HMO Basic (HMO) / HMO 40 (HMO) / HMO 20 (HMO) Summary of Benefits

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1 / / Summary of Benefits January 1, 2015 December 31, 2015 Call toll-free 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 med-hmosob-0814 H1463_15_21457 H1463_15_21456 H1463_15_21454

2 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). 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 HMO Basic [HMO], HMO 40 [HMO] or HMO 20 [HMO]). TIPS FOR COMPARING YOUR MEDICARE CHOICES This Summary of Benefits booklet gives you a summary of what, and cover 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, or Monthly Premium, Deductible and Limits on How Much You Pay for Covered Services Covered Medical and Hospital 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 or, for TTY users, 711. THINGS TO KNOW ABOUT HEALTH ALLIANCE MEDICARE HMO BASIC (HMO), AND HOURS OF OPERATION From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Central time. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Central time. HEALTH ALLIANCE MEDICARE HMO BASIC (HMO), AND PHONE NUMBERS AND WEBSITE If you are a member of this plan, call toll-free or, for TTY users, 711. If you are not a member of this plan, call toll-free or, for TTY users, 711. Our website: 1

3 WHO CAN JOIN? To join, or, you must be entitled to Medicare Part A, be enrolled in Medicare Part B and live in our service area. Our service area includes the following counties in Illinois: Boone, Bureau, Cass, Champaign, Christian, Coles, De Witt, DeKalb, Douglas, Ford, Franklin, Henry, Jackson, Johnson, Kankakee, Knox, Logan, Macon, Macoupin, Marshall, Mason, McLean, Menard, Mercer, Montgomery, Morgan, Moultrie, Peoria, Perry, Piatt, Putnam, Rock Island, Saline, Sangamon, Scott, Stark, Tazewell, Vermilion, Williamson, Winnebago, and Woodford. WHICH DOCTORS AND HOSPITALS CAN I USE?, and have a network of doctors, hospitals and other providers. If you use the providers that are not in our network, the plan may not pay for these services. You can see our plan s provider directory at our website ( Or, call us and we will send you a copy of the provider directory. 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., and cover Part B drugs including chemotherapy and some drugs administered by your provider. However, these plans do not cover Part D prescription drugs. 2

4 If you have any questions about this plan s benefits or costs, please contact Health Alliance Medical Plans for details. SECTION II SUMMARY OF BENEFITS MONTHLY PREMIUM, DEDUCTIBLE AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is the monthly premium? How much is the deductible? Is there any limit on how much I will pay for my covered services? $0 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. 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. $39 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. 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. $85 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. 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. Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers. Your yearly limit(s) in this plan: $4,500 for services you receive from in-network providers. Your yearly limit(s) in this plan: $3,400 for services you receive from in-network providers. Is there a limit on how much the plan will pay? If you reach the limit on out-ofpocket costs, you 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. No. There are no limits on how much our plan will pay. If you reach the limit on out-ofpocket costs, you 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. No. There are no limits on how much our plan will pay. If you reach the limit on out-ofpocket costs, you 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. No. There are no limits on how much our plan will pay. is an HMO plan with a Medicare Contract. Enrollment in HMO depends on contract renewal. 3

5 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 Not covered Not covered Not covered Other Alternative Therapies Ambulance $200 copay $100 copay $100 copay Chiropractic Care 1, 2 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 copay Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 copay Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 copay Dental Services Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth):$35 copay Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth):$25 copay Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth):$20 copay Preventive dental services: Cleaning (for up to 1 every year): Oral exam (for up to 1 every year): $20 copay When scheduling your annual dental cleaning, please be clear whether or not you would like the oral exam that often follows. The copay for the oral exam is listed above. Preventive dental services: Cleaning (for up to 1 every year): Oral exam (for up to 1 every year): $25 copay When scheduling your annual dental cleaning, please be clear whether or not you would like the oral exam that often follows. The copay for the oral exam is listed above. Preventive dental services: Cleaning (for up to 1 every year): Oral exam (for up to 1 every year): $20 copay When scheduling your annual dental cleaning, please be clear whether or not you would like the oral exam that often follows. The copay for the oral exam is listed above. 4

6 Diabetes Supplies and Services Diabetes monitoring supplies: 10-20% of the cost, depending on the supply Diabetes monitoring supplies: 10-20% of the cost, depending on the supply Diabetes monitoring supplies: 10-20% of the cost, depending on the supply Diabetes self-management training: Diabetes self-management training: Diabetes self-management training: Therapeutic shoes or inserts: 20% of the cost Therapeutic shoes or inserts: 20% of the cost Therapeutic shoes or inserts: 20% of the cost Diagnostic Tests, Lab and Radiology Services and X-rays Diagnostic radiology services (such as MRIs, CT scans): 20% of the cost Diagnostic tests and procedures: 20% of the cost Lab services: 20% of the cost Outpatient X-rays: 20% of the cost Therapeutic radiology services (such as radiation treatment for cancer): 20% of the cost Diagnostic radiology services (such as MRIs, CT scans): $150 copay Diagnostic tests and procedures: $5 copay Lab services: $5 copay Outpatient X-rays: $10 copay Therapeutic radiology services (such as radiation treatment for cancer): 20% of the cost 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): Doctor s Office Visits 2 Primary care physician visit: $10 copay Primary care physician visit: $10 copay Primary care physician visit: $20 copay Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Specialist visit: $50 copay Specialist visit: $45 copay Specialist visit: $40 copay 20% of the cost 20% of the cost 20% of the cost 5

7 Emergency Care $65 copay $65 copay $65 copay If you are immediately admitted to the hospital, 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. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $50 copay Exam to diagnose and treat hearing and balance issues: $35 copay If you are immediately admitted to the hospital, 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. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $45 copay Exam to diagnose and treat hearing and balance issues: $25 copay If you are immediately admitted to the hospital, 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. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $40 copay Exam to diagnose and treat hearing and balance issues: $20 copay Foot Care (Podiatry Services) 2 Hearing Services Routine hearing exam (for up to 1 every year): $35 copay Routine hearing exam (for up to 1 every year): $25 copay Home Health Care 1 Routine hearing exam (for up to 1 every year): $20 copay 6

8 Mental Health Care 1, 2 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 applies to inpatient mental services provided in a general hospital. 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 applies to inpatient mental services provided in a general hospital. 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 applies to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Our plan covers 90 days for an inpatient hospital stay. Our plan covers 90 days for an inpatient hospital stay. 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. 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. 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. $215 copay per day for days 1 through 7 per day for days 8 through 60 $100 copay per day for days 61 through 90 $175 copay per day for days 1 through 7 per day for days 8 through 60 $75 copay per day for days 61 through 90 $100 copay per day for days 1 through 7 per day for days 8 through 60 $50 copay per day for days 61 through 90 Outpatient group therapy visit: $40 copay Outpatient group therapy visit: $30 copay Outpatient group therapy visit: $20 copay Outpatient individual therapy visit: $40 copay Outpatient individual therapy visit: $30 copay Outpatient individual therapy visit: $20 copay 7

9 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): Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): 10% of the cost 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: $40 copay Occupational therapy visit: $40 copay Occupational therapy visit: $40 copay Physical therapy and speech and language therapy visit: $40 copay Physical therapy and speech and language therapy visit: $40 copay Physical therapy and speech and language therapy visit: $40 copay Outpatient Substance Abuse 1 Group therapy visit: 20% of the cost Individual therapy visit: 20% of the cost Group therapy visit: 10% of the cost Individual therapy visit: 10% of the cost Group therapy visit: $20 copay Individual therapy visit: $20 copay Outpatient Surgery Ambulatory surgical center: 20% of the cost Ambulatory surgical center: $150 copay Ambulatory surgical center: $100 copay Over-the-Counter Items Prosthetic Devices (Braces, Artificial Limbs, etc.) 1 Outpatient hospital: 20% of the cost Outpatient hospital: $150 copay Outpatient hospital: $100 copay Not covered Not covered Not covered Prosthetic devices: 20% of the cost Related medical supplies: 20% of the cost Prosthetic devices: 20% of the cost Related medical supplies: 20% of the cost Renal Dialysis 20% of the cost Transportation Not covered Not covered Not covered Urgent Care $65 copay $40 copay $20 copay Prosthetic devices: 20% of the cost Related medical supplies: 20% of the cost 8

10 Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $35 copay Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $25 copay Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $20 copay Routine eye exam (for up to 1 every year): $35 copay Routine eye exam (for up to 1 every year): $25 copay Routine eye exam (for up to 1 every year): $20 copay Eyeglasses or contact lenses after cataract surgery: Eyeglasses or contact lenses after cataract surgery: Eyeglasses or contact lenses after cataract surgery: 9

11 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 tobaccorelated disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit 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 tobaccorelated disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit 10 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 tobaccorelated disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit

12 Preventive Care (continued) Any additional preventive services approved by Medicare during the contract year will be covered. for hospice care from a Medicare-certifi ed hospice. You may have to pay part of the cost for drugs and respite care. Any additional preventive services approved by Medicare during the contract year will be covered. for hospice care from a Medicare-certifi ed hospice. You may have to pay part of the cost for drugs and respite care. Any additional preventive services approved by Medicare during the contract year will be covered. for hospice care from a Medicare-certifi ed hospice. You may have to pay part of the cost for drugs and respite care. Hospice INPATIENT CARE Inpatient Hospital Care 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. Our plan covers an unlimited number of days for an inpatient hospital stay. $235 per day for days 1 through 8 $0 copay per day for days 9 through 60 $100 copay per day for days 61 through 90 per day for days 91 and beyond For inpatient mental health care, see the Mental Health Care section of this booklet. Our plan covers up to 100 days in a SNF. $175 per day for days 1 through 7 $0 copay per day for days 8 through 60 $75 copay per day for days 61 through 90 per day for days 91 and beyond For inpatient mental health care, see the Mental Health Care section of this booklet. Our plan covers up to 100 days in a SNF. $100 per day for days 1 through 7 $0 copay per day for days 8 through 60 $50 copay per day for days 61 through 90 per day for days 91 and beyond For inpatient mental health care, see the Mental Health Care section of this booklet. Our plan covers up to 100 days in a SNF. Inpatient Mental Health Care Skilled Nursing Facility (SNF) 1 $0 copay per day for days 1 through 20 $150 copay per day for days 21 through 100 $0 copay per day for days 1 through 20 $150 copay per day for days 21 through 100 $25 copay per day for days 1 through 20 $125 copay per day for days 21 through

13 PRESCRIPTION DRUG BENEFITS How much do I pay? For Part B drugs such as chemotherapy drugs: 20% of the cost Other Part B drugs: 20% of the cost Our plan does not cover Part D prescription drugs. For Part B drugs such as chemotherapy drugs: 20% of the cost Other Part B drugs: 20% of the cost Our plan does not cover Part D prescription drugs. For Part B drugs such as chemotherapy drugs: 10% of the cost Other Part B drugs: 10% of the cost Our plan does not cover Part D prescription drugs. 12

14 ABOUT US has served Illinois for over 30 years. We have more than 17,000 Medicare members, and 96 percent of them stay with us year after year. TRUE SERVICE When you call, you ll speak with a helpful member services representative based out of Champaign. Most have been with us for years and know our plans inside and out. They will: Answer your questions. Sign you up for a seminar. Arrange for someone to meet with you. Help you enroll over the phone. Stop by 8 a.m. to 5 p.m. weekdays in the Champaign-Urbana area. We re at 206 W. Anthony Drive, near Alexander s Steakhouse just off Interstate 74 at Neil Street. Prospect Ave. I-74 Lincoln Ave. Neil St. KEEP YOUR DOCTOR With so many doctors in our network and more being added all the time chances are you can keep seeing the doctors you know and trust. Use our provider search at HealthAllianceMedicare.org or call today to learn more. With our HMO plans, your Primary Care Physician (PCP) helps you keep track of the care you need and connects you with specialists when you need them. EXTRAS SilverSneakers means free fitness club membership or at-home exercise kits. Information and support at SilverSneakers.com, too. Assist America helps with access to medical services while traveling. This free feature helps replace lost prescriptions and get members back home if they get sick. Plus, our members can call our 24-hour Anytime Nurse Line when their doctor s office is closed. 13

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