Medical Associates Community Plan (Cost) Summary of Benefits January 1, 2018 December 31, 2018
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1 (Cost) Summary of Benefits January 1, 2018 December 31, 2018 is a Medicare Cost plan with a Medicare contract. Enrollment in the 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 live in our service area. Our service area includes the following counties in Iowa: Dubuque, Jones, Jackson, Delaware, and Clayton. has a network of doctors, hospitals, pharmacies, and other providers. You can see our plan s provider directory on our website at If you use providers in the network, the plan will pay for Medicare eligible services. If you use the providers that are not in our network, the plan may not pay for Medicare eligible services and Original Medicare cost sharing would apply. H1651 PBP 004_MAHP 902 CMS Accepted IA Community Plan
2 Monthly Plan Premium Deductible Maximum Out-of-Pocket Responsibility Inpatient Hospital You pay $142; you must continue to pay your Medicare Part B premium. This plan has a deductible on emergency care/urgently needed care outside the United States. None 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. Outpatient Hospital Doctor Visits o Primary o Specialists Preventive Care Any additional preventive services approved by Medicare during the contract year will be covered. Emergency Care Worldwide Coverage Coverage outside of the United States and its territories: $250 annual deductible, then 20% coinsurance until lifetime maximum benefit of $50,000. Urgently Needed Services Worldwide Coverage Coverage outside of the United States and its territories: $250 annual deductible, then 20% coinsurance until lifetime maximum benefit of $50,000.
3 Diagnostic Services/Labs/Imaging o Diagnostic radiology service (e.g., MRI) o Lab services o Diagnostic tests and procedures o Outpatient x-rays Hearing Services o Hearing exam (diagnose and treat hearing and balance Issues) o Routine Hearing exam One routine hearing exam per calendar year with network provider. Dental Services o Oral exam & Cleaning o Fillings o Complete Dentures Vision Services o Vision Exam (diagnose and treat diseases/conditions of the eye) o Routine Eye Exam One routine vision exam per calendar year with a network provider. o Eyeglasses or contact lenses after cataract surgery
4 Mental Health Services o Inpatient visit Our plan covers 90 days for an inpatient hospital stay. 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 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. o Outpatient group o Outpatient individual Skilled Nursing Facility Our plan covers up to 100 days in a SNF. Physical Therapy o Occupational o Physical therapy and speech and language Ambulance Our plan covers up to the Medicare therapy limits. Our plan covers Medicare eligible ambulance services. Transportation Not covered Medicare Part B Drugs for chemotherapy drugs for other Part B drugs
5 Foot Care (podiatry services) o Foot exams and treatment o Routine foot care Six routine visits per calendar year with network provider. Medical Equipment/Supplies o Durable Medical Equipment (e.g., wheelchairs, oxygen) o Prosthetics (e.g., braces, artificial limbs) o Diabetes supplies Wellness Programs (e.g., fitness) Medicare Part D Drugs Not covered 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. For more information, please call us at the phone number below or visit us at or (toll-free), TTY users should call You can all us 7 days a week from 8:00 a.m. to 8:00 p.m. CST. Discrimination is Against the Law Medical Associates Health Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Medical Associates Health Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Medical Associates Health Plans 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. Medical Associates Health Plans provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages.
6 If you need these services, contact Member Services at or If you believe that Medical Associates Health Plans 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: Member Services, Address: 1605 Associates Drive Dubuque, IA 52002, Phone: or , TTY: , Fax: , memberservices@mahealthcare.com. You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Member Services 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 Language Access Services: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: ) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: ). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: ). ໂປດຊາບ: ຖ າວ າ ທ ານເວ າພາສາ ລາວ, ການບ ລການຊ ວຍເຫ (TTY: ). ອດ ານພາສາ, ໂດຍບ ເສ ຽຄ າ, ແ ມ ນ ມ ພ ອມໃຫ ທ ານ. ໂທຣ 1- 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. ध य न द : य द आप ह द ब लत ह त आपक लए म फ त म भ ष सह यत स व ए उपलब ध ह (TTY: ) पर क ल कर
7 ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS: ). Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call (TTY: ). เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: ). PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). (TTY: ) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ).
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