Summary of Benefits. January 1, 2018 December 31, Providence Medicare Dual Plus (HMO SNP)

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1 Summary of Benefits January 1, 2018 December 31, 2018 Providence Medicare Dual Plus (HMO SNP) This plan is available in Clackamas, Multnomah and Washington counties in Oregon for members who are eligible for Medicare and full Oregon Health Plan (Medicaid) benefits H9047_2018AM15_ACCEPTED

2 Providence Medicare Advantage Plans is an HMO, HMO-POS, and HMO SNP plan with a Medicare and Oregon Health Plan contract. Enrollment in Providence Medicare Advantage Plans depends on contract renewal. SECTION I- INTRODUCTION TO SUMMARY OF BENEFITS This booklet gives you a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please refer to the Evidence of Coverage. To obtain a copy of the EOC please contact customer service at or visit us online to request one at 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 Providence Medicare Dual Plus (HMO SNP) TIPS FOR COMPARING YOUR MEDICARE CHOICES This Summary of Benefits booklet gives you a summary of what Providence Medicare Dual Plus (HMO SNP) covers and what you pay. If you want to compare our plans with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on 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 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 Providence Medicare Dual Plus (HMO SNP) Monthly Premium, Deductible, and Maximum Out-of-Pocket Responsibility Covered Medical and Hospital Benefits Prescription Drug Benefits Summary of Oregon Health Plan (Medicaid) Covered Services THINGS TO KNOW ABOUT PROVIDENCE MEDICARE DUAL PLUS (HMO SNP) You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Pacific Standard Time. PROVIDENCE MEDICARE DUAL PLUS (HMO SNP) PHONE NUMBERS AND WEBSITE If you are member of this plan, call toll free , TTY users call 711. If you are not a member of this plan, call toll free , TTY users call 711. Our website:

3 WHO CAN JOIN To join Providence Medicare Dual Plus (HMO SNP) you must be entitled to Medicare Part A, be enrolled in Medicare Part B, be eligible for full Oregon Health Plan (Medicaid) benefits, and live in our service area. Our service area includes the following counties in Oregon: Clackamas, Multnomah and Washington. Providence Medicare Dual Plus (HMO SNP) covers both Medicare Part B prescription drugs and Medicare Part D prescription drugs. WHICH DOCTORS, HOSPITALS AND PHARMACIES CAN I USE? Providence Medicare Dual Plus (HMO SNP) has a network of doctors, hospitals, pharmacies, and other providers. For some services you can use providers that are not in our network. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. Some of our network pharmacies have preferred cost-sharing. You may pay less if you use these pharmacies. 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. 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, Or, call us and we will send you a copy of the formulary. HOW WILL I DETERMINE MY DRUG COSTS? The amount you pay depends on the drug you are taking and what stage of the benefit you have reached. Later in this document we discuss the benefits stages: Initial Coverage and Catastrophic Coverage. If you have any questions about this plan s benefits or costs, please contact Providence Health Assurance for details. You can see our plan s Provider and Pharmacy Directory at our website: providerdirectory or, call us and we will send you a copy of the Provider and Pharmacy Directory.

4 SECTION II- SUMMARY OF BENEFITS Providence Medicare Dual Plus (HMO SNP) MONTHLY PREMIUM, DEDUCTIBLE, AND MAXIMUM OUT-OF-POCKET RESPONSIBILITY Monthly premium Deductible Out-of-pocket maximum $0.00 You must continue to pay your Medicare Part B premium. $0 or $183 per year* $0 per year for Part D prescription drugs. *These amounts may change for 2018 and depends on your level of Medicaid eligibility. In this plan, you might pay nothing for Medicare covered services, depending on your level of Oregon Health Plan eligibility. Your yearly limit(s) in this plan In-network: $3,400 For Oregon Health Plan covered services, refer to the Medicare Coverage section of this document. COVERED MEDICAL AND HOSPITAL BENEFITS SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR Providence Medicare Dual Plus (HMO SNP) Inpatient Hospital Coverage 1 In-network: $0 or: $1316 deductible for each benefit period. $0 for days 1-60 $329 for days $658 for days 91+* *These amounts may change for 2018 Outpatient Hospital Coverage 1 Doctor s Visits (Primary and Specialist) 2 Preventive Care Emergency Care Urgent Care In-network: 0% or 20% of the total cost Primary Care Provider Visit: In-network:0% or 20% of the cost for each visit Specialist visit: In-network:0% or 20% of the cost for each visit In-network: You pay nothing 0% or 20% of the cost, up to $100 If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. 0% or 20% of the cost, up to $65 If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for urgent care.

5 SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR Diagnostic Services/Labs/ Imaging 1 Hearing Services 2 Dental Services 1,2 Vision Services Mental Health Services 1 Providence Medicare Dual Plus (HMO SNP) Diagnostic radiology services (such as MRIs, ultrasounds, CT Scans): Therapeutic radiology services: Diagnostic test and procedures: In-network:0% or 20% of the cost Lab Services: In-network: $0 copay Outpatient X-rays: In-network:0% or 20% of the cost In-network:0% or 20% of the cost Medicare-covered In-network:0% or 20% of the cost Medicare-covered Routine eye exam: In-network: $0 copay up to $50 allowance one per calendar year with a qualified licensed provider Routine eyeglasses or contact lenses: In-network: $200 benefit per calendar year with a qualified licensed provider Inpatient visit: In-network: $0 or $1316 deductible $0 days 1-60 $0 or $329 days Outpatient individual and group therapy visit: Skilled Nursing Facility 1 *These amounts may change for In-network: You pay nothing for days 1-20 $0 or $ copay per day for days *These amounts may change for 2018.

6 SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR Providence Medicare Dual Plus (HMO SNP) Occupational Therapy Visit: Rehabilitation Services Physical therapy and Speech and Language therapy visit Ambulance 1 0% or 20% of the cost Transportation Not covered Medicare Part B Drugs 1 Foot Care (podiatry services) 2 Durable medical equipment and supplies: Medical Equipment and Supplies 1 Prosthetic devices: Diabetic supplies: Diabetic therapeutic shoes or inserts: Wellness Program $500 annual benefit for health and wellness classes offered at participating Providence facilities

7 Prescription Drug Benefits For Providence Medicare Dual Plus (HMO SNP) Plan Yearly deductible: Because there is no deductible for the plan, this payment stage does not apply to you. If you receive Extra Help to pay your prescription drugs, this payment stage does not apply to you. You pay the following until your total yearly out-of-pocket costs reach $5,000. Initial Coverage 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 $3.70 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, but may pay more than you pay at an in-network pharmacy. You may get drugs from a standard in-network pharmacy, but may pay more than you pay at a preferred in-network pharmacy. Coverage Gap Catastrophic Coverage Because there is no coverage gap for the plan, this payment state does not apply to you. 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.

8 SUMMARY OF BENEFITS Summary of Oregon Health Plan (Medicaid) Covered Services In this section, you can see a summary of Medicaid benefits you may receive through the Oregon Health Plan. As long as you are eligible for the Oregon Health Plan and Medicare Parts A and B, the Medicaid Benefits Packages you can have through the Oregon Health Plan are the QMB + OHP with Limited Drug Benefit Package, or OHP with Limited Drug Benefit Package. Please contact your State Medicaid case worker if you do not know which benefit package you have through the Oregon Health Plan. This section does not list every Medicaid service covered or list every limitation or exclusion. To get a complete list of Medicaid benefits, please contact your Medicaid health plan Customer Service. Oregon Health Plan (OHP) Medicaid Benefits Packages: QMB + OHP with Limited Drug Benefit Package This benefit package is for people who qualify to have their Medicare Parts A and B cost sharing paid for by Medicaid. If you receive the QMB + OHP with Limited Drug Benefit Package you get the benefits listed in the chart below. The cost sharing amounts listed in Section II for the Medicare Parts A and B covered services are paid for by your Medicaid health plan. Your provider cannot bill you for any amounts beyond what your Medicare and Medicaid plans pay. You will still have to pay your Medicare Part D prescription drug cost sharing. OHP with Limited Drug Benefit Package This benefit package is for people who only qualify to have their Medicare Parts A and B cost sharing paid for by Medicaid for services normally covered by the Oregon Health Plan. If you receive the OHP with Limited Drug Benefit Package you get the benefits listed in the chart below. The cost sharing amounts listed in Section II for Medicare Parts A and B covered services will be covered only for services that the Oregon Health Plan would normally cover. Your provider cannot balance bill you for any amounts beyond what your Medicare and Medicaid plans pay for services normally covered by the Oregon Health Plan. If you receive a Medicare covered service that is not normally covered by the Oregon Health Plan you will have to pay the Medicare Parts A and B cost sharing yourself. See page 14 for more information on services not covered by Oregon Health Plan. You will still have to pay your Medicare Part D prescription drug cost sharing.

9 SUMMARY OF BENEFITS Below is a list of services that are covered by the Oregon Health Plan Medicaid and your Medicaid- Managed Care plan (does not include every service available): Benefit Category Premium and Other Important Information Oregon Health Plan Medicaid (member costs) This is a brief summary. Please refer to OHP member handbook for a detailed description of Medicaid benefits available to eligible Oregonians. Your Medicaid-Managed Care Plan (member costs) This is a brief summary. Please refer to OHP member handbook for a detailed description of Medicaid benefits available to eligible Oregonians. All cost sharing in this summary of benefits is based on your level of Medicaid eligibility. Doctor and Hospital Choice (for more information, see the Emergency and Urgently Needed Care sections) Inpatient Hospital Care Inpatient Mental Health Care Skilled Nursing Facility (In a Medicare-certified skilled nursing facility) Home Health Care (Includes medically necessary intermittent skilled nursing and rehabilitation services, home health aide services, etc.) Hospice Allows Fee for Service patients to go to any provider that accepts Medicaid. Inpatient Care You must go to network doctors, specialists, and hospitals. Referral required for network hospitals and specialists (for certain benefits) or other health care provider for

10 Benefit Category Doctor Office Visits Chiropractic Services Podiatry Services Outpatient Mental Health Care Outpatient Substance Abuse Care Outpatient Services/Surgery Ambulance Services (Medically necessary ambulance services) Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care) Urgently Needed Care (This is NOT emergency Care, and in most cases, is out of the service area) Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy) SUMMARY OF BENEFITS Outpatient Care Oregon Health Plan Medicaid (member costs) Your Medicaid-Managed Care Plan (member costs) or other health care provider for

11 SUMMARY OF BENEFITS Outpatient Medical Services and Supplies Benefit Category Durable Medical Equipment Prosthetic Devices Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies Diagnostic Tests, X-Rays, and Lab Services Bone Mass Measurement Colorectal Screening Exam Routine Immunizations Mammograms (Annual Screening) Covered annually under Medicaid Pap Smears and Pelvic Exams Covered annually under Medicaid Prostate Cancer Screening Exams End-Stage Renal Disease Oregon Health Plan Medicaid (member costs) Preventive Services services, except immunizations given for travel and other reasons. Your Medicaid-Managed Care Plan (member costs)

12 Prescription Drugs Dental Services SUMMARY OF BENEFITS Preventive Services $0 copayment for preferred generic and preferred brand-name drugs. $0 copayment for generic drugs and non-preferred brand name drugs. Mental health drugs are covered by the state and not your Medicaid managed care health plan. $0 copayment for restorative treatment. $0 copayment for Medicaid covered Dental diagnostic and preventative routine checkup Part D medications- Covered by your Medicare health plan (see page 7 for details) Part B Medications- You pay $0 yearly deductible for Part B-covered drugs. In-Network: $0 copayment for Medicaid covered service (not including Part B-covered chemotherapy drugs). Prior Authorization rules may apply In-network: $0 copayment for Medicaid covered service for Part B covered chemotherapy drugs. Prior Authorization rules may apply Medicaid-covered medications- Over the counter drugs when accompanied by a prescription Benzodiazepine and Barbiturate drugs when accompanied by a prescription Drugs when used for the symptomatic relief of cough or cold when accompanied by a prescription Vitamins and minerals when accompanied by a prescription Mental Health Drugs are not covered by your Medicaid Managed Care Plan. Your Medicaid Managed Care Plan uses a drug list (formulary). You can see the formulary on the website for your Managed Care Plan

13 SUMMARY OF BENEFITS Preventive Services Hearing Services Vision Services Physical Exams Health/Wellness Education Not Covered Not Covered Other Non-Covered Medicare In-network services that will be covered by the Oregon Health Plan Preventative Services: Maternity Case Management, including nutritional counseling Maternity and newborn care X-ray, lab, routine immunization and family planning or other health care provider for X-ray, lab, routine immunizations and family planning Well-child exams and immunizations In-network Family Planning Services: $0 copayment for Medicaid- Including birth control pills, covered Preventative and Family condoms, contraceptive Planning implants, and Depo-Provera Prior Authorization rules may Sterilizations apply. Services not covered by your Medicaid Managed Care Other Oregon Health Plan Services: Death with dignity services* Abortions* *Please Note: These services are covered by the state not by your Medicaid Managed Care health plan. Plan Death with dignity services * Abortions *

14 Services That Are Not Covered by the Oregon Health Plan Medicaid (Exclusions): Not all medical treatments are covered. When you need medical treatment, please contact your Primary Care Provider. These are some of the exclusions (does not include every exclusion): Medicare Part D covered prescription drugs Conditions where a home treatment is effective, such as applying ointment, resting a painful joint, drinking plenty of fluids, or a soft diet. Such conditions include: Canker sores Diaper rash Corns/calluses Sunburn Food poisoning Sprains Personal comfort or convenience items (radios, telephones, hot tubs, treadmills, etc.) Services that are primarily cosmetic, such as: Benign skin tumors Cosmetic surgery Removal of scars Conditions where treatment is not normally effective such as: Some back surgery TMJ surgery Some transplants Services performed by an immediate relative or member of your household Any services received outside the United States Non-Emergency care if you go to a provider who not a network provider Other non-covered services include, but are not limited to, the following: Circumcision (routine) Weight loss program Infertility services If you have any questions about covered or non-covered services, contact your Medicaid Managed Health Plan Customer Service. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, and/ or copayments/coinsurance may change on January 1st. The Part B premium is covered for full-dual enrollees who are eligible for Providence Medicare Dual Plus. Premium, copays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

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