Keystone 65 HMO Focus Individual

Transcription

1 Keystone 65 HMO Focus Individual $10/$40 - Focus HMO with Choice Keystone Health Plan East is a Health Maintenance Organization (HMO). This is a managed care program. is available when your care is provided by a Keystone 65 HMO network provider. You are required to select a primary care physician (PCP). Referrals are not required with our HMO plan, but we still encourage you to coordinate your medical care with your PCP. This program may not cover all your health care services. Services may not be covered because they are: Not covered under your benefit contract Not medically necessary Limited by a benefit maximum (e.g. visit limit) Your EOC handbook identifies details about your benefit program. It also includes information about exclusions and benefit limitations. After reviewing this information, please contact our Member Service Department if you have additional questions. Benefit*** Benefit Period *** Benefit Year Maximum Out-of-Pocket (MOOP) *** $6,700 Lifetime Maximum Unlimited Network Deductible N/A Annual Coinsurance N/A Medicare Preventive Services *** Please see listing on last page Benefit Allergy Immunotherapy Ambulance Non-emergent services requires prior authorization Chiropractic/Spinal Manipulations Medicare Covered Chiropractic Care Non-Medicare Covered Chiropractic Care Limit six supplemental visits annually Dialysis Doctor's Office Visits Primary Care Services Specialist Services Durable Medical Equipment and Supplies Diabetic Supplies Excluding diabetic shoes, equipment and inserts DME, Prosthetics and Orthotics Emergency Care Not waived if admitted $275 copay $20 copay $20 copay 20% coinsurance $10 copay 20% coinsurance $80 copay Benefits are administered by Keystone Health Plan East, a subsidiary of Independence Blue Crossindependent licensees of the Blue Cross and Blue Shield Association. 01/18 - PA /Individual /Focus HMO

2 Benefit Hearing Services Medicare-covered Hearing Exam Routine Hearing Exam Hearing Aids Administered by TruHearing Standard Premium Home Health Care Hospice Covered in full at a Medicare-certified hospice facility Inpatient Hospital Facility Care You are covered for unlimited days each benefit period Inpatient Mental Health/Substance Abuse Facility Care 190-day lifetime maximum applies to treatment received in a Medicare-approved mental health facility Medicare Part B Drugs/Chemotherapy Prior authorization is required for certain Part B injectable drugs when administered in a physician's office or outpatient setting Outpatient Diagnostic Procedures/Lab Outpatient Hospital Observation Stays Outpatient Mental Health-Psychiatric Services Includes partial hospitalization Outpatient Radiology/X-ray Services Advance Imaging (MRI/MRA/CT/CTA Scan) Standard Imaging (Routine/Diagnostic) Outpatient Rehabilitation/Therapy Speech Therapy Physical Therapy Pulmonary Rehabilitation Occupational Therapy Cardiac Rehabilitation Outpatient Substance Abuse Outpatient Surgical Procedures Outpatient Hospital Outpatient ASC Podiatry Services Medicare-covered Foot Care Non-Medicare Foot Care Limit six supplemental visits annually Radiation Therapy Skilled Nursing Facility *** 100-day maximum per benefit period Urgent Care Vision Care - Medicare-covered $699 per ear $999 per ear Refer to EOC $210 [days 1-6]; $1,260 maximum per stay. $210 [days 1-6]; $1,260 maximum per stay. 20% coinsurance $350 copay $200 copay $45 copay $5 copay $5 copay $350 copay $200 copay $60 copay $0 [days 1-20]; $164 [days ]

3 Benefit Vision Care - Medicare-covered Eyewear You are covered for one pair of eyeglasses or contact lenses after each cataract surgery. We will cover up to the Medicare allowance for a standard pair of cataract glasses. Cost of upgrades are not covered by plan *** Please see below bullets for additional information A benefit period is a consecutive 12-month period that begins on the first day of the year and ends on the last day of the year. In-network out-of-pocket maximum includes deductible, copays, and coinsurance. Routine care does not count towards your out-of-pocket maximum. Worldwide Emergency available. Amounts you pay for emergency and urgently needed care services received outside the United States do not count toward your maximum out-of-pocket amount (MOOP). For Preventive Services, if there is a separate and distinct office visit evaluation and service, a copay will apply. The copay amount depends on the provider type. No prior hospitalization required in order to obtain services from Skilled Nursing Facility. In-network and out-of-network maximum day period combined. Normal plan rules apply. Please refer to your EOC for more information.

4 Medicare-covered Preventive Services Medicare pays for many preventive services to keep you healthy. Preventive services can find health problems early, when treatment works best, and can keep you from getting certain diseases. Depending on your general health and medical history, you'll get advice, education, and counseling to help you prevent disease, improve your health, and stay well. Below is a checklist letting you know which screenings, shots, and other preventive services you may need. Abdominal Aortic Aneurysm Screening Alcohol Misuse Reduction Screening and Behavioral Counseling Interventions Annual ''Wellness'' Visit Bone Mass Measurement Exam Breast Cancer Screening (Mammogram) Cardiovascular Disease (CVD) Risk Reduction Visit (also referred to as Intensive Behavioral Therapy for Cardiovascular Disease) Cardiovascular Screening Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam) once every 24 months Colorectal Screenings (Includes coverage for colonoscopy, flexible sigmoidoscopy, and barium enema) Depression Screening Diabetes Screening Fecal Occult Blood Test Glaucoma Screening Human Immunodeficiency Virus (HIV) Screening Lung Cancer Screening Medical Nutrition Therapy Services Obesity Screening Prostate Cancer Screenings Sexually Transmitted Infections (STIs) Counseling and Screening Smoking and Tobacco Use Cessation (counseling to stop smoking) Vaccines, including flu shots, hepatitis B shots, pneumococcal shots ''Welcome to Medicare'' Preventive Visit (One-Time)

5 Language Assistance Services Spanish: ATENCIÓN: Si habla español, cuenta con servicios de asistencia en idiomas disponibles de forma gratuita para usted. Llame al (TTY: 711). Chinese: 注意 : 如果您讲中文, 您可以得到免费的语言协助服务 致电 Korean: 안내사항 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 번으로전화하십시오. Portuguese: ATENÇÃO: se você fala português, encontram-se disponíveis serviços gratuitos de assistência ao idioma. Ligue para Gujarati: ચન : જ તમ જર ત બ લત હ, ત ન: ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલ ધ છ ક લ કર. Vietnamese: LƯU Ý: Nếu bạn nói tiếng Việt, chúng tôi sẽ cung cấp dịch vụ hỗ trợ ngôn ngữ miễn phí cho bạn. Hãy gọi Russian: ВНИМАНИЕ: Если вы говорите по-русски, то можете бесплатно воспользоваться услугами перевода. Тел.: Polish UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer Italian: ATTENZIONE: Se lei parla italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero Arabic: ملحوظة: إذا كنت تتحدث اللغة العربية فإن خدمات المساعدة اللغوية متاحة لك بالمجان. اتصل برقم French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, magagamit mo ang mga serbisyo na tulong sa wika nang walang bayad. Tumawag sa French: ATTENTION: Si vous parlez français, des services d'aide linguistique-vous sont proposés gratuitement. Appelez le Pennsylvania Dutch: BASS UFF: Wann du Pennsylvania Deitsch schwetzscht, kannscht du Hilf griege in dei eegni Schprooch unni as es dich ennich eppes koschte zellt. Ruf die Nummer Hindi: य न द : य द आप ह द ब लत ह त आपक लए म त म भ ष सह यत स व ए उपल ध ह क ल कर German: ACHTUNG: Wenn Sie Deutsch sprechen, können Sie kostenlos sprachliche Unterstützung anfordern. Wählen Sie Japanese: 備考 : 母国語が日本語の方は 言語アシスタンスサービス ( 無料 ) をご利用いただけます へお電話ください Persian (Farsi): توجه: اگر فارسی صحبت می کنيد خدمات ترجمه به صورت رايگان برای شما فراھم می باشد. با شماره تماس بگيريد. Navajo: D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti go Diné Bizaad, saad bee 1k1 1n7da 1wo d66, t 11 jiik eh. H0d77lnih koj Urdu: توجہ درکارہے: اگر آپ اردو زبان بولتے ہيں تو آپ کے لئے مفت ميں زبان معاون خدمات دستياب ہيں کال کريں Mon-Khmer, Cambodian: ស ម ម ត ចប រមមណ របស ន ប អនកន យយភ មន- ខមរ ឬភ ខមរ ន ជ ន យ ផនកភ ន ងមនផ តល ជ នដល កអនក យឥត គ ត ថ ល ទ រសពទ ទ លខ Y0041_HM_17_47643 Accepted 10/14/2016 Taglines as of 10/14/2016

6 Discrimination is Against the Law This Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. This Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. This Plan provides: Free aids and services to people with disabilities to communicate effectively with us, such as: qualified sign language interpreters, and written information in other formats (large print, audio, accessible electronic formats, other formats). Free language services to people whose primary language is not English, such as: qualified interpreters and information written in other languages. If you need these services, contact our Civil Rights Coordinator. If you believe that This Plan 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 Civil Rights Coordinator. You can file a grievance in the following ways: In person or by mail: ATTN: Civil Rights Coordinator, 1901 Market Street, Philadelphia, PA 19103, By phone: (TTY: 711) By fax: , By civilrightscoordinator@1901market.com. If you need help filing a grievance, our Civil Rights Coordinator is available to help you. 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 or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at Y0041_HM_17_47643 Accepted 10/14/2016 Taglines as of 10/14/2016