Centers Plan for Dual Coverage Care (HMO SNP) 2018 Summary of Benefits

Transcription

1 Centers Plan for Dual Coverage Care (HMO SNP) 2018 Summary of Benefits H6988_002_ENR1099_CY2018 Accepted

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3 Centers Plan for Dual Coverage Care (HMO SNP) Summary of Benefits January 1, December 31, 2018 Bronx, Kings, New York, Queens and Richmond Counties H6988_002_ENR1099_CY2018 Accepted

4 My Primary Care Provider is: Name: Address: Phone number: My CPHL Representative is: Name: Phone number: IMPORTANT CONTACT INFORMATION Member Services is available 8:00 AM to 8:00 PM, seven days a week: PHONE: TTY users MAIL: Centers Plan for Healthy Living 75 Vanderbilt Avenue Suite 700 Staten Island, NY MemberServices@centersplan.com WEBSITE: 4

5 Table of Contents Section I: Introduction to the Summary of Benefits Section II: Summary of Benefits Section III: Additional Benefits Section IV: Overview of Medicaid-Covered Benefits

6 Language Assistance Services Notification ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: ). KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: ). ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم : (. লক ষ য কর ন যদ আপদন ব ল, কথ বলত প ত ন, হতল দন খ চ য় ভ ষ সহ য় পদ তষব উপলব ধ আত ফ ন কর ন ১ (TTY: ১ ) 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: ) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : ). ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε (TTY: ). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: ). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: ). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: ). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). 6

7 PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ) کريں کال ہيں دستياب ميں مفت خدمات کی مدد کی زبان کو آپ تو ہيں بولتے اردو آپ اگر :خبردار 9330 (TTY: ). רופט.אפצאל פון פריי סערוויסעס הילף שפראך אייך פאר פארהאן זענען,אידיש רעדט איר אויב :אויפמערקזאם (TTY: ) 7

8 We're Here To Help And Serve You Centers Plan for Healthy Living is a culturally diverse company. We welcome all eligible individuals into our health care program. Anyone entitled to Medicare Parts A and B may apply. Discrimination is Against the Law Centers Plan for Healthy Living complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Centers Plan for Healthy Living does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Centers Plan for Healthy Living provides: Free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters. Written information in other formats (large print, audio, accessible electronic formats, other formats) Free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact Member Services at (TTY users please call ( or 711). If you believe that Centers Plan for Healthy Living has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with our Grievances and Appeals Department: By Mail: Centers Plan for Healthy Living Attn: G&A Department 75 Vanderbilt Avenue Staten Island, NY By Phone: (TTY users call ) By Fax: By GandA@centersplan.com 8

9 You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Participant Services is available to help you seven days a week from 8am to 8pm. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https: /ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at http: / 9

10 SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the "Evidence of Coverage." You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Centers Plan for Dual Coverage Care (HMO SNP)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what Centers Plan for Dual Coverage Care (HMO SNP) covers and what you pay. If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on http: / 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 http: / 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 Centers Plan for Dual Coverage Care (HMO SNP) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits This document is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call us at (877) (TTY/TDD ). Esta información está disponible gratis en otros idiomas. Comuníquese con nuestro Servicio para Miembros at para obtener información adicional, (los usuarios de TTY deben llamar al ) de 8:00 am a 8: pm siete días a la semana. Los Servicios para Miembros también tienen servicios de intérpretes de idiomas gratis disponibles para las personas que no hablan inglés. También podemos darles información en sistema Braille, en letra grande u otros formatos. Things to Know About Centers Plan for Dual Coverage Care (HMO SNP) Hours of Operation You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. 10

11 Centers Plan for Dual Coverage Care (HMO SNP) Phone Numbers and Website If you are a member of this plan, call toll-free (877) (TTY/TDD ). If you are not a member of this plan, call toll-free (877) (TTY/TDD ). Our website: http: / Who can join? To join Centers Plan for Dual Coverage Care (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and be eligible for, New York State Medicaid program and live in our service area. Our service area includes the following counties in New York: Bronx, Kings, New York, Queens, and Richmond. Which doctors, hospitals, and pharmacies can I use? Centers Plan for Dual Coverage Care (HMO SNP) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan's provider and pharmacy directory at our website ( com). Or, call us and we will send you a copy of the provider and pharmacy directories. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers - and more. Our plan members get all of the benefits covered by Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, http: / Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? The amount you pay for drugs depends on the drug you are taking and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage. Centers Plan for Dual Coverage Care (HMO SNP) Comprehensive Formulary (List of Covered Drugs) is accessible on our website at If you prefer a hard copy of the Formulary, call Member Services. 11

12 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the monthly premium? $39.00 per month. In addition, you must keep paying your Medicare Part B premium. How much is the deductible? This plan has deductibles for some hospital and medical services. $0 to $83 per year for Part D prescription drugs. Is there any limit on how much I will pay for my covered services? Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. In this plan, you may pay nothing for some services, depending on your level of New York State Medicaid program eligibility. Your yearly limit(s) in this plan: $6,700 for services you receive from innetwork providers. If you reach the limit on out-of-pocket 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 and costsharing for your Part D prescription drugs. Is there a limit on how much the plan will pay? Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. 12

13 SECTION II - SUMMARY OF BENEFITS 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. Monthly Plan Premium, including Part C and Part D Premium Dual Coverage Care (HMO SNP) $39 per month for Part D Premium $0 per month for Part C Premium Depending on your level of Medicaid and LIS eligibility, you may not have any premium costs. $0 or $39 per month Part D Premium Deductible $0 Pharmacy (Part D) deductible Maximum Out-of-Pocket Responsibility (does not include prescription drugs) $405 $6,700 Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 13

14 Inpatient Hospital Care 1 Outpatient Hospital Coverage Doctor s Office Visits Dual Coverage Care (HMO SNP) The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. Our plan covers an unlimited number of 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. In 2017 the amounts for each benefit period were: $1,316 copay per days for days 1 through 60 $329 copay per days for days 61 through 90 $658 for days 91 and beyond per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime) These amounts may change for % of the cost. Authorization required. Primary care physician visit: $0 copay Specialist visit: $0 copay Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 14

15 Preventive Care Emergency Care Dual Coverage Care (HMO SNP) $0 copay for the following preventative services: 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 Colorectal cancer screenings (Colonoscopy, Fecal occult blood test Flexible sigmoidoscopy) Depression screening Diabetes screenings HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" preventive visit (one-time) Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. Annual physical exam: You pay nothing $0 to $75 copay If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. Worldwide Emergency/Urgent Coverage is provided. The Worldwide/Urgent Coverage maximum benefit amount is $25,000. Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 15

16 Urgently Needed Services Diagnostic Test, Lab and Radiology Services and X-Rays (Cost for these services may be different if received in an outpatient surgery setting) 1 Hearing Services Dental Services Vision Services Dual Coverage Care (HMO SNP) $0 or $30 copay If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for urgently needed services. Worldwide Emergency/Urgent Coverage is provided. The Worldwide/Urgent Coverage maximum benefit amount is $25,000. Diagnostic radiology services (such as MRIs, CT scans): 0% or 20% of the cost Diagnostic tests and procedures: 0% or 20% of the cost Lab services: You pay nothing Outpatient x-rays: 0% or 20% of the cost Therapeutic radiology services (such as radiation treatment for cancer): 0% or 20% of the cost Exam to diagnose and treat hearing and balance issues: 0% or 20% of the cost Routine hearing exam (for up to 1 every year): 20% of the cost Hearing aid fitting/evaluation (for up to 1 every three years): 20% of the cost Hearing aid: $0 copay Our plan pays up to $1,400 every three years for hearing aids. (For up to $700 per ear every three years). Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): You pay nothing Preventive dental services: Cleaning (for up to 1 every six months): $0 copay Dental x-ray(s) (for up to 1 every six months): $0 copay Oral exam (for up to 1 every six months): $0 copay Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): 0% or 20% of the cost Routine eye exam (for up to 1 every year): 20% of the cost Eyeglasses (frames and lenses) (for up to 1 every two years): $0 copay Eyeglasses or contact lenses after cataract surgery: $0 copay Our plan pays up to $150 every two years for eyeglasses (frames and lenses). Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 16

17 Mental Health Services Skilled Nursing Facility (SNF) 1 Rehabilitation Services Physical Therapy and Speech-language Pathology Services 1 Dual Coverage Care (HMO SNP) Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. 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. In 2017 the amounts for each benefit period are $0 or: $1,316 deductible for days 1 through 60 $329 copay per day for days 61 through 90 $658 copay per day for 60 lifetime reserve days. These amounts may change for Outpatient group therapy visit: You pay nothing Outpatient individual therapy visit: You pay nothing In 2017 the amounts for each benefit period are $0 or: $1,316 deductible for days 1 through 60 $329 copay per day for days 61 through 90 $658 copay per day for 60 lifetime reserve days. These amounts may change for % or 20% of the cost Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 17

18 Ambulance Transportation Medicare Part B Drugs ADDITIONAL BENEFITS Chiropractic Care 1,2 Diabetes Supplies and Services 1 Home Health Care 1 Outpatient Rehabilitation 1 Outpatient Substance Abuse 1 Outpatient Surgery 1 Over-the-Counter Items Prosthetic Devices (braces, artificial limbs, etc.) 1 Renal Dialysis 1 Hospice INPATIENT CARE Dual Coverage Care (HMO SNP) 0% or 20% of the cost If you are admitted to the hospital within 24 hours, you do not have to pay for the ambulance services. $0 copay plan-approved locations. The plan covers 5 round trips every three months to plan-approved locations. Prior Authorization Required. 20% of the cost. Authorization required. Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): 0% or 20% of the cost Prior Authorization is Required. Diabetes monitoring supplies: $0 copay Diabetes self-management training: $0 copay Therapeutic shoes or inserts: $0 copay $0 copay Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): 0% or 20% of the cost Occupational therapy visit: 0% or 20% of the cost Physical therapy and speech and language therapy visit: 0% or 20% of the cost Group therapy visit: 0% or 20% of the cost Individual therapy visit: 0% or 20% of the cost Ambulatory surgical center: $250 copay Outpatient hospital: 20% of the cost Please visit our website to see our list of covered over-the-counter items. Prosthetic devices: O% or 20% of the cost Related medical supplies: 0% or 20% of the cost 0% or 20% of the cost You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. Hospice is covered outside our plan. Please contact us for more details. Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 18

19 Inpatient Mental Health Care Dual Coverage Care (HMO SNP) For inpatient mental health care, see the "Mental Health Care" section of this booklet. PRESCRIPTION DRUGS BENEFITS How much do I pay? Initial Coverage Catastrophic Coverage For Part B drugs such as chemotherapy drugs 1 : 0% or 20% of the cost Other Part B drugs 1 : 0% or 20% of the cost Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: $0 copay; or $1.25 copay; or $3.35 copay For all other drugs, either: $0 copay; or $3.35 copay; or $8.35 copay. You may get your drugs at network retail pharmacies and mail order pharmacies. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $5,000, you pay nothing for all drugs. Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 19

20 SECTION III - ADDITIONAL BENEFITS Over-the-Counter Debit Card Comprehensive Dental Services Wellness Programs (e.g., fitness) Dual Coverage Care (HMO SNP) Up to $90.00 per month for OTC items. Monthly balances cannot carry over from month to month. Please contact the plan for more details. Comprehensive Dental Services including crown and fillings. One denture per arch (upper and lower) covered every 3 years. Limitations apply. Contact your plan for coverage details. The Plan will reimburse you up to $8.33 every month (up to $100 annually) for membership fees that you have paid for access to or use of any commercial or community gym or fitness facility. You will only be paid for membership fees incurred during your current plan enrollment year. Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 20

21 Section IV: Overview of Medicaid-Covered Benefits Dual eligibles are people who qualify for both Medicare and Medicaid. Consequently, as a dual eligible individual, you are eligible for benefits under both the Federal Medicare program as well as the New York State Medicaid program. The Original Medicare and supplemental benefits you receive as a member of this plan can be found in Section II. The kind of Medicaid benefits you receive are determined by your State and may vary based upon your income and resources. With the assistance of Medicaid, some dual eligibles do not have to pay for certain Medicare costs. The Medicaid benefit categories and type of assistance served by our plan are as follows: 1. QMB-Plus: Payment of your Medicare Part A and Part B premiums, deductibles, cost-sharing (excluding Part D copayments) and full Medicaid benefits 2. Qualified Medicare Beneficiary (QMB Only): Payment of your Medicare Part A and/or Part B premiums, deductibles and cost-sharing (excluding Part D copayments). 3. Full Benefit Dual Eligible (FBDE): Payment of your Medicare Part B premiums, in some cases Medicare Part A premiums and full Medicaid benefits. 4. Qualified Disabled and Working Individual (QDWI): Payment of your Medicare Part A premiums. 5. Qualifying Individual (QI): Payment of your Medicare Part B premiums. 6. Specified Low Income Medicare Beneficiary (SLMB): Payment of your Medicare Part B premiums. Comprehensive Written Statement for people with Medicare and Medicaid To be eligible to enroll in the Centers Plan for Dual Coverage Care (HMO SNP) Plan you must also participate in the New York State Medicaid Program. The benefits described in the Covered Medical and Hospital Benefits section of the Summary of Benefits are covered by Medicare. For each benefit listed below, you will be able to see the portion New York State Medicaid covers as well as what our plan covers. What you pay for covered services is dependent on your level of Medicaid eligibility. Should you have any questions concerning what benefits you are entitled to under the New York State Medicaid program, please call the New York City Medicaid staff the Human Resources Administration at If you reside outside of New York City please call your local district. The benefits described below are covered by Medicaid. The benefits described in the Covered Medical and Hospital Benefits section of the Summary of Benefits are covered by Medicare. For each benefit listed below, you can see what New York State Medicaid covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. 21

22 New York State Medicaid Fee For Service Centers Plan for Dual Coverage Care (HMO SNP) Adult Day Health Care Medicaid coverage provided Not a covered benefit under the plan. AIDS Adult Day Health Care Medicaid coverage provided Ambulance Services Medicaid covers Medicare deductibles, copays and coinsurances. Not a covered benefit under the plan. $0% or 20% of the cost Assisted Living Program Medicaid coverage provided Not a covered benefit under the plan. Certain Mental Health Services Chiropractic Services Comprehensive Medicaid Case Management Medicaid coverage of Certain Mental Health Services includes: Intensive Psychiatric Rehabilitation Treatment Programs, Day Treatment, Continuing Day Treatment, Case Management for Seriously and Persistently Mentally Ill (sponsored by state or local mental health units), Partial Hospitalizations, Assertive Community Treatment (ACT), Personalized Recovery Oriented Services (PROS) Medicaid covers Medicare deductibles, copays and coinsurances (QMB and QMB-Plus Only) Medicaid coverage provided Not a covered benefit under the plan Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): 0% or 20% of the cost Not a covered benefit under the plan. 22

23 Dental Diagnostic Tests, X-Rays, Lab Services, and Radiology Services Directly Observed Therapy for Tuberculosis (TB) Disease Emergency Care New York State Medicaid Fee For Service Medicaid covers Medicare deductibles, copays and coinsurances. Medicaid covered dental services including necessary preventive, prophylactic and other routine dental care, services, and supplies and dental prosthetics to alleviate a serious health condition. Ambulatory or inpatient surgical dental services subject to prior authorization. Medicaid covers Medicare deductibles, copays and coinsurances. Medicaid coverage provided Medicaid covers Medicare deductibles, copays and coinsurances. Centers Plan for Dual Coverage Care (HMO SNP) For more information please call the plan or reference Chapter 4 of the Evidence of Coverage for more details of dental services. Diagnostic radiology services (such as MRIs, CT scans): 0% or 20% of the cost Diagnostic tests and procedures: 0% or 20% of the cost Lab services: You pay nothing Outpatient x-rays: 0% or 20% of the cost Therapeutic radiology services (such as radiation treatment for cancer): 0% or 20% Not a covered benefit under the plan. $0 or $75 copay If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. Worldwide Emergency/Urgent Coverage is provided. The Worldwide Emergency/Urgent Coverage maximum benefit amount is $25,

24 End Stage Renal Disease Foot Care (podiatry services) HIV COBRA Case Management Hospice New York State Medicaid Fee For Service Medicaid covers Medicare deductibles, copays and coinsurances. Medicaid covers Medicare deductibles, copays and coinsurances (QMB and QMB- Plus Only) Medicaid coverage provided Medicaid covers Medicare deductibles, copays and coinsurance. Centers Plan for Dual Coverage Care (HMO SNP) 0% or 20% of the cost Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing Not a covered benefit under the plan. You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. 24

25 Inpatient Hospital Care including Substance Abuse and Rehabilitation Services New York State Medicaid Fee For Service Medicaid covers Medicare deductibles, copays and coinsurances. Up to 365 days per year (366 days for leap year) Centers Plan for Dual Coverage Care (HMO SNP) The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. 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. In 2017 the amounts for each benefit period are $0 or: $1,316 deductible for days 1 through 60 $329 coinsurance per day for days 61 through 90 $658 for days 91 and beyond per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime) These amounts may change for

26 Inpatient Mental Health Services (over 190-day lifetime limit) Methadone Maintenance Treatment Programs (MMTP) Non-Medicare Covered Durable Medical Equipment New York State Medicaid Fee For Service Medicaid covered Medicare deductibles, copays and coinsurances All inpatient mental health services, including voluntary or involuntary admissions for mental health services over the Medicare 190 day lifetime limit. Medicaid coverage provided Medicaid covered durable medical equipment, including devices and equipment other than medical/ surgical supplies, enteral formula and prosthetic or orthotic appliances having the following characteristics: can withstand repeated use for a protracted period time; are primarily and customarily used for medical purposes; are generally not useful to a person in the absence of illness or injury and are usually fitted, designed or fashioned for a particular individual's use. Must be ordered by a practitioner. No homebound prerequisite and including non-medicare DME covered by Medicaid (e.g. tub stool; grab bar) Centers Plan for Dual Coverage Care (HMO SNP) 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. Not a covered benefit under the plan. Not a covered benefit under the plan 26

27 Non-Medicare Covered Hearing Services Non-Medicare Covered Home Health Services New York State Medicaid Fee For Service Medicaid covers Medicare deductibles, copays and coinsurances. Hearing services and products when medically necessary to alleviate disability caused by the loss or impairment of hearing. Services include hearing and selecting, fitting, and dispensing, hearing aid checks following dispensing, conformity evaluations and hearing aid repairs; audiology services including examinations and testing, hearing aid evaluations and hearing aid prescriptions; and hearing aid products including hearing aids, ear molds, special fittings and replacement parts. Medically necessary intermittent skilled nursing care, home health aide services and rehabilitation services. Also includes non- Medicare covered home health services (e.g. home health aide services with nursing supervision to medically unstable individuals) Centers Plan for Dual Coverage Care (HMO SNP) Hearing aid: You pay nothing Our plan pays up to $700 per ear every three years. Routine hearing exam (for up to 1 every year) 20% of the cost Not a covered benefit under the plan. 27

28 Non-Medicare Covered Vision Services Office for People with developmental Disabilities (OPWDD) Services Out-of-Network Family Planning services provided under the direct access provisions of the waiver New York State Medicaid Fee For Service Medicaid covers Medicare deductibles, copays and coinsurances. Services of Optometrists, Ophthalmologists, and Ophthalmic dispensers including eyeglasses, medically necessary contact lenses and polycarbonate lenses, artificial eyes (stock or custom-made), low vision aids and low vision services. Coverage also includes the repair or replacement of parts. Coverage also includes examinations for diagnosis and treatment for visual defects and/or eye disease. Examinations for refraction are limited to every two (2) years unless otherwise justified as medically necessary. Eyeglasses do not require changing more frequently than every two (2) years unless medically necessary or unless the glasses are lost, damaged or destroyed. Medicaid coverage provided Medicaid coverage provided Centers Plan for Dual Coverage Care (HMO SNP) Routine eye exam (for up to 1 every year) 20% of the cost Our plan pays up to $150 every two years for eyeglasses (frames and lenses) Not a covered benefit under the plan. Not a covered benefit under the plan 28

29 Outpatient Rehabilitation Services Outpatient Services/ Surgery Outpatient Substance Abuse Care Over the Counter Drugs New York State Medicaid Fee For Service Medicaid covers Medicare deductibles, copays and coinsurances. Occupational, Physical and Speech therapies are limited to twenty (20) visits per therapy per year, except for children under age 21, or you have been determined to be developmentally disabled by the Office for People with Developmental Disabilities, or if you have a traumatic brain injury. Medicaid covers Medicare deductibles, copays and coinsurances. Medicaid covers Medicare deductibles, copays and coinsurances. Certain Over the Counter medications are covered. Centers Plan for Dual Coverage Care (HMO SNP) Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): 0% or 20% of the cost Occupational therapy visit: 0% or 20% of the cost Physical therapy and speech and language therapy visit: 0% or 20% of the cost Ambulatory surgical center: 0% or 20% of the cost Outpatient hospital: 0% or 20% of the cost Group therapy visit: 0% or 20% of the cost Individual therapy visit: 0% or 20% of the cost $90 monthly benefit for over-thecounter items. Monthly balances cannot be carry from month to month. Please visit our website to see our list of covered over-thecounter items. 29

30 Outpatient Mental Health New York State Medicaid Fee For Service Medicaid covers Medicare deductibles, copays and coinsurances Centers Plan for Dual Coverage Care (HMO SNP) Centers Plan for Dual Coverage Care covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. 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. In 2017 the amounts for each benefit period were $0 or: $1,316 deductible for days 1 through 60 $329 copay per day for days 61 through 90 $658 copay per day for 60 lifetime reserve days These amounts may change in

31 Personal Care Services Personal Emergency Response Services (PERS) Prescription Drugs New York State Medicaid Fee For Service Medicaid coverage provided Provides some or total assistance with such activities as personal hygiene, dressing and feeding and nutritional and environmental support function tasks. Services must be medically necessary and ordered by the enrollee s physician and provided by a qualified person. Medicaid coverage provided An electronic device which enables certain high risk patients to secure help in the event of a physical, emotional or environmental emergency. A variety of electronic alert systems exist using different signaling devices. Such systems are usually connected to a patient s phone and signal a response center when a help button is activated. In the event of an emergency, the signal is received and appropriately acted on by a response center. Medicaid does not cover Part D covered drugs or copays. Medicaid Pharmacy Benefits allowed by State Law (select drug categories excluded from the Medicare Part D benefit). Certain Medical Supplies and Enteral Formula when not covered by Medicare. Centers Plan for Dual Coverage Care (HMO SNP) Not a covered benefit under the plan Not a covered benefit under the plan. For Part B drugs such as chemotherapy drugs: 0% or 20% of the cost Other Part B drugs: 0% or 20% of the cost 31

32 Private Duty Nursing Services Prosthetic Devices Rehabilitation Services Provided to Residents of OMH Licensed Community Residence (CRs) and Family Based Treatment Programs Skilled Nursing Facility (SNF) New York State Medicaid Fee For Service Private duty nursing services are covered when determined by the physician to be medically necessary. Nursing services can be provided through an approved certified home health agency, a licensed home care agency, or a private practitioner. Nursing services may be intermittent, part time or continuous and must be provided in an Enrollee's home in accordance with the ordering physician, registered physician assistant or certified nurse practitioner's written treatment plan. Medicaid covers Medicare deductibles, copays and coinsurances. Centers Plan for Dual Coverage Care (HMO SNP) Not a covered benefit under the plan. Prosthetic devices: 0% or 20% of the cost Medicaid coverage provided Not a covered benefit under the plan. Medicaid covers Medicare deductibles, copays and coinsurances. Medicaid covers additional days beyond Medicare 100 day limit. Centers Plan for Dual Coverage Care (HMO SNP) covers up to 100 days in a Skilled Nursing Facility. In 2017 the amounts for each benefit period were: $1,316 deductible for days 1 through 60 $329 copay per day for days 61 through 90 $658 copay per day for 60 lifetime reserve days These amounts may change for

33 Transportation Urgently Needed Services New York State Medicaid Fee For Service Includes ambulate, invalid coach, taxicab, livery, public transportation, or other means appropriate to the enrollee s medical condition. Medicaid covered Medicare deductibles, copays and coinsurances Medicaid covers Medicare deductibles, copays, and coinsurances. Centers Plan for Dual Coverage Care (HMO SNP) $ 0 copayment for up to 5 round trips to plan-approved location every three months (in a plan approved mode of transportation.) $0 or $30 copay If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for urgent care. Worldwide Emergency/Urgent Coverage is provided. The Worldwide Emergency/Urgent Coverage maximum benefit amount is $25,000 33

34 For more information, please contact us at the phone number listed below or visit us at You can see plan's Provider and Pharmacy Directory on our website You can also see our Comprehensive Formulary (Complete list of Part D prescription drugs) and any restrictions on our website at To contact the Member Services Department, call: If you re hearing impaired, call TTY: Department hours are 8 a.m. 8 p.m., 7 days a week. Centers Plan for Dual Coverage Care (HMO SNP) is an HMO with a Medicare and Medicaid contract. Enrollment in Centers Plan for Dual Coverage Care (HMO SNP) is dependent upon contract renewal. Benefits, formulary, pharmacy network, provider network, and co-payments/co- insurance may change on January 1 of each year. This information is not a complete description of benefits. Contact the plan for more information. Enrolled members must continue to pay their Medicare Part B premium if not otherwise paid for under Medicaid. 34

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36 For More Information or to Enroll Call (toll free) TTY Users Seven days a week, 8:00 AM to 8:00 PM MemberServices@centersplan.com