H Summary of Benefits 2017 MiaMi-DaDe. Y0114_17_28279_U_001 Accepted

Transcription

1 H Summary of s 2017 MiaMi-DaDe Y0114_17_28279_U_001 Accepted

2 Simply Complete (HMO SNP) Miami-Dade County January 1, 2017 December 31, 2017 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 Simply Complete (HMO SNP)). Tips for comparing your Medicare choices This Summary of s booklet gives you a summary of what Simply Complete (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 s 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

3 Sections in this booklet Things to Know About Simply Complete (HMO SNP) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital s Prescription Drug s Additional Covered Medical and Hospital s Summary of Medicaid-Covered s This document is available in other formats such as Braille and large print. This information is available for free in other languages. Please call our Member Services toll-free number at /TTY: 711. From October 1 to February 14, we are open 7 days a week from 8 a.m. - 8 p.m., EST. Beginning February 15 until September 30, we are open Monday through Friday, 8 a.m. - 8 p.m. EST. Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro número de Servicios al Afiliado sin cargo al /TTY: 711. Desde el 1 de octubre al 14 de febrero atendemos los 7 días de la semana de 8 a.m. a 8 p.m., hora del este. A partir del 15 de febrero hasta el 30 de septiembre atendemos de lunes a viernes de 8 a.m. a 8 p.m., hora del este. Simply Healthcare Plans, Inc., is a Medicare-contracted coordinated care plan that has a Medicaid contract with the State of Florida Agency for Health Care Administration to provide benefits or arrange for benefits to be provided to enrollees. Enrollment in Simply Healthcare Plans, Inc. depends on contract renewal. Things to Know About Simply Complete (HMO SNP) Hours of Operation From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. EST. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. EST. Simply Complete (HMO SNP) Phone Numbers and Website If you are a member of this plan, call toll-free (877) (TTY/TDD 711). If you are not a member of this plan, call toll-free (888) (TTY/TDD 711). Our website: 4

4 Who can join? To join Simply Complete (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and Florida Medicaid, and live in our service area. Our service area includes the following county in Florida: Miami-Dade. Which doctors, hospitals, and pharmacies can I use? Simply Complete (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 directory at our website ( You can see our plan s pharmacy directory at our website ( Or, call us and we will send you a copy of the provider and pharmacy directory. 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, prescription-drug-benefit/formularies. Or, call us and we will send you a copy of the formulary. 5

5 How will I determine my drug costs? Our plan groups each medication into one of five tiers. You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug s tier 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 and Catastrophic Coverage. It s important we treat you fairly That s why we follow Federal civil rights laws in our health programs and activities. We don t discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn t English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call Member Services for help (TTY: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Grievance and Appeals Department in writing, 9250 W. Flagler Street, Suite 600; Miami, FL Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C or by calling (TTY: ) or online at Complaint forms are available at 6

6 Simply Multi-language Healthcare Interpreter Plans, Inc. for Services details. English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). Spanish: ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). Amharic: ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ (መስማት ለተሳናቸው: 711). Arabic: ملحوظة: ا ذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم (رقم هاتف الصم والبكم: 117). Chinese: 㲐シ烉 㝄ぐ ἧ 䓐 橼 㔯炻ぐ ẍ 屣䌚 婆妨mm 㚵 ˤ 婳农暣 ġġ 炷 TTY 烉 711 炸 ˤġ French: ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : 711). German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). Haitian: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711). Y0114_17_28458_I 08/10/2016 7

7 Multi-language Interpreter Services continued Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). Korean: 㨰㢌 agg 䚐 ạ 㛨 G 㟝䚌㐐 G 㟤 SG 㛬㛨 G 㫴㠄 G PTE p.m. Gⱨ G 㢨㟝䚌㐘 G メカ トン G 㢼 UG (TTY: 711)ⶼ 㡰 G 㤸䞈䚨 G 㨰㐡㐐㝘 U Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). Portuguese: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: 711). Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). Thai: เรยน: ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร (TTY: 711). Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). Y0114_17_28458_I 08/10/2016 8

8 Simply SUMMARY Healthcare OF Plans, BENEFITS Inc. for details. January 1, 2017 December 31, 2017 MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is the monthly $0 per month. In addition, you must keep paying your premium? Medicare Part B premium. How much is the deductible? Because you have to receive Extra Help to pay for your prescription drugs to be on this plan, this stage does not apply to you. Is there any limit on how much I will pay for my covered services? Is there a limit on how much the plan will pay? 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 Medicarecovered services, depending on your level of Florida Medicaid eligibility. Your yearly limit(s) in this plan: $500 for services you receive from in-network 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. Refer to the Medicare & You handbook for Medicare-covered services. For Florida Medicaidcovered services, refer to the Medicaid Coverage section in this document. Please note that you will still need to pay your cost-sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. 9

9 COVERED MEDICAL AND HOSPITAL BENEFITS Inpatient Hospital Care Our plan covers an unlimited number of days for an inpatient hospital stay. Doctor s Office Visits Primary care physician visit: Specialist visit: Preventive Care 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 Depression screening Diabetes screenings 10

10 Preventive Care (Cont.) HIV screening Lung Cancer Screening with low dose computed tomography (LDCT) 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: 11

11 Emergency Care You are covered for up to $50,000 in emergency care worldwide. Urgently Needed Services This is NOT emergency care. Diagnostic Tests, Lab and Radiology Services, and X-Rays (Costs for these services may be different if received in an outpatient surgery setting) Diagnostic radiology services (such as MRIs, CT scans): Diagnostic tests and procedures: Lab services: Outpatient x-rays: Therapeutic radiology services (such as radiation treatment for cancer): Hearing Services Exam to diagnose and treat hearing and balance issues: Routine hearing exam (for up to 1 every year): 12

12 Hearing Services (Cont.) Hearing aid fitting/evaluation (for up to 1 every year): Hearing aid: Our plan pays up to $1,500 every year for hearing aids. $750 benefit coverage limit per ear, per year for: up to 2 inner-ear hearing aid(s) every year up to 2 outer-ear hearing aid(s) every year up to 2 over-the-ear hearing aid(s) every year Dental Services Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): Preventive dental services: Cleaning (for up to 2 every year): Dental x-ray(s) (for up to 3 every year): Oral exam (for up to 2 every year): Plan offers additional supplemental comprehensive dental benefits. Contact our Member Services Department for more information. 13

13 Vision Services Mental Health Care 14 Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): Routine eye exam (for up to 1 every year): Contact lenses: Eyeglasses (frames and lenses) (for up to 1 every year): Eyeglass frames (for up to 1 every year): Eyeglass lenses (for up to 1 every year): Eyeglasses or contact lenses after cataract surgery: Our plan pays up to $300 every year for eyewear. 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. 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.

14 Mental Health Care (Cont.) Outpatient group therapy visit: Outpatient individual therapy visit: Skilled Nursing Facility (SNF) Our plan covers up to 100 days in a SNF. Rehabilitation Services Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): Occupational therapy visit: Physical therapy and speech and language therapy visit: Ambulance Member must receive Authorization for non-emergency Medicare services. 15

15 Transportation Foot Care (podiatry services) You are covered for unlimited trip(s) by van for access to medical care every year. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: Routine foot care: Durable Medical Equipment (wheelchairs, oxygen, etc.) Prosthetic Devices (braces, artificial limbs, etc.) Diabetes Supplies and Services Health Club Membership - SilverSneakers 16 You are covered for unlimited routine footcare. Prosthetic devices: Related medical supplies: Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts: Coverage for a monthly membership in the SilverSneakers Fitness Program, including home-based and facility-based programs and use of contracted network fitness centers.

16 PRESCRIPTION DRUG BENEFITS How much do I pay? For Part B drugs such as chemotherapy drugs: Other Part B drugs: Initial Coverage For Part D drugs you pay the following: You may get your drugs at network retail pharmacies and mail order pharmacies. Standard and Preferred Retail Cost-Sharing Tier One-month Two-month Three-month supply supply supply Tier 1 $0 $0 $0 (Preferred Generic) Tier 2 (Generic) $0 $0 $0 Tier 3 (Preferred Brand) For generic drugs (including brand drugs treated as generic), either: ; or $1.20 copay; or $3.30 copay For all other drugs, either: ; or $3.70 copay; or $8.25 copay. For generic drugs (including brand drugs treated as generic), either: ; or $1.20 copay; or $3.30 copay For all other drugs, either: ; or $3.70 copay; or $8.25 copay. For generic drugs (including brand drugs treated as generic), either: ; or $1.20 copay; or $3.30 copay For all other drugs, either: ; or $3.70 copay; or $8.25 copay. 17

17 PRESCRIPTION DRUG BENEFITS Initial Standard and Preferred Retail Cost-Sharing Coverage One-month Two-month (Cont.) Tier supply supply Tier 4 For generic drugs Not Offered (Non- (including brand Preferred drugs treated as Brand) generic), either: ; or $1.20 copay; or $3.30 copay For all other drugs, either: ; or $3.70 copay; or $8.25 copay. Three-month supply Not Offered Tier 5 (Specialty Tier) For generic drugs (including brand drugs treated as generic), either: Not Offered Not Offered ; or $1.20 copay; or $3.30 copay For all other drugs, either: ; or $3.70 copay; or $8.25 copay. 18

18 PRESCRIPTION DRUG BENEFITS Initial Standard Mail Order Cost-Sharing Coverage Tier One-month Two-month Three-month (Cont.) supply supply supply Tier 1 $0 $0 $0 (Preferred Generic) Tier 2 $0 $0 $0 (Generic) Tier 3 (Preferred Brand) For generic drugs (including brand drugs treated as generic), either: For generic drugs (including brand drugs treated as generic), either: For generic drugs (including brand drugs treated as generic), either: Tier 4 (Non Preferred Brand) ; or $1.20 copay; or $3.30 copay For all other drugs, either: ; or $3.70 copay; or $8.25 copay. For generic drugs (including brand drugs treated as generic), either: ; or $1.20 copay; or $3.30 copay For all other drugs, either: ; or $3.70 copay; or $8.25 copay. ; or $1.20 copay; or $3.30 copay For all other drugs, either: ; or $3.70 copay; or $8.25 copay. Not Offered ; or $1.20 copay; or $3.30 copay For all other drugs, either: ; or $3.70 copay; or $8.25 copay. Not Offered 19

19 PRESCRIPTION DRUG BENEFITS Initial Standard Mail Order Cost-Sharing Coverage Tier One-month Two-month (Cont.) supply supply Tier 5 For generic drugs Not Offered (Specialty (including brand Tier) drugs treated as generic), either: ; or $1.20 copay; or $3.30 copay For all other drugs, either: ; or $3.70 copay; or $8.25 copay. Three-month supply Not Offered 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. Out-of-Network - Plan drugs may be covered in special circumstances, such as, illness while traveling outside of the plan s service area where there is no network pharmacy. You may have to pay more if you get your drugs at an out-of-network pharmacy. Contact our plan for more information. Catastrophic Coverage 20 After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,950, you pay nothing for all drugs.

20 ADDITIONAL COVERED MEDICAL AND HOSPITAL BENEFITS Acupuncture Not covered Chiropractic Care Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): Routine chiropractic visit (for up to 12 every year): Home Health Care Outpatient Substance Abuse Group therapy visit: Individual therapy visit: Outpatient Surgery Ambulatory surgical center: Outpatient hospital: 21

21 Over-the-Counter Items Renal Dialysis Please visit our website to see our list of covered over-the-counter items. You are eligible for up to $51 maximum monthly benefit allowance to be used toward the purchase of covered over-the-counter (OTC) health and wellness products. Hospice Meals - Post Hospitalization 22 for hospice care from a Medicarecertified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. After you are discharged from an inpatient stay at a hospital or nursing facility, you qualify to have up to ten days (1 meal per day) of nutritious, precooked, frozen meals delivered to you at no cost. Just call Member Services after your discharge, provide your Simply member ID number, and other basic information, and a representative will arrange for a care manager to contact you to complete a nutritional assessment and provide nutritional guidance. The care manager may schedule delivery depending on your healthcare needs, diagnosis and/or recommendations made by your provider.

22 Personal Emergency Response System (PERS) Chronic Condition Nutrition Readmission Prevention - Simply Aid The Personal Emergency Response System benefit provides an in-home device to notify appropriate personnel of an emergency (e.g., a fall). Authorization is based on the need as determined through the completion of a health risk assessment. A meal program benefit is available if recommended by your provider to assist you in modifying and enhancing your nutritional behavior to better support your healthcare needs. A care manager will contact you to complete a nutritional assessment and provide nutritional guidance. Depending on your healthcare needs, diagnosis, and recommendations made by your provider, you may receive up to a three meal per day course for up to 12 days per year, to assist you in maintaining a healthy diet to support your medical condition or nutritional needs. Immediately following an inpatient admission, members receive up to 16 hours of care at home, usable in onehour increments for covered services; not to exceed four weeks duration, to prevent readmission to a hospital or other institution. Services include a full inhome assessment conducted by a nurse or other qualified health practitioner, a safety assessment, and postdischarge medication reconciliation. 23

23 Comprehensive Written Statement for Prospective Enrollees The benefits described below are covered by Medicaid. The benefits described in the Covered Medical and Hospital s section of the Summary of s are covered by Medicare. For each benefit listed below, you can see what Florida Medicaid covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. Coverage of the benefits described below depends upon your level of Medicaid eligibility. No matter what your level of Medicaid eligibility is, Simply Complete (HMO SNP) will cover the benefits described in the Covered Medical and Hospital s section of the Summary of s. If you have questions about your Medicaid eligibility and what benefits you are entitled to call the Florida Agency for Health Care Administration toll-free at or the Florida Department of Children and Families (DCF) ACCESS Program toll free at A detailed explanation of Florida Medicaid benefits can be found in the Florida Summary of Services online at: Summary of Medicaid-Covered s for Contract H5471, Plan 001 Category Medicaid Simply Complete (HMO SNP) Adult Dental Services for Adult Hearing Services for Adult Vision Services for Advanced Registered for Nurse Practitioner Assistive Care Services (ACS) for Behavioral Health Services for Chiropractic Services for Clinic Services - County for Health Department (CHD) 24

24 Comprehensive Written Simply Statement Healthcare for Plans, Prospective Inc. for details. Enrollees continued Category Medicaid Simply Complete (HMO SNP) Community Mental Health for Durable Medical Equipment (DME), Prostheses, Orthoses for and Medical Supplies Federally Qualified Health for Centers (FQHC) Freestanding Dialysis for Center Services Home Health Services for Hospice Services for Hospital Inpatient Services for Hospital Outpatient for Services Lab and X-ray Services for Mental Health Targeted for Case Management Nursing Home Crossover Patient Transportation Physician Services Physician Assistant Services Podiatry Services Prescribed Medicines for for for for for for Registered Physical for Therapist 25

25 Comprehensive Written Statement for Prospective Enrollees continued Category Medicaid Simply Complete (HMO SNP) Rural Health Clinic (RHC) for Services Screening Services for Therapy Services for Occupational (OT) Therapy Services for Physical (PT) Therapy Services Respiratory for Therapy Services Speech/ for Language Pathology 26

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