SUMMARY OF BENEFITS. Illinois. Molina Dual Options Medicare-Medicaid Plan

Transcription

1 SUMMARY OF BENEFITS Illinis 2015 Mlina Dual Optins Medicare-Medicaid Plan Member Services (877) , TTY/TDD 711 Mnday - Friday, 8 a.m. - 8 p.m. lcal time H8046_15_16001_0001_MMPILSB Apprved

2 H8046_15_16001_0001_MMPILSB Accepted This is a summary f health services cvered by Mlina Dual Optins Medicare-Medicaid Plan fr This is nly a summary. Please read the Member Handbk fr the full list f benefits. v v v v v v v Mlina Dual Optins is a health plan that cntracts with bth Medicare and Illinis Medicaid t prvide benefits f bth prgrams t enrllees. It is fr peple with bth Medicare and Medicaid. Under Mlina Dual Optins yu can get yur Medicare and Medicaid services in ne health plan. A Mlina Dual Optins case manager will help manage yur health care needs. This is nt a cmplete list. The benefit infrmatin is a brief summary, nt a cmplete descriptin f benefits. Fr mre infrmatin cntact the plan r read the Member Handbk. Limitatins, cpays, and restrictins may apply. Fr mre infrmatin, call Mlina Dual Optins Member Services r read the Mlina Dual Optins Member Handbk. Benefits, List f Cvered Drugs, pharmacy and prvider netwrks, and/r cpayments may change frm time t time thrughut the year and n January 1 f each year. Cpays fr prescriptin drugs may vary based n the level f Extra Help yu receive. Please cntact the plan fr mre details. Yu can ask fr this infrmatin in ther frmats, such as Braille r large print. Call (877) The call is free. v Yu can get this dcument in Spanish, r speak with smene abut this infrmatin in ther languages fr free. Call (877) The call is free. v Puede btener este dcument en españl, hablar cn una persna acerca de esta infrmación en trs idimas gratuitamente. Llame al (877) Esta llamada es gratis. time. The call is free. Fr mre infrmatin, visit 1

3 The fllwing chart lists frequently asked questins. Frequently Asked Questins (FAQ) What is a Medicare-Medicaid Plan What is a Mlina Dual Optins Case Manager What are lng-term services and supprts Will yu get the same Medicare and Medicaid benefits in Mlina Dual Optins that yu get nw Answers A Medicare-Medicaid Plan is an rganizatin made up f dctrs, hspitals, pharmacies, prviders f lng-term services, and ther prviders. It als has case managers t help yu manage all yur prviders and services. They all wrk tgether t prvide the care yu need. A Mlina Dual Optins Case Manager is ne main persn fr yu t cntact. This persn helps manage all yur prviders and services and makes sure yu get what yu need. Lng-term services and supprts are services prvided thrugh a Lng Term Care Facility r thrugh a Hme and Cmmunity Based Waiver. Enrllees have the ptin t receive lng-term services and supprts (LTSS) in the least restrictive setting when apprpriate, with a preference fr the hme and the cmmunity, and in accrdance with the Enrllee s wishes and Care Plan. Yu will get yur cvered Medicare and Medicaid benefits directly frm Mlina Dual Optins. 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 Medicaid benefits directly frm Mlina Dual Optins, but yu may get sme benefits the same way yu d nw, utside f the plan. When yu enrll in Mlina Dual Optins, yu and yur care team will wrk tgether t develp an Individualized Care Plan t address yur health and supprt needs. During this time, yu can keep seeing yur dctrs and getting yur current services fr 180 days, r until yur care plan is cmplete. When yu jin ur plan, if yu are taking any Medicare Part D prescriptin drugs that Mlina Dual Optins des nt nrmally cver, yu can get a temprary supply. We will help yu get anther drug r get an exceptin fr Mlina Dual Optins t cver yur drug, if medically necessary. time. The call is free. Fr mre infrmatin, visit 2

4 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 Mlina Dual Optins netwrk can prvide it Where is Mlina Dual Optins available D yu pay a mnthly amunt (als called a premium) under Mlina Dual Optins What is prir authrizatin Answers Often that is the case. If yur prviders (including dctrs, therapists, and pharmacies) wrk with Mlina Dual Optins 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 Mlina Dual Optins netwrk. If yu need urgent r emergency care, family planning services r ut-f-area dialysis services, yu can use prviders utside f Mlina Dual Optins plan. T find ut if yur dctrs are in the plan s netwrk, call Member Services r read Mlina Dual Optins Prvider and Pharmacy Directry. If Mlina Dual Optins is new fr yu, yu can cntinue seeing the dctrs yu g t nw fr 180 days. Mst services will be prvided by ur netwrk prviders. If yu need a service that cannt be prvided within ur netwrk, Mlina Dual Optins will pay fr the cst f an ut-f-netwrk prvider. The service area fr this plan includes: Champaign, Christian, DeWitt, Frd, Knx, Lgan, Macn, McLean, Menard, Peria, Piatt, Sangamn, Stark, Tazewell, and Vermilin Cunties, Illinis. Yu must live in ne f these areas t jin the plan. Yu will nt pay any mnthly premiums t Mlina Dual Optins fr yur health cverage. Prir authrizatin means that yu must get apprval frm Mlina Dual Optins befre yu can get a specific service r drug r see an ut-f-netwrk prvider. Mlina Dual Optins may nt cver the service r drug if yu dn t get apprval. If yu need urgent r emergency care, family planning services r ut-f-area dialysis services, yu dn't need t get apprval first. time. The call is free. Fr mre infrmatin, visit 3

5 Frequently Asked Questins (FAQ) What is a referral What is Extra Help Wh shuld yu cntact if yu have questins r need help Answers 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, Mlina Dual Optins may nt cver the services. There are certain specialists in which yu d nt need a referral, such as wmen health specialists. Fr mre infrmatin n when a referral is necessary, see the Member Handbk. Extra Help is a Medicare prgram that helps reduce yur prescriptin drug prgram csts such as cpays. Yur prescriptin drug cpays under Mlina Dual Optins already include the amunt f Extra Help yu qualify fr. Fr mre infrmatin abut this extra help, cntact yur lcal Scial Security Office, r call Scial Security at TTY users may call If yu have general questins r questins abut ur plan, services, billing, r member cards, please call Mlina Dual Optins Member Services: CALL (877) Calls t this number are free. Mnday Friday, 8 a.m. t 8 p.m., lcal time. Selfservice ptins are available n weekends, after regular business hurs and hlidays. Member Services als has free language interpreter services available fr peple wh d nt speak English. TTY 711 Calls t this number are free. Mnday Friday, 8 a.m. t 8 p.m., lcal time. time. The call is free. Fr mre infrmatin, visit 4

6 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 Line: CALL (888) Calls t this number are free. 24 hurs a day, 7 days a week. Nurse Advice Line als has free language interpreter services available fr peple wh d nt speak English. TTY 711 This number is fr peple wh have hearing r speaking prblems. Yu must have special telephne equipment t call it. Calls t this number are free. 24 hurs a day, 7 days a week. If yu need immediate behaviral health, please call the Nurse Advice Line: CALL (888) Calls t this number are free 24 hurs a day, 7 days a week. Nurse Advice Line als has free language interpreter services available fr peple wh d nt speak English. TTY 711 This number is fr peple wh have hearing r speaking prblems. Yu must have special telephne equipment t call it. Calls t this number are free. 24 hurs a day, 7 days a week. time. The call is free. Fr mre infrmatin, visit 5

7 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 Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu want t see a dctr Visits t treat an injury r illness $0 Authrizatin rules may apply. Wellness visits, such as a physical $0 Annual wellness visit every 12 mnths Transprtatin t a dctr s ffice and t the pharmacy after a dctr s appintment $0 Rides limited t cvered services Specialist care $0 Authrizatin rules may apply. Care t keep yu frm getting sick, such as flu shts Welcme t Medicare preventive visit (ne time nly) Yu need medical tests Lab tests, such as bld wrk $0 Authrizatin rules may apply. X-rays r ther pictures, such as CAT scans Screening tests, such as tests t check fr cancer $0 $0 $0 Authrizatin rules may apply. $0 Authrizatin rules may apply. time. The call is free. Fr mre infrmatin, visit 6

8 Health need r prblem Services yu may need Yur csts fr in-netwrk - netwrk prviders Cpays fr prescriptin drugs may vary based n the level f Extra Help yu receive. Please cntact the plan fr mre details. Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need drugs t treat Generic drugs (n brand name) $0 fr a 31-day There may be limitatins n the types f yur illness r cnditin supply. drugs cvered. Please see Mlina Dual Optins List f Cvered Drugs (Drug List) fr mre infrmatin. 90 day supply at retail and mail rder is available fr the same Lw Incme Cst Sharing (LICS) cpay. Different ut-f-pcket csts may apply fr peple wh: - have limited incmes, r - live in lng-term care facilities Ttal yearly drug csts are the ttal drug csts paid by bth yu and a Part D plan. The plan may require yu t first try ne drug t treat yur cnditin befre it will cver anther drug fr that cnditin. Sme drugs have quantity limits. Yur prvider must get prir authrizatin frm Mlina Dual Optins fr certain drugs. time. The call is free. Fr mre infrmatin, visit 7

9 Health need r prblem Services yu may need Yur csts fr in-netwrk - netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need drugs t treat Brand name drugs $0, $3.60 r $6.60 There may be limitatins n the types f yur illness r cnditin fr a 31-day supply. drugs cvered. Please see Mlina Dual Optins List f Cvered Drugs (Drug List) fr (cntinued) Cpays fr mre infrmatin. prescriptin drugs may vary based n 90 day supply at retail and mail rder is the level f Extra available fr the same Lw Incme Cst Sharing (LICS) cpay. Help yu receive. Please cntact the Different ut-f-pcket csts may apply fr peple wh: plan fr mre details. - have limited incmes, r - live in lng-term care facilities Ttal yearly drug csts are the ttal drug csts paid by bth yu and a Part D plan. The plan may require yu t first try ne drug t treat yur cnditin befre it will cver anther drug fr that cnditin. Sme drugs have quantity limits. Yur prvider must get prir authrizatin frm Mlina Dual Optins fr certain drugs. time. The call is free. Fr mre infrmatin, visit 8

10 Health need r prblem Services yu may need Yur csts fr in-netwrk - 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 Mlina Dual Optins List f Cvered Drugs (Drug List) fr mre infrmatin. 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. Authrizatin rules may apply. Yu need therapy after a strke r accident Yu need emergency care Occupatinal, physical, r speech therapy $0 Medically necessary physical therapy, ccupatinal therapy, and speech and language pathlgy services are cvered. Referral requirements may apply. Authrizatin rules may apply. Cntact plan fr details. Emergency rm services $0 Yu may get cvered emergency medical care whenever yu need it, anywhere in the United States r its territries, withut prir authrizatin. Nt cvered utside the U.S. and its territries except under limited circumstances. Cntact plan fr details. Ambulance services $0 Authrizatin rules may apply fr nnemergent use f grund r air ambulance. time. The call is free. Fr mre infrmatin, visit 9

11 Health need r prblem Services yu may need Yur csts fr in-netwrk - netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Urgent care $0 Yu may get urgent care services whenever yu need it, anywhere in the United States r its territries, withut prir authrizatin. Nt cvered utside the U.S. and its territries except under limited circumstances. Cntact plan fr details. Yu need hspital care Hspital stay $0 Authrizatin rules may apply. Except in an emergency, yur dctr must tell the plan that yu are ging t be admitted t the hspital. N limit t the number f days cvered by the plan each hspital stay. Yu need help getting better r have special health needs Dctr r surgen care $0 Authrizatin rules may apply. Rehabilitatin services $0 Authrizatin rules may apply. Medical equipment fr hme care $0 Authrizatin rules may apply. Skilled nursing care $0 Referral requirements may apply. Cntact plan fr details. Authrizatin rules may apply. Hme Health Services -Additinal hurs f care time. The call is free. Fr mre infrmatin, visit 10

12 Health need r prblem Services yu may need Yur csts fr in-netwrk - netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need eye care Eye exams $0 Diagnsis and treatment fr diseases and cnditins f the eye, including an annual glaucma screening fr peple at risk Up t 1 supplemental rutine eye exam every year Glasses r cntact lenses $0 - ne pair f eyeglasses (lenses and frames) r cntact lenses after cataract surgery - up t 1 pair f eyeglasses (lenses and frames) every tw years Plan cvers up t $125 a year fr cntact lenses and eyeglass frames Yu need dental care Dental check-ups $0 Preventive dental services: - up t 2 ral exam(s) every year - up t 2 cleaning(s) every year - 1 fluride treatment(s) every year - 1 dental x-ray(s) every year Plan ffers additinal supplemental cmprehensive dental benefits. Yu need hearing/auditry services Hearing screenings $0 Hearing aids $0 Up t 1 fitting-evaluatin fr a supplemental hearing aid cvered Up t 1 pair f supplemental hearing aid(s) every three years time. The call is free. Fr mre infrmatin, visit 11

13 Health need r prblem Yu have a chrnic cnditin, such as diabetes r heart disease Yu have a mental health cnditin Services yu may need Yur csts fr in-netwrk - netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Services t help manage yur disease $0 Authrizatin rules may apply. Diabetes self-management training. Diabetes supplies and services $0 Authrizatin rules may apply. Diabetes mnitring supplies. Therapeutic shes r inserts. Mental r behaviral health services $0 Authrizatin rules may apply. Yu have a substance abuse prblem Yu need lng-term mental health services Yu need durable medical equipment (DME) Substance abuse services $0 Authrizatin rules may apply. Inpatient care fr peple wh need mental health care $0 Authrizatin rules may apply. Our plan cvers unlimited number f days fr inpatient hspital stay. Wheelchairs $0 Authrizatin rules may apply. Canes $0 Authrizatin rules may apply. Crutches $0 Authrizatin rules may apply. Walkers $0 Authrizatin rules may apply. Oxygen $0 Authrizatin rules may apply. time. The call is free. Fr mre infrmatin, visit 12

14 Health need r prblem Yu need help living at hme Services yu may need Services f the Elderly Waiver Adult Day Service, includes transprtatin Emergency Hme Respnse Hmemaker Services f the Persns with Disabilities Waiver Adaptive Equipment Adult Day Service, includes transprtatin Emergency Hme Respnse Envirnmental Accessibility Adaptatins Hme Delivered Meals Hme Health Aide Hmemaker Nursing Skilled Nursing Intermittent Persnal Assistant Service Physical, Occupatinal, and Speech Therapy Respite Yur csts fr in-netwrk - netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) $0 Individuals eligible fr this specific waiver prgram may qualify fr this service. Eligibility is based n determinatin f need. $0 Individuals eligible fr this specific waiver prgram may qualify fr this service. Eligibility is based n determinatin f need. time. The call is free. Fr mre infrmatin, visit 13

15 Health need r prblem Services yu may need Services f the Traumatic Brain Injury Waiver Adaptive Equipment Adult Day Service, includes transprtatin Behaviral Services Day Habilitatin Emergency Hme Respnse Envirnmental Accessibility Adaptatins Hme Delivered Meals Hme Health Aide Hmemaker Nursing Skilled Nursing Intermittent Persnal Assistant Service Physical, Occupatinal, and Speech Therapy Prevcatinal Services Respite Supprted Emplyment Yur csts fr in-netwrk - netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) $0 Individuals eligible fr this specific waiver prgram may qualify fr this service. Eligibility is based n determinatin f need. time. The call is free. Fr mre infrmatin, visit 14

16 Health need r prblem Yu need a place t live with peple available t help yu Services yu may need Services f the HIV/AIDS Waiver Adaptive Equipment Adult Day Service, includes transprtatin Emergency Hme Respnse Envirnmental Accessibility Adaptatins Hme Delivered Meals Hme Health Aide Hmemaker Nursing Skilled Nursing Intermittent Persnal Assistant Service Physical, Occupatinal, and Speech Therapy Respite Services f the Supprtive Living Facilities (SLF) Waiver Assisted living r ther husing services Yur csts fr in-netwrk - netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) $0 Individuals eligible fr this specific waiver prgram may qualify fr this service. Eligibility is based n determinatin f need. $0 Individuals eligible fr this specific waiver prgram may qualify fr this service. Eligibility is based n determinatin f need. Nursing hme care $0 Authrizatin rules may apply. N limit t the number f days cvered by the plan each Skilled Nursing Facility (SNF) stay N prir hspital stay is required. Yur caregiver needs sme time ff Respite care $0 Individuals eligible fr a specific waiver prgram may qualify fr this service. Eligibility is based n determinatin f need. time. The call is free. Fr mre infrmatin, visit 15

17 Other services that Mlina Dual Optins cvers: Other services Mlina Dual Optins cvers (This is nt a cmplete list. Call Member Services r read the Member Handbk t find ut abut ther cvered services.) Hspice Kidney Disease and Cnditins Pulmnary Rehabilitatin Services Family Planning Services Tbacc Cessatin Cunseling Behaviral Health Telehealth Yu must get care frm a Medicare-certified hspice. Yu must cnsult with yur plan befre yu select hspice. Authrizatin rules may apply. $0 cpay fr renal dialysis $0 cpay fr kidney disease educatin services Authrizatin rules may apply. $0 cpay $0 cpay $0 cpay $0 cpay Authrizatin rules may apply. $0 cpay time. The call is free. Fr mre infrmatin, visit 16

18 Services that Mlina Dual Optins des nt cver: All services r supplies that are nt medically necessary Experimental services and prcedures, including drugs Services fr the treatment f besity, unless determined medically necessary Persnal items in yur rm at a hspital r a skilled nursing facility, such as a telephne r a televisin. Inpatient hspital custdial 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 necessary. Csmetic surgery r prcedures, unless because f an accidental injury r t imprve a malfrmed part f the bdy. Hwever, all stages f recnstructin are cvered fr a breast after a mastectmy, as well as fr the unaffected breast t prduce a symmetrical appearance. Reversal f sterilizatin prcedures, sex change peratins, and nn-prescriptin cntraceptive supplies. Acupuncture and bifeedback services Abrtins except in the case f a reprted rape, incest r when medically necessary t save the life f the mther time. The call is free. Fr mre infrmatin, visit 17

19 Yur rights as a member f the plan As a member f Mlina Dual Optins, 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: D Yu have a right t respect, fairness and dignity. This includes: D Yu have the right t make decisins abut yur care, including refusing treatment. This includes the right: The right t get cvered services withut cncern abut race, ethnicity, natinal rigin, religin, gender, age, mental r physical disability, sexual rientatin, genetic infrmatin, ability t pay, r ability t speak English The right t request infrmatin in ther frmats (e.g., audi CD ROM, large print, cassette, Braille) The right t be free frm any frm f restraint r seclusin T chse a Primary Care Prvider (PCP) and yu can change yur PCP at any time T see a wmen s health care prvider withut a referral T get yur cvered services and drugs quickly T knw abut all treatment ptins, n matter what they cst r whether they are cvered T refuse treatment, even if yur dctr advises against it T stp taking medicine D The right nt t be billed by 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 D T ask fr a secnd pinin. Mlina Dual Optins 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. time. The call is free. Fr mre infrmatin, visit 18

20 D Yu have the right t seek emergency and urgent care D Yu have the right t make cmplaints abut yur when yu need it. This means: cvered services r care. This includes the right t: Yu have the right t get emergency services withut File a cmplaint r grievance against us r ur prviders prir apprval in an emergency Ask fr a state fair hearing Yu have the right t see an ut f netwrk urgent r emergency care prvider, when necessary Get a detailed reasn fr why services were denied D Yu have a right t cnfidentiality and privacy. This includes: The right t ask fr and get a cpy f yur medical recrds in a way that yu can understand and t ask fr yur recrds t be changed r crrected. The right t have yur persnal health infrmatin kept private. Fr mre infrmatin abut yur rights, yu can read the Mlina Dual Optins Member Handbk. If yu have questins, yu can als call Mlina Dual Optins Member Services. time. The call is free. Fr mre infrmatin, visit 19

21 If yu have a cmplaint r think we shuld cver smething we denied If yu have a cmplaint r think Mlina Dual Optins shuld cver smething we denied, call Mlina Dual Optins at (877) , TTY/TDD: 711. Yu may be able t appeal ur decisin. Fr questins abut cmplaints and appeals, yu can read Chapter 9 f the Mlina Dual Optins Member Handbk. Yu can als call Mlina Dual Optins Member Services. Or yu can write t Mlina Healthcare Attn: Grievance and Appeals P.O. Bx Lng Beach, CA FAX: 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. D D D Call us at Mlina Dual Optins 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. Yu can cntact the Illinis Office f Inspectr General t reprt Medicaid fraud. Call (855) r visit t cmplete an nline frm. time. The call is free. Fr mre infrmatin, visit 20

22 Member Services (877) , TTY/TDD 711 Mnday - Friday, 8 a.m. - 8 p.m. lcal time 44148MMP0914