2017 MetroPlus Advantage Plan (HMO SNP) Summary of Benefits

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1 2017 MetroPlus Advantage Plan Summary of Benefits (HMO SNP) is an HMO plan with a Medicare contract. Enrollment in MetroPlus Health Plan depends on contract renewal. The benefit information provided is 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 request the Evidence of Coverage. To join, you must be entitled to Medicare Part A, be enrolled in Medicare Part B and Medicaid, and reside in Manhattan, Brooklyn, Queens or The Bronx. 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 can see our plan s Provider/Pharmacy Directory at Or, call us and we will send you a copy of the directory. This is a summary of drug and health services covered by January 1, December 31, 2017 DOCTORS IN YOUR NEIGHBORHOOD H0423_MEM2004 Accepted

2 Premiums and Benefits What you should know Monthly Plan Premium You pay $41. Deductible Maximum Out-of-Pocket Responsibility (does not include prescription drugs) Inpatient Hospital Coverage Doctor Visits Primary Specialists Preventive Care The deductible in 2016 was $0 or 166. This may change in $6,700 annually. In 2016 the amounts for each benefit period were $0 or: $1,288 (1 60 Days), $322 (61 90 Days), $644 (60 Lifetime Reserve Days) This may change for You pay nothing. Emergency Care You pay 0% or 20% of the cost (up to $75). Urgently Needed Services You pay 0% or 20% of the cost (up to $65). Diagnostic Services/Labs/ Imaging Diagnostic radiology service (e.g., MRI) Lab services Diagnostic tests and procedures Outpatient x-rays Hearing Services Exam to diagnose and treat balance issues Dental Services Vision Services You pay nothing. You pay nothing. You must continue to pay your Medicare Part B premium. The most you pay for copays, coinsurance and other costs for medical services for the year. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. Prior authorization is required. Prior authorization is required for specialist visits. Any additional preventive services approved by Medicare during the contract year will be covered. If you are admitted to the hospital within 3 days, you do not have to pay your share of the cost for emergency care. If you are admitted to the hospital within 3 days, you do not have to pay your share of the cost for urgent care. Prior authorization is required for some services by your doctor or other network providers. Please contact the plan for more information. Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth).

3 Premiums and Benefits What you should know Mental Health Services (Inpatient) Mental Health Services (Outpatient) Skilled Nursing Facility Rehabilitation Services Occupational therapy visit Physical therapy and speech and language therapy visit Ambulance Transportation Foot Care (podiatry services) Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions Routine foot care Medical Equipment/ Supplies Durable Medical Equipment (e.g., wheelchairs, oxygen) Prosthetics (e.g., braces, artificial limbs) Diabetes supplies Wellness Programs (e.g., fitness) Medicare Part B Drugs In 2016 the amounts for each benefit period were $0 or: $1,288 (1-60 days), $322 (61-90 days), $644 (60 lifetime reserve days) This may change for In 2016 the benefit was: You pay nothing (1 20 days) $161 copay per day for days This benefit may change for 2017 Not covered. You pay nothing. Not covered You pay 0% or 20% of the cost for chemotherapy drugs. You pay 0% or 20% of the cost for other Part B drugs. Prior authorization is required. Our plan covers up to 100 days in a SNF. Prior authorization is required. Prior authorization is required. If you are admitted to the hospital, you do not have to pay for the ambulance services. Routine foot care is available for 2 visits per year. Prior authorization is required. Depending on your level of Medicaid eligibility, you may not have any cost-sharing responsibility for original Medicare services.

4 Outpatient Prescription Drugs Stage 1: Yearly Deductible Stage If you receive Extra Help to pay your prescription drugs, your deductible amount will be either $0 or $82, depending on the level of Extra Help you receive. Stage 2: Initial Coverage (After you pay your deductible, if applicable) Tier 1: Generic Drugs (including brand drugs treated as generic) Tier 2: All other drugs Retail Rx 30-day supply You pay 25% coinsurance You pay 25% coinsurance Mail Order 90-day supply You pay 25% coinsurance You pay 25% coinsurance You remain in the Initial Coverage Stage until the total amount for the prescription drugs you have filled and refilled reaches $3,700. Cost- Sharing may change when you enter another phase of the Part D benefit. For more information on the phases of the benefit, please call us or access our Evidence of Coverage online. Stage 3: Coverage Gap Stage Tier 1 Tier 2 You pay the larger of 5% or $3.30 You pay the larger of 5% or $8.25 You continue paying for drugs until your yearly out-of-pocket payments reach a maximum amount that Medicare has set. In 2017, that amount is $4,850. Stage 4: Catastrophic Coverage Stage You pay nothing. Once you are in the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the year. 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 This document is available in other formats such as Braille, large print or audio.

5 SUMMARY OF MEDICAID COVERED BENEFITS The benefits described below are covered by 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 Medicaid covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. Members who qualify for Medicare and Medicaid are known as dual eligibles. As a dual eligible member, you are eligible for benefits under both the federal Medicare Program and the New York State Medicaid Program. The Medicaid benefits you receive 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 listed below: Full Benefit Dual Eligible (FBDE): Payment of your Medicare Part B premiums, in some cases Medicare Part A premiums and full Medicaid benefits. Qualified Disabled and Working Individual (QDWI): Payment of your Medicare Part A premiums. Qualifying Individual (QI): Payment of your Medicare Part B premiums. Specified Low Income Medicare Beneficiary (SLMB): Payment of your Medicare Part B premiums. SLMB-Plus: Payment of your Medicare Part B premiums and full Medicaid benefits. Qualified Medicare Beneficiary (QMB Only): Payment of your Medicare Part A and/or Part B premiums, deductibles and cost-sharing (excluding Part D copayments). QMB-Plus: Payment of your Medicare Part A and Part B premiums, deductibles, cost-sharing (excluding Part D copayments) and full Medicaid benefits. If you are a QMB or QMB-Plus, you pay $0 for Medicare-covered services as shown in Section II, except any copayments for Part D prescription drugs. If you are not a QMB or QMB-Plus but qualify for full Medicaid benefits, you may have to pay some copayments, coinsurance, and deductibles, depending on your Medicaid benefits. The following chart lists services that are available under Medicaid for people who qualify for full Medicaid benefits. The chart also explains if a similar benefit is available under our plan. It is important to understand that Medicaid benefits can vary based on your income level and other standards. Also, your Medicaid benefits can change throughout the year. Depending on your current status, you may not be qualified for all Medicaid benefits. However, while a member of our plan, you can access plan benefits regardless of your Medicaid status. The services listed below are available under Medicaid for people who qualify for full Medicaid benefits by using your New York State issued Medicaid identification (ID) card. Coverage of the benefits described below depends upon your level of Medicaid eligibility. No matter what your level of Medicaid eligibility is, will cover the benefits described in the Covered Medical and Hospital Benefits section of the Summary of Benefits. If you have questions about your Medicaid eligibility and what benefits you are entitled to call: New York City Human Resources Administration at

6 Benefit Inpatient Mental Health Non-Medicare Covered Home Health Services Non-Medicare Covered Durable Medical Equipment All inpatient mental health services, including voluntary or involuntary admissions for mental health services over the Medicare 190-Day Lifetime Limit. Medicaid covered home health services include the provision of skilled services not covered by Medicare (e.g. physical therapist to supervise maintenance program for patients who have reached their maximum restorative potential or nurse to pre-fill syringes for disabled individuals with diabetes) and/or home health aide services as required by an approved plan of care developed by a certified home health agency. Medicare and 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 of 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. 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. In 2016 the amounts for each benefit period were $0 or: $1,288 deductible for days 1 through 60 $322 copay per day for days 61 through 90 $644 copay per day for 60 lifetime reserve days This benefit may change for 2017

7 Benefit Private Duty Nursing Services Hearing Services Private duty nursing services provided by a person possessing a license and current registration from the NYS Education Department to practice as a registered professional nurse or licensed practical nurse. Private duty nursing services can be provided through an approved certified home health agency, a licensed home care agency, or a private Practitioner. Private duty nursing services are covered when determined by the attending physician to be medically necessary. Nursing services may be intermittent, part-time or continuous and must be provided in your home in accordance with the ordering physician, registered physician assistant or certified nurse practitioner s written treatment plan. Hearing services and products when medically necessary to alleviate disability caused by the loss or impairment of hearing. Services include hearing aid 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. Exam to diagnose and treat hearing and balance issues: 0% or 20% of the cost.

8 Vision Services Dental Services Benefit Services of optometrists, ophthalmologists and ophthalmic dispensers including eyeglasses, medically necessary contact lenses and poly-carbonate 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. Dental services include, but shall not be limited to, preventive, prophylactic and other routine dental care, services, supplies and dental prosthetics required to alleviate a serious health condition, including one which affects employability. Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): 0% or 20% of the cost. Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): 0% or 20% of the cost.

9 Benefit Non-Emergency Transportation Personal Care Services Skilled Nursing Facility Days Not Covered by Medicare Transportation expenses are covered when transportation is essential in order for you to obtain necessary medical care and services which are covered under the Medicaid program. Transportation services means transportation by ambulance, ambulette, fixed wing or airplane transport, invalid coach, taxicab, livery, public transportation, or other means appropriate to your medical condition; and a transportation attendant to accompany you, if necessary. Such services may include the transportation attendant s transportation, meals, lodging and salary; however, no salary will be paid to a transportation attendant who is a member of your family. If you have disabilities, the method of transportation must reasonably your needs, taking into account the severity and nature of the disability. Personal care services (PCS) involve the provision of some or total assistance with personal hygiene, dressing and feeding and nutritional and environmental support (meal preparation and housekeeping). Such services must be essential to the maintenance of your health and safety in your own home. The services must be ordered by a physician, and there has to be a medical need for the services. To receive PCS you must have a stable medical condition and be generally expected to be in receipt of such services for an extended period of time (years). Skilled nursing facility days for Medicaid Advantage Enrollees in excess of the first one hundred (100) days in the benefit period are covered by Medicaid on a fee for service basis.

10 Benefit Prescription Drugs Permitted by State Law, Certain Medical Supplies and Enteral Formulas Not Covered by Medicare NYS Medicaid continues to provide coverage for categories of drugs excluded from the Medicare Part D benefit such as barbiturates, benzodiazepines, and some prescription vitamins, and some nonprescription drugs. Certain medical/ surgical supplies and enteral formula covered by Medicaid and not included in the Contractor s Medicare Advantage Benefit Package also will be paid for by Medicaid fee-forservice. Medical/surgical supplies are items other than drugs, prosthetic or orthotic appliances, or DME, which have been ordered by a qualified practitioner in the treatment of a specific medical condition and which are: consumable, non-reusable, disposable, or for a specific rather than incidental purpose, and generally have no salvageable value (e.g. gauze pads, bandages and diapers). Pharmaceuticals and medical supplies routinely furnished or administered as part of a clinic or office visit are covered by the Contractor. Enteral formula and nutritional supplements is limited to individuals who cannot obtain nutrition through any other means, and to the following three conditions: 1) tube-fed individuals who cannot chew or swallow food and must obtain nutrition through formula via tube; 2) individuals with rare inborn metabolic disorders requiring specific medical formulas to provide essential nutrients not available through any other means; and 3) children who require medical formulas due to mitigating factors in growth and development. Coverage of certain inherited disease of amino acid and organic acid metabolism shall include modified solid food products that are low-protein or which contain modified protein.

11 Benefit Out of Network Family Planning Services Methadone Maintenance Treatment Program (MMTP) Certain Mental Health Services Rehabilitation Services Provided to Residents of OMH Licensed Community Residences (CRs) and Family Based Treatment Programs Family Planning and Reproductive Health Services means those health services which enable you to prevent or reduce the incidence of unwanted pregnancy. These include: diagnosis and all medically necessary treatment, sterilization, screening and treatment for sexually transmissible diseases and screening for disease and pregnancy. Also included are HIV counseling and testing when provided as part of a family planning visit. Additionally, reproductive health care includes coverage of all abortions. Fertility services are not covered. MMTP consists of drug detoxification, drug dependence counseling, and rehabilitation services which include chemical management of the patient with methadone. a. Intensive Psychiatric Rehabilitation Treatment Programs (IPRT) b. Day Treatment c. Continuing Day Treatment d. Case Management for Seriously and Persistently Mentally Ill Sponsored by State or Local Mental Health Units. e. Partial Hospitalization Not Covered by Medicare f. Assertive Community Treatment g. Personalized Recovery Oriented Services (PROS) a. OMH Licensed CRs b. Family-Based Treatment

12 Benefit Office for People With Developmental Disabilities Services Comprehensive Medicaid Case Management (CMCM) Directly Observed Therapy for Tuberculosis Disease AIDS Adult Day Health Care HIV COBRA Case Management Adult Day Health Care a. Long Term Therapy Services b. Day Treatment c. Medicaid Service Coordination (MSC) d. Home And Community Based Services Waivers (HCBS) e. Services Provided Through the Care At Home Program (OPWDD) A program which provides social work case management referral services. A CMCM case manager will assist a client in accessing necessary services in accordance with goals contained in a written case management plan. Tuberculosis directly observed therapy (TB/DOT) is the direct observation of oral ingestion of TB medications to assure patient compliance with the physician s prescribed medication regimen. Adult Day Health Care Programs (ADHCP) are programs designed to assist individuals with HIV disease to live more independently in the community or eliminate the need for residential health care services. The HIV COBRA Case Management Program is a program that provides intensive, family-centered case management and community followup activities by case managers, case management technicians, and community follow-up workers. Adult Day Health Care means care and services provided to in a residential health care facility or approved extension site under the medical direction of a physician and which is provided by personnel of the adult day health care program in accordance with a comprehensive assessment of care needs and an individualized health care plan, and providing ongoing implementation and coordination of the health care plan, and transportation.

13 For more information, please call us at the phone number below or visit us at Call us at (TTY: 711). Hours are 8 a.m. 8 p.m., Monday Saturday, February 15 September 30 and 8 a.m. 8 p.m., 7 days a week, October 1 February 14. After 8 p.m., Sundays & Holidays, call our 24/7 Medical Answering Service 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 at DOCTORS IN YOUR NEIGHBORHOOD