SUMMARY OF BENEFITS. Buckeye Health Plan MyCare Ohio (Medicare-Medicaid Plan) H0022_18_SB_Approved_

Transcription

1 2018 SUMMARY OF BENEFITS Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan) H0022_18_SB_Apprved_

2 H0022_18_SB_Apprved_ Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits This is a summary f health services cvered by Buckeye Health Plan MyCare Ohi (Medicare- Medicaid Plan) fr This is nly a summary. Please read the Member Handbk fr the full list f benefits. Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan) (Buckeye) is a health plan that cntracts with bth Medicare and Ohi Medicaid t prvide benefits f bth prgrams t enrllees. It is fr peple with bth Medicare and Medicaid. Under Buckeye yu can get yur Medicare and Medicaid services in ne health plan. A Buckeye care manager will help manage yur health care needs. This is nt a cmplete list. The benefit infrmatin is a brief summary, nt a cmplete descriptin f benefits. Fr mre infrmatin, cntact the plan r read the Member Handbk. Limitatins and restrictins may apply. Fr mre infrmatin, call Buckeye Member Services r read the Buckeye Member Handbk. The List f Cvered Drugs and/r pharmacy and prvider netwrks may change thrughut the year. We will send yu a ntice befre we make a change that affects yu. Benefits may change n January 1 f each year. If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are free. Fr mre infrmatin, visit 1

3 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits If yu speak English, language assistance services, free f charge, are available t yu. Call (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. The call is free. Si habla españl, tiene a su dispsición servicis gratuits de asistencia lingüística. Llame al (TTY: 711) de 8 a. m. a 8 p. m., de lunes a viernes. Lueg del hrari de atención, ls fines de semana y ls días feriads, es psible que se le pida que deje un mensaje. Le devlverems la llamada durante el próxim día hábil. La llamada es gratis. Haddii aad ku hash Smaaliga, adeegyada caawimada luqadda, bilaashka ah, ayaa laguu heli karaa adiga. Wac (TTY: 711) laga bilaab 8 subaxnim ilaa 8 habeenim, Isniinta ilaa Jimcaha. Saacadaha ka dib shaqada, dhammaadka tdbaadka iy fasaxyada, waxaa lagu waydiin kartaa inaad fariin ka tagr. Wicitaankaaga waa laga s celin dnaa gudaha maalinta shaq eek u xigta. Wicitaanka waa bilaash. Yu can get this dcument fr free in ther frmats, such as large print, braille, r audi. Call (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. The call is free. In additin t asking fr materials in ther languages and frmats, yu can als ask that we send yu future materials in this same language r frmat. T get these materials, please call Member Services. If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are free. Fr mre infrmatin, visit 2

4 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits The fllwing chart lists frequently asked questins. Frequently Asked Questins (FAQ) What is a MyCare Ohi Plan What is a Buckeye care manager What are lng-term services and supprts Will yu get the same Medicare and Medicaid benefits in Buckeye that yu get nw Answers A MyCare Ohi Plan is an rganizatin made up f dctrs, hspitals, pharmacies, prviders f lng-term services, and ther prviders. It als has care teams and care managers t help yu manage all yur prviders and services. They all wrk tgether t prvide the care yu need. A Buckeye care manager is ne main persn fr yu t cntact. This persn helps manage all yur prviders and services and makes sure yu get what yu need. Lng-term services and supprts are help fr peple wh need assistance t d everyday tasks like taking a bath, getting dressed, making fd, and taking medicine. Mst f these services are prvided at yur hme r in yur cmmunity but culd be prvided in a nursing hme r hspital. Yu will get yur cvered Medicare and Medicaid benefits directly frm Buckeye. Yu will wrk with a care team wh will help determine what services will best meet yur needs. This means that sme f the services yu get nw may change. Yu will get almst all f yur cvered Medicare and Medicaid benefits directly frm Buckeye, but yu may get sme benefits the same way yu d nw, utside f the plan. When yu enrll in Buckeye, yu and yur care team will wrk tgether t develp an Individualized Care Plan t address yur health and supprt needs. When yu jin ur plan, if yu are taking any Medicare Part D prescriptin drugs that Buckeye des nt nrmally cver, yu can get a temprary supply. We will help yu get anther drug r get an exceptin fr Buckey e t cver yur drug, if medically necessary. If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are free. Fr mre infrmatin, visit 3

5 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits Frequently Asked Questins (FAQ) Can yu g t the same dctrs yu see nw What happens if yu need a service but n ne in Buckeye s netwrk can prvide it Where is Buckeye available Answers Often that is the case. If yur prviders (including dctrs, therapists, and pharmacies) wrk with Buckeye and have a cntract with us, yu can keep ging t them. Prviders with an agreement with us are in-netwrk. Yu must use the prviders in Buckeye s netwrk. Hwever, this rule des nt apply in sme cases:» If yu need urgent r emergency care r ut-f-area dialysis services, yu can use prviders utside f Buckeye s netwrk.» Yu can see ut-f-netwrk Federally Qualified Health Centers, Rural Health Clinics, and qualified family planning prviders listed in the Prvider and Pharmacy Directry.» If yu are getting assisted living waiver services r lng-term nursing facility services frm an ut-f-netwrk prvider n and befre the day yu becme a member, yu can cntinue t get the services frm that ut-f-netwrk prvider. T find ut if yur dctrs are in the plan s netwrk, call Member Services r read Buckeye s Prvider and Pharmacy Directry. Mst services will be prvided by ur netwrk prviders. If yu need a service that cannt be prvided within ur netwrk, Buckeye will pay fr the cst f an ut-f-netwrk prvider. The service area fr this plan includes: Clark, Cuyahga, Fultn, Geauga, Greene, Lake, Lrain, Lucas, Medina, Mntgmery, Ottawa, and Wd Cunties, Ohi. Yu must live in ne f these areas t jin the plan. If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are free. Fr mre infrmatin, visit 4

6 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits Frequently Asked Questins (FAQ) D yu pay a mnthly amunt (als called a premium) under Buckeye What is prir authrizatin Will yu need a referral frm yur PCP t see ther dctrs r specialists Answers Yu will nt pay any mnthly premiums t Buckeye fr yur health cverage. Prir authrizatin means that yu must get apprval frm Buckeye befre yu can get a specific service r drug r see an ut-f-netwrk prvider. Buckeye may nt cver the service r drug if yu dn t get apprval. If yu need urgent r emergency care r ut-f-area dialysis services, yu dn't need t get apprval first. Althugh yu d nt need apprval (called a referral) frm yur Primary Care Prvider (PCP) t see ther prviders, it is still imprtant t cntact yur PCP befre yu see a specialist r after yu have an urgent r emergency department visit. This allws yur PCP t manage yur care fr the best utcmes. If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are free. Fr mre infrmatin, visit 5

7 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits Frequentl y Asked Questins (FAQ) Wh shuld yu cntact if yu have questins r need help Answers If yu have general questins r questins abut ur plan, services, service area, billing, r Member ID Cards, please call Buckey e Member Services: CALL Calls t this number are free. Hurs are frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. Member Services als has free language interpreter services available fr peple wh d nt speak English. TTY 711 This number is fr peple wh have hearing r speaking prblems. Yu must have special telephne equipment t call it. Calls t this number are free. Hurs are frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu have questins abut yur health, please call the 24-Hur Nurse Advice Call Line: CALL TTY Calls t this number are free. Hurs are 24 hurs a day, 7 days a week. 711 This number is fr peple wh have hearing r speaking prblems. Yu must have special telephne equipment t call it. Calls t this number are free. Hurs are 24 hurs a day, 7 days a week. If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are free. Fr mre infrmatin, visit 6

8 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits Frequently Asked Questins (FAQ) Wh shuld yu cntact if yu have questins r need help (cntinued) Answers If yu need immediate behaviral health services, please call the Behaviral Health Crisis Line: CALL Calls t this number are free. Hurs are 24 hurs a day, 7 days a week. TTY 711 This number is fr peple wh have hearing r speaking prblems. Yu must have special telephne e quipment t call it. Calls t this number are free. Hurs are 24 hurs a day, 7 days a week. If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are free. Fr mre infrmatin, visit 7

9 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits The fllwing chart is a quick verview f what services yu may need, yur csts and rules abut the benefits. Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Yu want t see a dctr Visits t treat an injury r illness $0 Nne. Wellness visits, such as a physical Transprtatin t a dctr s ffice $0 Nne. Specialist care $0 Nne. Limitatins, exceptins, & benefit infrmatin (rules abut benefits) $0 Prir authrizatin may be required. Limited t 30 ne-way trips every year t plan-apprved lcatins (cvered health care/dental appintments, WIC appintments, and redeterminatin appintments with yur CDJFS casewrker). Cntact Member Services r yur care manager fr details. Fr infrmatin specific t waiver transprtatin services, call yur waiver service c rdinatr. In cases that are nt emergencies, ambulance r wheelchair van transprt services are cvered when medically necessary. Care t keep yu frm getting sick, such as flu shts Welcme t Medicare preventive visit (ne time nly) $0 Nne. $0 Nne. If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are free. Fr mre infrmatin, visit 8

10 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need medical tests Lab tests, such as bld wrk $0 Prir authrizatin may be required. Yu need drugs t treat yur illness r cnditin X-rays r ther pictures, such as CAT scans Screening tests, such as tests t check fr cancer Generic drugs (n brand name) $0 Prir authrizatin may be required. $0 Prir authrizatin may be required. $0 cpay fr a 30-day supply. $0 cpay fr a 60-day supply. $0 cpay fr a 90-day supply. There may be limitatins n the types f drugs cvered. Please see Buckeye s List f Cvered Drugs (Drug List) fr mre infrmatin. Sme prescriptin drugs may require prir authrizatin r may require that yu try a different drug first. Quantity limits may apply. An extended-day supply f sme drugs is available thrugh mail rder and certain retail pharmacies. Fr mre infrmatin, please refer t ur List f Drugs t view thse drugs available fr an extended-day supply. If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are free. Fr mre infrmatin, visit 9

11 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need drugs t treat yur illness r cnditin (cntinued) Brand name drugs $0 cpay fr a 30-day supply. $0 cpay fr a 60-day supply. $0 cpay fr a 90-day supply. There may be limitatins n the types f drugs cvered. Please see Buckeye s List f Cvered Drugs (Drug List) fr mre infrmatin. Sme prescriptin drugs may require prir authrizatin r may require that yu try a different drug first. Quantity limits may apply. An extended-day supply f sme drugs is available thrugh mail rder and certain retail pharmacies. Fr mre infrmatin, please refer t ur List f Drugs t view thse drugs available fr an extended-day supply. Over-the-cunter drugs $0 There may be limitatins n the types f drugs cvered. Please see Buckeye s List f Cvered Drugs (Drug List) fr mre infrmatin. Yu need therapy after a strke r accident Medicare Part B prescriptin drugs Occupatinal, physical, r speech therapy $0 Part B drugs include drugs given by yur dctr in his r her ffice, sme ral cancer drugs, and sme drugs used with certain medical equipment. Read the Member Handbk fr mre infrmatin n thes e drugs. Prir authrizatin may be required. $0 Prir authrizatin may be required. If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are free. Fr mre infrmatin, visit 10

12 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need emergency care Emergency rm services $0 Emergency rm services d nt require a referral r prir authrizatin and can be prvided at an in-netwrk r ut-f-netwrk facility. Emergency rm services are nt cvered utside the U.S. and its territries except under limited circum stances. Ambulance services $0 Ambulance services fr emergencies d nt require a referral r prir authrizatin and can be prvided by an in-netwrk r ut-f-netwrk prvider. Prir authrizatin may be required fr ambulance services in nn-emergency situatins. Urgent care $0 Urgent care services d nt require a referral r prir authrizatin. Yu can get urgent care services at in-netwrk prviders r at ut-fnetwrk prviders if netwrk prviders are temprarily unavailable r inaccessible. Nt cvered utside the U.S. and its territries. Yu need hspital care Hspital stay $0 Prir authrizatin may be required, except in an emergency. Dctr r surgen care $0 During an authrized hspital stay, dctr and surgen care are cvered. If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are free. Fr mre infrmatin, visit 11

13 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits Health need r prblem Yu need help getting better r have special health needs Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Rehabilitatin services $0 Prir authrizatin may be required. Medical equipment at hme $0 Prir authrizatin may be required. Skilled nursing care $0 Prir authrizatin may be required. Acupuncture $0 This service is limited t pain management f migraine headaches and lwer back pain. Referral is required. Limited t 30 treatments every year. Prir authrizatin may be required if mre than 30 treatments are needed per year. Yu need medicine r ther items that d nt require a prescriptin Over-the-cunter items $0 As an extra benefit, ur plan cvers up t $25 every calendar mnth fr eligible ver-thecunter (OTC) items available via mail rder. This OTC benefit is limited t ne rder (via mail rder) per calendar mnth. Any unused amunt des nt carry ver t the next mnth. Sme items may require that yur PCP verbally recmmend the item fr a diagnsable cnditin. Please cntact the plan fr mre infrmatin. If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are free. Fr mre infrmatin, visit 12

14 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need eye care Eye exams $0 A rutine eye exam is cvered nce every year fr individuals 20 and under and 60 and ver, and nce per 2 years fr individuals age N referral r prir authrizatin is needed fr a rutine eye exam. Glasses r cntact lenses $0 Eye glasses r cntact lenses when medically necessary are cvered nce every year fr individuals 20 and under and 60 and ver, and nce per 2 years fr individuals age Yu need dental care Dental check-ups $0 Oral examinatins are cvered annually fr individuals 21 and ver and twice annually fr thse 20 and under. Yu need hearing/auditry services Yu have a chrnic cnditin, such as diabetes r heart disease Hearing screenings $0 Nne. Hearing aids $0 Services t help manage yur disease Prir authrizatin may be required. Cvered when medically necessary, but nt mre than nce every 4 years fr cnventinal and 5 years fr digital / prgrammable. $0 The plan als ffers additinal disease management services fr certain chrnic cnditins. Cntact Member Services fr mre infrmatin. Diabetes supplies and services $0 Therapeutic shes r inserts are cvered when medically necessary. If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are free. Fr mre infrmatin, visit 13

15 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits Health need r prblem Yu have a mental health cnditin Yu have a substance abuse prblem Yu need lng-term mental health services Yu need durable medical equipment (DME) Services yu may need Mental r behaviral health services Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) $0 Prir authrizatin may be required. Substance abuse services $0 Prir authrizatin may be required. Inpatient care fr peple wh need mental health care $0 Prir authrizatin may be required. Wheelchairs $0 Prir authrizatin may be required. Nebulizers $0 Prir authrizatin may be required. Crutches $0 Prir authrizatin may be required. Walkers $0 Prir authrizatin may be required. Oxygen equipment and supplies $0 Prir authrizatin may be required. Incntinence garments $0 Prir authrizatin may be required. If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are free. Fr mre infrmatin, visit 14

16 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits Health need r prblem Yu need help living at hme Services yu may need Meals brught t yur hme $0 Hme services, such as cleaning r husekeeping Changes t yur hme, such as ramps and wheelchair access Persnal care assistant (Yu may be able t emply yur wn assistant. Cntact yur Care Manager r Waiver Services Crdinatr fr mre infrmatin.) Yur csts fr in-netwrk prviders $0 $0 $0 Cmmunity transitin services $0 Hme health care services $0 Limitatins, exceptins, & benefit infrmatin (rules abut benefits) These services are available nly if yur need fr lng-term care has been determined by Ohi Medicaid. Yu may be respnsible fr paying a patient liability fr nursing facility r waiver services that are cvered thrugh yur Medi caid benefit. The Cunty Department f Jb and Family Services will determine if yur incme and certain expenses require yu t have a patient liability. Prir authrizatin may be required. Services t help yu live n yur wn Adult day services r ther supprt services $0 $0 If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are free. Fr mre infrmatin, visit 15

17 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits Health need r prblem Yu need a place t live with peple available t help yu Yur caregiver needs sme time ff Services yu may need Assisted living $0 Nursing hme care $0 Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) These services are available nly if yur need fr lng-term care has been determined by Ohi Medicaid. Yu may be respnsible fr paying a patient liability fr nursing facility r waiver services that are cvered thrugh yur Medi caid benefit. The Cunty Department f Jb and Family Services will determine if yur incme and certain expenses require yu t have a patient liability. Prir authrizatin may be required. Respite care $0 This service is available nly if yur need fr lng-term care has been determined by Ohi Medicaid. Yu may be respnsible fr paying a patient liability fr nursing facility r waiver services that are cvered thrugh yur Medi caid benefit. The Cunty Department f Jb and Family Services will determine if yur incme and certain expenses require yu t have a patient liability. Prir authrizatin may be required. If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are fre e. Fr mre infrmatin, visit 16

18 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits Benefits cvered utside f Buckeye The fllwing services are nt cvered by Buckeye but are available thrugh Medicare. Call Member Services t find ut abut services nt cvered by Buckeye but available thrugh Medicare. Other services cvered by Medicare Yur csts Sme hspice care services $0 Services that Buckeye, Medicare, and Medicaid d nt cver This is nt a cmplete list. Call Member Services t find ut abut ther excluded services. Services nt cvered by Buckeye, Medicare, r Medicaid Abrtins, except in the case f a reprted rape, incest, r when medically necessary t save the life f the mther. Chirpractic care, ther than diagnstic x-rays and manual manipulatin (adjustments) f the spine t crrect alignment cnsistent with Medicare and Medicaid cverage guidelines. Csmetic surgery r ther csmetic wrk, unless it is needed because f an accidental injury r t imprve a part f the bdy that is nt shaped right. Hwever, the plan will cver recnstructin f a breast after a mastectmy and fr treating the ther breast t match it. Elective r vluntary enhancement prcedures r services (including weight lss, hair grwth, sexual perfrmance, athletic perfrmance, csmetic purpses, LASIK surgery, anti-aging and mental perfrmance), except when medically necessary. Experimental medical and surgical treatments, items, and drugs, unless cvered by Medicare r under a Medicare-apprved clinical research study r by ur plan. Experimental treatment and items are thse that are nt generally accepted by the medical cmmunity. Infertility services fr males r females. If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are free. Fr mre infrmatin, visit 17

19 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits Services nt cvered by Buckeye, Medicare, r Medicaid Inpatient hspital custdial care. Naturpath services (the use f natural r alternative treatments). Orthpedic shes, unless the shes are part f a leg brace and are included in the cst f the brace, r the shes are fr a persn with diabetic ft disease. Paternity testing. Persnal items in yur rm at a hspital r a nursing facility, such as a telephne r a televisin. A private rm in a hspital, except when it is medically needed. Reversal f sterilizatin prcedures and nnprescriptin cntraceptive supplies. Rutine ft care, except fr the limited cverage prvided accrding t Medicare and Medicaid guidelines. Services cnsidered nt reasnable and necessary, accrding t the standards f Medicare and Medicaid, unless these services are listed by ur plan as cvered services. Services prvided t veterans in Veterans Affairs (VA) facilities. Hwever, when emergency services are received at VA hspital and the VA cst sharing is mre than the cst sharing under ur plan, we will reimburse veterans fr the difference. Services received withut an authrizatin, when an authrizatin is required fr getting that service. Services that yu get frm nn-plan prviders, except fr a medical emergency, urgently needed care, and renal (kidney) dialysis services that yu get when yu are temprarily utside the Buckeye service area. Services t find cause f death (autpsy). Supprtive devices fr the feet, except fr rthpedic r therapeutic shes fr peple with diabetic ft disease. Surgical treatment fr mrbid besity, except when it is medically needed and Medicare cvers it. Vluntary sterilizatin if under 21 years f age r legally incapable f cnsenting t the prcedure. If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are fre e. Fr mre infrmatin, visit 18

20 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits Yur rights as a member f the plan As a member f Buckeye, yu have certain rights. Yu can exercise these rights withut being punished. Yu can als use these rights withut lsing yur health care services. We will tell yu abut yur rights at least nce a year. Fr mre infrmatin n yur rights, please read Chapter 8 the Member Handbk. Yur rights include, but are nt limited t, the fllwing: Yu have a right t respect, fairness and dignity. This includes the right t: Yu have the right t make decisins abut yur care, including refusing treatment. This includes the right t: Get cvered services withut cncern abut race, ethnicity, natinal rigin, religin, gender, age, mental r physical disability, sexual rientatin, genetic infrmatin, ability t pay, r ability t speak English. Get infrmatin in ther frmats (e.g., large print, braille, audi). Be free frm any frm f physical restraint r seclusin. Nt be billed by netwrk prviders. Yu have the right t get infrmatin abut yur health care. This includes infrmatin n treatment and yur treatment ptins. This infrmatin shuld be in a frmat yu can understand. These rights include getting infrmatin n: Descriptin f the services we cver Hw t get services Hw much services will cst yu Chse a Primary Care Prvider (PCP) and change yur PCP at any time. See a wmen s health care prvider withut a referral. Get yur cvered services and drugs quickly. Knw abut all treatment ptins, n matter what they cst r whether they are cvered. Refuse treatment, even if yur dctr advises against it. Stp taking medicine. Ask fr a secnd pinin. Buckeye will pay fr the cst f yur secnd pinin visit. Yu have the right t timely access t care that des nt have any cmmunicatin r physical access barriers. This includes the right t : Get medical care timely. Names f health care prviders and care managers If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are free. Fr mre infrmatin, visit 19

21 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits Get in and ut f a health care prvider s ffice. This means barrier free access fr peple with disabilities, in accrdance with the Americans with Disabilities Act. Have interpreters t help with cmmunicatin with yur dctrs and yur health plan. Yu have a right t cnfidentiality and privacy. This includes the right t: Ask fr and get a cpy f yur medical recrds in a way that yu can understand and t ask fr yur recrds t be changed r crrected. Yu have the right t seek emergency and urgent care when yu need it. This means yu have the right t: Get emergency services withut prir apprval in an emergency. See an ut f netwrk urgent r emergency care prvider, when necessary. Have yur persnal health infrmatin kept private. Yu have the right t make cmplaints abut yur cvered services r care. This includes the right t: File a cmplaint r grievance against us r ur prviders. Ask fr a state fair hearing. Get a detailed reasn fr why services were denied. Fr mre infrmatin abut yur rights, yu can read the Buckeye Member Handbk. If yu have questins, yu can als call Buckeye Member Services. If yu have a cmplaint r think we shuld cver smething we denied If yu have a cmplaint r think Buckeye shuld cver smething we denied, call Buckeye at (TTY: 711). Yu may be able t appeal ur decisin. Hurs are frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. Fr questins abut cmplaints and appeals, yu can read Chapter 9 f the Buckeye Member Handbk. Yu can als call Buckeye Member Services. If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are free. Fr mre infrmatin, visit 20

22 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits Yu can call us at: (TTY: 711). Hurs are frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. Yu can fax us at: Yu can write t us at: Buckeye Health Plan MyCare Ohi 4349 Eastn Way, Suite 300 Clumbus, OH If yu suspect fraud Mst health care prfessinals and rganizatins that prvide services are hnest. Unfrtunately, there may be sme wh are dishnest. If yu think a dctr, hspital r ther pharmacy is ding smething wrng, please cntact us. Call us at Buckeye Member Services. Phne numbers are n the cver f this summary. Or, call Medicare at MEDICARE ( ). TTY users shuld call Yu can call these numbers fr free, 24 hurs a day, 7 days a week. Or, call the Ohi Attrney General's Office at If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are free. Fr mre infrmatin, visit 21

23 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits Ntice f Nn-Discriminatin. Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan) cmplies with applicable federal civil rights laws and des nt discriminate n the basis f race, clr, natinal rigin, age, disability, r sex. Buckeye Health Plan des nt exclude peple r treat them differently because f race, clr, natinal rigin, age, disability, r sex. Buckeye Health Plan: Prvides free aids and services t peple with disabilities t cmmunicate effectively with us, such as qualified sign language interpreters and written infrmatin in ther frmats (large print, accessible electrnic frmats, ther frmats). Prvides free language services t peple whse primary language is nt English, such as qualified interpreters and infrmatin written in ther languages. If yu need these services, cntact Buckeye Health Plan's Member Services at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu believe that Buckeye Health Plan has failed t prvide these services r discriminated in anther way n the basis f race, clr, natinal rigin, age, disability r sex, yu can file a grievance by calling the number abve and telling them yu need help filing a grievance; Buckeye Health Plan's Member Services is available t help yu. Yu can als file a civil rights cmplaint with the U.S. Department f Health and Human Services, Office fr Civil Rights, electrnically thrugh the Office fr Civil Rights Cmplaint Prtal, available at r by mail r phne at: U.S. Department f Health and Human Services, 200 Independence Avenue SW., Rm 509F, HHH Building, Washingtn, DC 20201, , (TDD: ). Cmplaint frms are available at If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are free. Fr mre infrmatin, visit 22

24 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits Multi-Language Insert Multi-language Interpreter Services English: ATTENTION: If yu speak English, language assistance services, free f charge, are available t yu. Call (TTY: 711). Spanish: ATENCIÓN: si habla españl, tiene a su dispsición servicis gratuits de asistencia lingüística. Llame al (TTY: 711). Chinese Mandarin: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711) Chinese Cantnese: 注意 : 如果您說中文, 您可獲得免費的語言協助服務 請致電 (TTY: 711) German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kstenls sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). ملحوظة: إذا كنت تتحدث اللغة العربية فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم Arabic: (رقم ھاتف الصم والبكم: 711). Pennsylvania Dutch: Wann du Deitsch (Pennsylvania German / Dutch) schwetzscht, kannscht du mitaus Kschte ebber gricke, ass dihr helft mit die englisch Schprch. Ruf selli Nummer uff: Call (TTY: 711). Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). French: ATTENTION : Si vus parlez français, des services d'aide linguistique vus snt prpsés gratuitement. Appelez le (ATS : 711). H0022_MLI_17R_Apprved_ If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are free. Fr mre infrmatin, visit 23

25 Buckeye Health Plan MyCare Ohi (Medicare-Medicaid Plan): Summary f Benefits Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành ch bạn. Gọi số (TTY: 711). Cushite (Orm): XIYYEEFFANNAA: Afaan dubbattu Ormiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (TTY: 711). Krean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Italian: ATTENZIONE: In cas la lingua parlata sia l'italian, sn dispnibili servizi di assistenza linguistica gratuiti. Chiamare il numer (TTY: 711). Japanese: 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 711) まで お電話にてご連絡ください Dutch: AANDACHT: Als u nederlands spreekt, kunt u gratis gebruikmaken van de taalkundige diensten. Bel (TTY: 711). Ukrainian: УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером (телетайп: 711). Rmanian: ATENȚIE: Dacă vrbiți limba rmână, vă stau la dispziție servicii de asistență lingvistică, gratuit. Sunați la (TTY: 711). Smali: LA SOCO: Haddii aad ku hadash Ingiriisi, adeegyada taageerada luqada, bilaash ah, ayaad heli kartaa, Wac (TTY: 711). If yu have questins, please call Buckeye at (TTY: 711) frm 8 a.m. t 8 p.m., Mnday thrugh Friday. After hurs, n weekends and n hlidays, yu may be asked t leave a message. Yur call will be returned within the next business day. If yu need t speak t yur care manager, please call (TTY: 711), 24 hurs a day, 7 days a week. These calls are fre e. Fr mre infrmatin, visit 24

26 4349 Eastn Way Suite 300 Clumbus, OH TTY: Buckeye Health Plan. All rights reserved.