H2134: 001 Premiums / Copays / Coinsurance Premiums, copays, coinsurance, and deductibles may vary based on your Medicaid eligibility category and/or the level of Extra Help you receive. Monthly Plan Premium $0 based on your level of Medicaid eligibility You must continue to pay your Medicare Part B premium, if not otherwise paid for by Medicaid or another third party. Deductible $0 deductible for covered medical services $415 deductible for Part D prescription drugs Maximum Out-of-Pocket Responsibility (does not include prescription drugs) Inpatient Hospital Coverage* Outpatient Hospital* $3,400 annually This is the most you will pay in copays and coinsurance for medical services for the year. $0 copay per benefit period Outpatient Hospital (includes ambulatory surgical center and observation services: $0 copay per visit Doctor Visits* Primary Care: $0 copay per visit Specialist: $0 copay per visit Preventive Care* (e.g. flu vaccine, diabetic screening) Emergency Care $0 copay for Medicare-covered preventive services Other preventive services are available. $0 copay per visit Urgently Needed Diagnostic /Labs/ Imaging* $0 copay per visit Lab services: $0 copay Diagnostic tests and procedures: $0 copay Outpatient X-ray services: $0 copay Diagnostic Radiological services: $0 copay Hearing Dental Hearing exam (Medicare-covered): $0 copay Dental services (Medicare-covered): $0 copay per visit with an * (asterisk) may require prior authorization and / or a referral from your doctor.

4 Benefits Allwell Dual Medicare (HMO SNP) H2134: 001 Premiums / Copays / Coinsurance Vision Vision exam (Medicare-covered): $0 copay per visit Mental Health * Individual and group therapy: $0 copay per visit Skilled Nursing Facility* $0 copay per stay Physical Therapy* $0 copay per visit Ambulance* Transportation* Medicare Part B Drugs* Ground ambulance services: $0 copay (per one-way trip) Air ambulance services: $0 copay (per one-way trip) $0 copay for each one-way trip Up to 48 one-way trips to plan-approved locations (up to 30 miles each one way per trip) each calendar year Chemotherapy drugs: $0 copay Other Part B drugs: $0 copay Deductible Phase Part D Prescription Drugs $415 deductible Initial Coverage Phase (after you pay your Part D deductible, if applicable) Important Info: 30-day supply without LIS Standard Retail Cost Sharing 30-day supply with LIS 25% coinsurance Generic: $0, $1.25 or $3.40 Brand: $0, $3.80, or $8.50 Cost-sharing may change depending on the level of help you receive, the pharmacy you choose (such as Standard Retail, Mail- Order, Long-Term Care or Home Infusion) and when you enter another of the four phases of the Part D benefit. For more information about the costs for Long-Term Supply, Home Infusion, or additional pharmacy-specific cost-sharing and the phases of the benefit, please call us or access our EOC online. Low income subsidy (LIS) is extra help you receive from Medicare. To find out if you qualify, visit Medicare.gov or call Member at (TTY: 711). with an * (asterisk) may require prior authorization and / or a referral from your doctor.

5 Additional Covered Benefits Benefits Allwell Dual Medicare (HMO SNP) H2134: 001 Premiums / Copays / Coinsurance Chiropractic Care* Medical Equipment/ Supplies* Foot Care * (Podiatry ) Wellness Programs Chiropractic services (Medicare-covered): $0 copay per visit Routine chiropractic services: $0 copay per visit 12 visits per calendar year Durable Medical Equipment (e.g., wheelchairs, oxygen): $0 copay Prosthetics (e.g., braces, artificial limbs): $0 copay Diabetic supplies: $0 copay Foot exams and treatment (Medicare-covered): $0 copay per visit 24-hour nurse advice line: $0 copay For a detailed list of wellness program benefits offered, please refer to the EOC New Mexico Centennial Care Covered Benefits Western Sky Community Care covers a broad range of medical services for your healthcare needs. Some services must be prescribed by your doctor. Some services must be approved by Western Sky Community Care in advance. NOTE: There are some services that your doctor has to get prior authorization before giving you the care. If you want to know if a service needs prior authorization, you can call Member. The phone number is (TTY: 711). There is more information about this later in the handbook. See the section for. Centennial Care Covered Service Accredited Residential Treatment Center Applied Behavior Analysis (ABA) Adult Psychological Rehabilitation Ambulance - Emergency Includes ground and emergency helicopter ambulance (when medically necessary.) with an * (asterisk) may require prior authorization and / or a referral from your doctor.

6 Service Ambulance - n-emergency Ambulatory surgical center services Anesthesia Annual Physical Exam and Consultation Assertive Community Treatment Bariatric Surgery Behavioral Health Professional Case Management Limits and restrictions may apply Includes health appraisal exam, laboratory and radiological tests, and early detection procedures Restrictions may apply; must meet medical guidelines Outpatient behavioral health and substance abuse services Certain procedures require prior authorizations Certain procedures require prior authorizations under certain if getting services from a non-participating provider Community Interveners for the Deaf and Blind Comprehensive Community Support Day Treatment Dental Diagnostic Imaging and Therapeutic Radiology Dialysis Restrictions and limitations may apply. See Dental section for more information under certain t for Annual Preventative. Other services may require a prior authorization under certain Durable Medical Equipment (DME) and Supplies Items that are not medically necessary, or are not ordered by a provider are not covered. under certain

7 Service Emergency Experimental or Investigative Procedures, Technology, or n-drug Therapies Early and Periodic Screening, Diagnosis and Treatment (EPSDT) EPSDT Personal Care Service EPSDT Private Duty Nursing EPSDT Rehabilitation Family Planning Family Support (Behavioral Health) Includes emergency room visits and psychiatric ER Restriction and limitations apply are for members under 21 years of age. May use own PCP or any family planning provider without referral and regardless of whether they are providers for Centennial Care under certain Federally Qualified Health Center (FQHC) Hearing Aids and Related Evaluations Home Health for cochlear implants Hospice Hospital Inpatient Includes detoxification services Hospital Outpatient under certain Inpatient Hospitalization in Freestanding Psychiatric Hospitals

8 Service Intensive Outpatient Program IV Outpatient Lab Medication Assisted Treatment for Opioid Dependence Midwife n-accredited Residential Treatment Centers and Group Homes under certain under certain Nursing Facilities Must meet requirements Occupational Office/Physician Visits Outpatient Hospitalbased Psychiatric and Partial Hospitalization Outpatient and Partial Hospitalization in Freestanding Psychiatric Hospital Outpatient Health Care Professional Pharmacy Physical Therapy Podiatry Limitations or restrictions may apply Covered with all in network providers Restrictions and limitations may apply Some Over-the-counter (OTC) medications require a doctor s prescription See Pharmacy section for more information Limitations and restrictions may apply for office visits with a non-participating provider under certain under certain under certain

9 Service Preventive Prosthetics and Orthotics Psychosocial Rehabilitation Radiology Facilities Recovery (Behavioral Health) Rehabilitation Option Rehabilitation Providers Reproductive Health Respite (Behavioral Health) Rural Health Clinics (RHC) School-Based Smoking Cessation Treatment Speech and Language Therapy Swing Bed Hospital Telemedicine Transplant Transportation (medical) Treatment Foster Care I and Treatment Foster Care II X-rays are covered if they are ordered by a provider. Infertility are not covered Limits and restrictions may apply Certain medications, patches or gum to help you stop smoking are covered. Limitations and restrictions may apply under certain Prior authorization required for high-tech radiology including CT, MRI, and MRA. under certain if non-participating provider under certain

10 Service Vision Care Limitations and restrictions may apply See the Vision section for more information Agency-Based Community Benefit Included under Centennial Care Agency-Based Community Benefit Service Adult Day Health Assisted Living Behavior Support Consultation Community Transition Emergency Response Employment Supports Environmental $5000 limit every five years Modifications Home Health Aide Personal Care Consumer Directed and Consumer Delegated Private Duty Nursing for Restrictions may apply Adults Respite Annual limits may apply Skilled Maintenance Therapy Self-Directed Community Benefit Included under Centennial Care Self-Directed Community Benefit Service Behavior Support Restrictions may apply Consultation Customized Community Support Emergency Response Employment Supports Restrictions may apply Environmental $5000 limit every five years Modifications Home Health Aide

11 Self-Directed Community Benefit Service Self-Directed Personal Care (formerly Homemaker) Nutritional Counseling Private Duty Nursing for Restrictions may apply Adults Related Goods Annual limits may apply Respite Annual Limits may apply Skilled Maintenance Therapy Specialized Therapies Annual limits may apply Transportation (nonmedical) Annual limits and restrictions may apply

12 Section 1557 n-discrimination Language tice of n-discrimination Allwell complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Allwell does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Allwell: Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Allwell s Member telephone number listed for your state on the Member Telephone Numbers by State Chart. From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. If you believe that Allwell has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by calling the number in the chart below and telling them you need help filing a grievance; Allwell s Member is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, (TTY: ). Complaint forms are available at Member Telephone Numbers by State Chart State Telephone Number and Plan Type Arizona / (HMO and HMO SNP) (TTY: 711) Arkansas (HMO) (TTY: 711) Florida (HMO); (HMO SNP) (TTY: 711) Georgia (HMO); (HMO SNP) (TTY: 711) Illinois (HMO) (TTY: 711) Indiana (HMO and PPO); (HMO SNP) (TTY: 711) Kansas (HMO); (HMO SNP) (TTY: 711) Louisiana (HMO) (TTY: 711) Mississippi (HMO); (HMO SNP) (TTY: 711) Missouri (HMO); (HMO SNP) (TTY: 711) New Mexico (HMO SNP) (TTY: 711) Ohio (HMO); (HMO SNP) (TTY: 711) Pennsylvania (HMO); (HMO SNP) (TTY: 711) South Carolina (HMO and HMO SNP) (TTY: 711) Texas (HMO); (HMO SNP) (TTY: 711) Wisconsin (HMO SNP) (TTY: 711) ALL_19_8450FLY_C_ACCEPTED_

13 Section 1557 n-discrimination Language Multi-Language Interpreter

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15 Allwell is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Allwell depends on contract renewal. FLY020520ZK00 (8/18)

16 For more information, please contact: Allwell Dual Medicare (HMO SNP) 5300 Homestead Road NE Albuquerque, NM allwell.westernskycommunitycare.com Current members should call: (TTY: 711) Prospective members should call: (TTY: 711) From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. 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 This plan is available to anyone who has both Medical Assistance from the State and Medicare. This information is not a complete description of benefits. Call (TTY: 711) for more information. Coinsurance is the percentage you pay of the total cost of certain medical and prescription drug services. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. This document is available in other formats such as Braille, large print or audio. Allwell is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Allwell depends on contract. SBS025474ED00 (10/18)