SUMMARY OF BENEFITS. Superior HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) H6870_18_SB_Accepted_

Transcription

1 2018 SUMMARY OF BENEFITS Superir HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) H6870_18_SB_Accepted_

2 H6870_18_SB_Accepted_ Superir HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP): Summary f Benefits This is a summary f health services cvered by Superir STAR+PLUS MMP fr This is nly a summary. Please read the Member Handbk fr the full list f benefits. Superir HealthPlan STAR+PLUS Medicare-Medicaid Plan (MMP) is a health plan that cntracts with bth Medicare and Texas Medicaid t prvide benefits f bth prgrams t enrllees. It is fr peple with bth Medicare and Texas Medicaid. Under Superir STAR+PLUS MMP yu can get yur Medicare and Texas Medicaid services in ne health plan. A Superir STAR+PLUS MMP service crdinatr 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 Superir STAR+PLUS MMP Member Services r read the Superir STAR+PLUS MMP 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 speak a language ther than 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., lunes a viernes. Después de hras hábiles, ls fines de semana y ls días festivs, es psible que se le pida que deje un mensaje. Le devlverems la llamada el próxim día hábil. La llamada es gratuita. If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 1

3 Superir STAR+PLUS MMP: Summary f Benefits 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. The fllwing chart lists frequently asked questins. Frequently Asked Questins (FAQ) What is a Medicare-Medicaid Plan What is a Superir STAR+PLUS MMP service crdinatr What are lng-term services and supprts Answers A Medicare-Medicaid Plan is an rganizatin made up f dctrs, hspitals, pharmacies, prviders f lng-term services and supprts, and ther prviders. It als has service crdinatrs t help yu manage all yur prviders and services. They all wrk tgether t prvide the care yu need. A Superir STAR+PLUS MMP service crdinatr 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. If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 2

4 Superir STAR+PLUS MMP: Summary f Benefits Frequently Asked Questins (FAQ) Will yu get the same Medicare and Texas Medicaid benefits in Superir STAR+PLUS MMP that yu get nw Answers Yu will get yur cvered Medicare and Texas Medicaid benefits directly frm Superir STAR+PLUS MMP. Yu will wrk with a team f prviders 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 Texas Medicaid benefits directly frm Superir STAR+PLUS MMP, but yu may get sme benefits the same way yu d nw, utside f the plan. When yu enrll in Superir STAR+PLUS MMP, yu and yur service crdinatin team will wrk tgether t develp a Plan f Care t address yur health and supprt needs. During this time, yu can keep seeing yur dctrs and getting yur current services fr 90 days (six mnths fr lng-term services and supprts (LTSS), r nine mnths if yu are diagnsed with and receiving treatment fr a terminal illness), r until yur Plan f Care is cmplete. When yu jin ur plan, if yu are taking any Medicare Part D prescriptin drugs that Superir STAR+PLUS MMP des nt nrmally cver, yu can get a temprary supply. We will help yu get anther drug r get an exceptin fr Superir STAR+PLUS MMP t cver yur drug, if medically necessary. If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 3

5 Superir STAR+PLUS MMP: 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 Superir STAR+PLUS MMP s netwrk can prvide it Where is Superir STAR+PLUS MMP available D yu pay a mnthly amunt (als called a premium) under Superir STAR+PLUS MMP Answers Often that is the case. If yur prviders (including dctrs, therapists, and pharmacies) wrk with Superir STAR+PLUS MMP 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 Superir STAR+PLUS MMP s netwrk. If yu need urgent r emergency care r ut-f-area dialysis services, yu can use prviders utside f Superir STAR+PLUS MMP's plan. If yu get emergency care at an ut-f-netwrk hspital and need inpatient care after yur emergency is stabilized, yu must return t a netwrk hspital fr yur care t cntinue t be paid fr. Yu can stay in the ut-f-netwrk hspital fr yur inpatient care nly if the plan apprves yur stay. T find ut if yur dctrs are in the plan s netwrk, call Member Services r read Superir STAR+PLUS MMP s Prvider and Pharmacy Directry. If Superir STAR+PLUS MMP is new fr yu, yu can cntinue seeing the dctrs yu g t nw fr 90 days (six mnths fr lng-term services and supprts (LTSS), r nine mnths if yu are diagnsed with and receiving treatment fr a terminal illness), r until yur Plan f Care is cmplete. Mst services will be prvided by ur netwrk prviders. If yu need a service that cannt be prvided within ur netwrk, Superir STAR+PLUS MMP will pay fr the cst f an ut-fnetwrk prvider. The service area fr this plan includes: Bexar, Dallas, and Hidalg Cunties, Texas. Yu must live in ne f these areas t jin the plan. Yu will nt pay any mnthly premiums t Superir STAR+PLUS MMP fr yur health cverage. If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 4

6 Superir STAR+PLUS MMP: Summary f Benefits Frequently Asked Questins (FAQ) What is prir authrizatin What is a referral Wh shuld yu cntact if yu have questins r need help Answers Prir authrizatin means that yu must get apprval frm Superir STAR+PLUS MMP befre yu can get a specific service r drug r see an ut-f-netwrk prvider. Superir STAR+PLUS MMP 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. A referral means that yur primary care prvider must give yu apprval t see smene that is nt yur primary care prvider. If yu dn t get apprval, Superir STAR+PLUS MMP may nt cver the services. There are certain specialists in which yu d nt need a referral, such as wmen s health specialists. Fr mre infrmatin n when a referral is necessary, see the Member Handbk. If yu have general questins r questins abut ur plan, services, service area, billing, r Member ID Cards, please call Superir STAR+PLUS MMP Member Services: CALL TTY 711 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. 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, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 5

7 Superir STAR+PLUS MMP: Summary f Benefits Frequently Asked Questins (FAQ) Wh shuld yu cntact if yu have questins r need help (cntinued) Answers If yu have questins abut yur health, please call the Nurse Advice Call 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 equipment t call it. Calls t this number are free. Hurs are 24 hurs a day, 7 days a week. If yu need immediate behaviral health services, please call the Behaviral Health Crisis Line: CALL TTY 711 Calls t this number are free. Hurs are 24 hurs a day, 7 days a week. 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 Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 6

8 Superir STAR+PLUS MMP: 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. Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Wellness visits, such as a physical $0 Prir authrizatin may be required. Specialist care $0 Referral and prir authrizatin may be required. Care t keep yu frm getting sick, such as flu shts Welcme t Medicare preventive visit (ne time nly) $0 Prir authrizatin may be required. $0 Prir authrizatin may be required. Yu need medical tests Lab tests, such as bld wrk $0 Referral and prir authrizatin may be required. X-rays r ther pictures, such as CAT scans Screening tests, such as tests t check fr cancer $0 Referral and prir authrizatin may be required. $0 Referral and prir authrizatin may be required. If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 7

9 Superir STAR+PLUS MMP: 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 Generic drugs (n brand name) $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 Superir STAR+PLUS MMP 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 drugs is available thrugh mail rder and sme retail pharmacies. Please refer t ur Drug List t view thse drugs available fr an extendedday supply. 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 Superir STAR+PLUS MMP 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 drugs is available thrugh mail rder and sme retail pharmacies. Please refer t ur Drug List t view thse drugs available fr an extendedday supply. If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 8

10 Superir STAR+PLUS MMP: Summary f Benefits Health need r prblem Yu need drugs t treat yur illness r cnditin (cntinued) Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Over-the-cunter drugs $0 There may be limitatins n the types f drugs cvered. Please see Superir STAR+PLUS MMP s List f Cvered Drugs (Drug List) fr mre infrmatin. Yu need therapy after a strke r accident Medicare Part B prescriptin drugs $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 these drugs. Prir authrizatin may be required. Occupatinal, physical, r speech therapy $0 Referral and prir authrizatin may be required. 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. Nt cvered utside the U.S. and its territries. 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 nn-emergency ambulance services. If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 9

11 Superir STAR+PLUS MMP: Summary f Benefits Health need r prblem Yu need emergency care (cntinued) Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) 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-f-netwrk 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 Referral and prir authrizatin may be required. Yu need help getting better r have special health needs Except in an emergency, yur dctr must tell the plan yu are ging t be admitted t the hspital. Dctr r surgen care $0 During an authrized hspital stay, dctr and surgen care are cvered. Rehabilitatin services $0 Referral and prir authrizatin may be required. Medical equipment fr hme care $0 Prir authrizatin may be required. Skilled nursing care $0 Referral and prir authrizatin may be required. If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 10

12 Superir STAR+PLUS MMP: Summary f Benefits Health need r prblem Yu need medicine r ther items that d nt require a prescriptin Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Over-the-cunter items $0 As a Flexible Benefit, ur plan cvers up t $25 every calendar mnth fr eligible ver-the-cunter (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. This benefit is nly available t plan members in the cmmunity. It is nt available t plan members in a nursing facility. Please cntact the plan fr mre infrmatin. Yu need eye care Eye exams $0 A rutine eye exam is cvered nce every year as a Flexible Benefit. Eye exams fr diagnsis and treatment f diseases and injuries f the eye are cvered. N referral r prir authrizatin is required fr eye exams. Glasses r cntact lenses $0 The plan cvers 1 pair f glasses (lenses and frames) AND ne pair f cntact lenses each year up t a $200 limit as a Flexible Benefit. If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 11

13 Superir STAR+PLUS MMP: 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 dental care Dental check-ups $0 Limited dental services are available t members enrlled in the HCBS STAR+PLUS waiver services. Yu need hearing/auditry services Yu have a chrnic cnditin, such as diabetes r heart disease Hearing screenings $0 Nne. Hearing aids $0 The plan cvers: The annual cst cap f this service is $5,000 per waiver plan year. Exceptins t the $5,000 cap may be made up t an additinal $5,000 per waiver plan year when the services f an ral surgen are required. Cntact Member Services fr mre infrmatin. 1 hearing aid every five years. Fittings/evaluatins fr hearing aid Services t help manage yur disease $0 N referral r prir authrizatin required fr kidney disease educatin services. Prir authrizatin may be required fr diabetes self-management training. The plan als ffers additinal disease management services fr certain chrnic cnditins. Cntact Member Services fr mre infrmatin. Diabetes supplies and services $0 Prir authrizatin may be required. Yu have a mental health cnditin Mental r behaviral health services $0 Referral and prir authrizatin may be required. If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 12

14 Superir STAR+PLUS MMP: Summary f Benefits Health need r prblem Yu have a substance abuse prblem Yu need lng-term mental health services Yu need durable medical equipment (DME) Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Substance abuse services $0 Referral and prir authrizatin may be required. Inpatient care fr peple wh need mental health care $0 Referral and 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. Yu need help living at hme Meals brught t yur hme $0 This service is prvided t members enrlled in the HCBS STAR+PLUS waiver services. Once eligibility fr services has been determined, prir authrizatin may be required t receive services within the specific waiver. Hme-delivered meals are als a Flexible Benefit ffered fr free n a limited basis t Superir STAR+PLUS MMP nn-waiver members. Prir authrizatin may be required. The meal prvides a minimum f ne-third f the current recmmended dietary allwance fr the member as adpted by the United States Department f Agriculture. If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 13

15 Superir STAR+PLUS MMP: Summary f Benefits Health need r prblem Yu need help living at hme (cntinued) Services yu may need 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. Call Member Services fr mre infrmatin.) Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) $0 This service is prvided nly t members enrlled in the HCBS STAR+PLUS waiver services. Yu must be fund eligible t receive waiver services. Once eligibility fr services has been determined, prir authrizatin may be required t receive services within the specific waiver. $0 The minr hme mdificatins benefit is subject t a $7,500 lifetime limit and $300 annually fr repairs. This service is prvided nly t members enrlled in the HCBS STAR+PLUS waiver services. Yu must be fund eligible t receive waiver services. Once eligibility fr services has been determined, prir authrizatin may be required t receive services within the specific waiver. $0 Prir authrizatin may be required. If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 14

16 Superir STAR+PLUS MMP: Summary f Benefits Health need r prblem Yu need help living at hme (cntinued) Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Training t help yu get paid r unpaid jbs $0 This service is prvided nly t members enrlled in the HCBS STAR+PLUS waiver services. Yu must be fund eligible t receive waiver services. Once eligibility fr services has been determined, prir authrizatin may be required t receive services within the specific waiver. Hme health care services $0 Referral and prir authrizatin may be required. Services t help yu live n yur wn $0 This service is prvided nly t members enrlled in the HCBS STAR+PLUS waiver services. Yu must be fund eligible t receive waiver services. Once eligibility fr services has been determined, prir authrizatin may be required t receive services within the specific waiver. If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 15

17 Superir STAR+PLUS MMP: Summary f Benefits Health need r prblem Yu need help living at hme (cntinued) Yu need a place t live with peple available t help yu Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Adult day services r ther supprt services $0 This service is prvided nly t members enrlled in the HCBS STAR+PLUS waiver services. Yu must be fund eligible t receive waiver services. Once eligibility fr services has been determined, prir authrizatin may be required t receive services within the specific waiver. Assisted living r ther husing services $0 This service is prvided nly t members enrlled in the HCBS STAR+PLUS waiver services. Yu must be fund eligible t receive waiver services. Once eligibility fr services has been determined, prir authrizatin may be required t receive services within the specific waiver. Nursing hme care $0 Prir authrizatin may be required. If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 16

18 Superir STAR+PLUS MMP: Summary f Benefits Health need r prblem Yur caregiver needs sme time ff Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Respite care $0 Limited t 30 visits per year. This service is prvided t members enrlled in the HCBS STAR+PLUS waiver services. Once eligibility fr services has been determined, prir authrizatin may be required t receive services within the specific waiver. Respite care is als a flexible benefit ffered fr free n a limited basis t Superir STAR+PLUS MMP nn-waiver members. Prir authrizatin may be required. Other services that Superir STAR+PLUS MMP cvers This is nt a cmplete list. Call Member Services r read the Member Handbk t find ut abut ther cvered services. Other services cvered by Superir STAR+PLUS MMP Yur csts fr in-netwrk prviders Adaptive Aids and Medical Supplies $0 Adult Fster Care $0 Cgnitive Rehabilitatin Therapy $0 Cunseling Services $0 Cunseling t Stp Smking r Tbacc Use $0 If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 17

19 Superir STAR+PLUS MMP: Summary f Benefits Other services cvered by Superir STAR+PLUS MMP (cntinued) Yur csts fr in-netwrk prviders Day Habilitatin Services $0 Dental Services $0 Emergency Respnse Services $0 Enhanced Disease Management $0 Functinal Living Task Services $0 Nursing Services $0 Persnal Emergency Respnse System (PERS) $0 Pdiatry $0 Remte Access Technlgies (Including Web/Phne Based Technlgies and Nursing Htline) Supprt Cnsultatin $0 Supprted Emplyment $0 Telemnitring Services $0 Transitinal Assistance Services $0 $0 If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 18

20 Superir STAR+PLUS MMP: Summary f Benefits Benefits cvered utside f Superir STAR+PLUS MMP This is nt a cmplete list. Call Member Services t find ut abut ther services nt cvered by Superir STAR+PLUS MMP but available thrugh Medicare r Texas Medicaid. Other services cvered by Medicare r Texas Medicaid Yur csts Sme hspice care services $0 Nnemergency medical transprtatin services $0 Pre-admissin screening and resident review (PASRR) $0 Benefits nt cvered by Superir STAR+PLUS MMP, Medicare, r Texas Medicaid This is nt a cmplete list. Call Member Services r read the Member Handbk t find ut abut ther excluded services. Benefits nt cvered by Superir STAR+PLUS MMP, Medicare, r Texas Medicaid Acupuncture Chirpractic care, ther than manual manipulatin f the spine cnsistent with Medicare 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 pay fr recnstructin f a breast after a mastectmy and fr treating the ther breast t match it. Dental care, such as cleanings, fillings r dentures, unless the member qualifies fr the hme and cmmunity-based waiver services. Hwever, dental care required t treat illness r injury may be cvered as inpatient r utpatient care Elective r vluntary enhancement prcedures r services (including weight lss, hair grwth, sexual perfrmance, athletic perfrmance, csmetic purpses, anti-aging and mental perfrmance), except when medically needed 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 If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 19

21 Superir STAR+PLUS MMP: Summary f Benefits Benefits nt cvered by Superir STAR+PLUS MMP, Medicare, r Texas Medicaid (cntinued) Fees charged by yur immediate relatives r members f yur husehld Full-time nursing care in yur hme Hmemaker services unless the member qualifies fr the hme and cmmunity-based waiver services Naturpath services (the use f natural r alternative treatments) Nn-prescriptin cntraceptive supplies 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 Persnal items in yur rm at a hspital r a nursing facility, such as a telephne r a televisin Private duty nurses Private rm in a hspital, except when it is medically needed Reversal f sterilizatin prcedures Services cnsidered nt reasnable and necessary, accrding t the standards f Medicare and Texas Medicaid, unless these services are listed by ur plan as cvered services Services prvided t veterans in Veterans Affairs (VA) facilities. Hwever, when a veteran gets emergency services at a VA hspital and the VA cst sharing is mre than the cst sharing under ur plan, we will reimburse the veteran fr the difference 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 pays fr it Unauthrized services that yu get frm nn-plan prviders except fr emergency care, urgently needed care, and renal (kidney) dialysis services when yu are temprarily utside the service area Visin prcedures such as radial kerattmy, LASIK surgery, and visin therapy; and ther lw-visin aids If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 20

22 Superir STAR+PLUS MMP: Summary f Benefits Yur rights as a member f the plan As a member f Superir STAR+PLUS MMP, 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 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: Chse a Primary Care Prvider (PCP) and yu can change yur PCP at any time 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 Names f health care prviders and care managers Yu have the right t make decisins abut yur care, including refusing treatment. This includes the right t: 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. Superir STAR+PLUS MMP 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 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. If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 21

23 Superir STAR+PLUS MMP: Summary f Benefits 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 Yu have a right t cnfidentiality and privacy. This includes the right t: 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 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. Fr mre infrmatin abut yur rights, yu can read the Superir STAR+PLUS MMP Member Handbk. If yu have questins, yu can als call Superir STAR+PLUS MMP Member Services. If yu have a cmplaint r think we shuld cver smething we denied If yu have a cmplaint r think Superir STAR+PLUS MMP shuld cver smething we denied, call Superir STAR+PLUS MMP at (TTY: 711). Yu may be able t appeal ur decisin. Member Services 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 Superir STAR+PLUS MMP Member Handbk. Yu can als call Superir STAR+PLUS MMP Member Services. If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 22

24 Superir STAR+PLUS MMP: Summary f Benefits T file a cmplaint, grievance, r appeal with ur plan: Yu can call us 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. Yu can fax us at: Yu can write t us at: Superir STAR+PLUS MMP Attn: Appeals and Grievances -- Medicare Operatins 7700 Frsyth Blvd St. Luis, MO 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 Superir STAR+PLUS MMP 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. Let us knw if yu think a dctr, dentist, pharmacist at a drug stre, ther health care prviders, r a persn getting benefits is ding smething wrng. Ding smething wrng culd be fraud, waste, r abuse, which is against the law. Fr example, tell us if yu think smene is: Getting paid fr services that weren t given r weren t necessary. Nt telling the truth abut a medical cnditin t get medical treatment. If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 23

25 Superir STAR+PLUS MMP: Summary f Benefits Letting smene else use their Texas Medicaid ID. Using smene else s Texas Medicaid ID. Nt telling the truth abut the amunt f mney r resurces he r she has t get benefits. T reprt fraud, waste, r abuse, chse ne f the fllwing: Call the OIG Htline at ; Visit and pick Click Here t Reprt Waste, Abuse, and Fraud t cmplete the nline frm; r Yu can reprt directly t yur health plan: Superir STAR+PLUS MMP; ATTN: Cmpliance Officer, 5900 E. Ben White Blvd., Austin, TX 78741; and (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. T reprt fraud, waste, r abuse, gather as much infrmatin as pssible. When reprting abut a prvider (a dctr, dentist, cunselr, etc.), include: Name, address, and phne number f prvider Name and address f the facility (hspital, nursing hme, hme health agency, etc.) Texas Medicaid number f the prvider and facility, if yu have it Type f prvider (dctr, dentist, therapist, pharmacist, etc.) Names and phne numbers f ther witnesses wh can help in the investigatin Dates f events Summary f what happened If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 24

26 Superir STAR+PLUS MMP: Summary f Benefits When reprting abut smene wh gets benefits, include: The persn s name The persn s date f birth, Scial Security Number, r case number if yu have it The city where the persn lives Specific details abut the fraud, waste, r abuse Yu may als cntact yur lcal Texas plice department. If yu have questins, please call Superir STAR+PLUS MMP 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. The call is free. Fr mre infrmatin, visit 25

27 Superir HealthPlan (Superir) STAR+PLUS Medicare-Medicaid Plan (MMP) cmplies with applicable federal civil rights laws and des nt discriminate n the basis f race, clr, natinal rigin, age, disability, r sex. Superir STAR+PLUS MMP des nt exclude peple r treat them differently because f race, clr, natinal rigin, age, disability, r sex. Superir STAR+PLUS MMP: 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 Superir STAR+PLUS MMP 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. The call is free. Superir HealthPlan (Superir) STAR+PLUS Medicare-Medicaid Plan (MMP) cumple cn las leyes federales de derechs civiles aplicables y n discrimina pr cuestines de raza, clr, nacinalidad, edad, discapacidad sex. Superir STAR+PLUS MMP n excluye a ninguna persna ni la trata de manera diferente pr mtivs de raza, clr, nacinalidad, edad, discapacidad sex. Superir STAR+PLUS MMP: Brinda asistencia y servicis gratis a las persnas cn discapacidades para que puedan cmunicarse de manera eficaz cn nstrs cm, pr ejempl, intérpretes de lenguaje de señas calificads e infrmación escrita en trs frmats (letra grande, frmats electrónics accesibles y trs frmats). Brinda servicis lingüístics gratis a aquellas persnas cuya lengua materna n es el inglés, cm intérpretes calificads e infrmación escrita en trs idimas. Si necesita ests servicis, póngase en cntact cn Servicis para afiliads de Superir STAR+PLUS MMP al (ls usuaris de TTY deben llamar al 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 el próxim día hábil. La llamada es gratuita. SHP_ A-MMP Statement f Nn-Discriminatin If yu believe that Superir STAR+PLUS MMP 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; Superir STAR+PLUS MMP 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 Declaración de n discriminación Si usted cnsidera que Superir STAR+PLUS MMP n le ha brindad ests servicis l ha discriminad de alguna tra manera debid a su raza, clr, nacinalidad, edad, discapacidad sex, puede presentar un reclam llamand al númer que aparece arriba e infrmand que necesita ayuda para presentar el reclam; el Departament de Servicis para afiliads de Superir STAR+PLUS MMP está dispnible para ayudarl. También puede presentar una queja sbre derechs civiles ante la Oficina de Derechs Civiles del Departament de Salud y Servicis Sciales de ls EE. UU. de manera electrónica a través del Office fr Civil Rights Cmplaint Prtal (Prtal de quejas de la Oficina de Derechs Civiles) dispnible en bien, pr crre electrónic a ls teléfns que figuran a cntinuación: U.S. Department f Health and Human Services, 200 Independence Avenue SW., Rm 509F, HHH Building, Washingtn, DC 20201, , (TDD: ) Ls frmularis de quejas se encuentran dispnibles en

28 SPANISH: ATENCIÓN: si habla españl, tiene a su dispsición servicis gratuits de asistencia lingüística. Llame al (TTY: 711). 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). CHINESE: 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) KOREAN: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. ARABIC: ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم: 711). خبردار: اگر آپ اردو بولتے ہیں تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں کال کریں.(711 (TTY: URDU: TAGALOG: FRENCH: HINDI: PERSIAN/ FARSI: GERMAN: PAUNAWA: Kung nagsasalita ka ng Tagalg, maaari kang gumamit ng mga serbisy ng tulng sa wika nang walang bayad. Tumawag sa (TTY: 711). ATTENTION : Si vus parlez français, des services d'aide linguistique vus snt prpsés gratuitement. Appelez le (ATS : 711). ध य न द: यद आप ह द ब लत ह त आपक लए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY:711) पर क ल कर توجھ: اگر بھ زبان فارسی گفتگو می کنید تسھیلات زبانی بصورت رایگان برای شما فراھم می باشد. با (TTY:711) تماس بگیرید. ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kstenls sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). GUJARATI: ચન : જ તમ જર ત બ લત હ, ત ન: લ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર (TTY: 711). RUSSIAN: JAPANESE: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). 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 LAOTIAN: SHP_ C-MMP ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລການຊ ວຍເຫ (TTY: 711). ອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແມ ນມ ພ ອມໃຫ ທ ານ. ໂທຣ

29 Frum II Building 7990 IH 10 West, Suite 300 San Antni, TX TTY: Superir HealthPlan, Inc. All rights reserved.