Summary of Benefits Advantra Freedom PEBTF

Transcription

1 Advantra Freedom is a Medicare Advantage Private Fee-For-Service (PFFS) Plan. This Summary of Benefits tells you some features of our Plan. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of your benefits, refer to your Evidence of Coverage (EOC). CAN I CHOOSE MY DOCTORS? As a member of Advantra Freedom, you can use any Medicare doctor, specialist, or hospital that accepts Medicare and Advantra Freedom s terms and conditions of payment. Providers have the right to decide if they will accept Advantra Freedom s terms and conditions of payment each time you seek treatment. Advantra Freedom has the right to determine if the service or treatment ordered by your health care provider is covered under the Advantra Freedom plan. WHAT TYPES OF DRUGS MAY BE COVERED UNDER MEDICARE PART B? The following outpatient prescription drugs may be covered under Medicare Part B. This may include, but is not limited to, the following types of drugs. Contact Advantra Freedom for more details. Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision. Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with Medicare. Erythropoietin (Epoetin alpha or Epogen ): By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia. Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia. Injectable Drugs: Most injectable drugs administered incident to a physician s service. Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant was paid for by Medicare, or paid by a private insurance that paid as a primary payer to your Medicare Part A coverage, in a Medicarecertified facility. Some Oral Cancer Drugs: If the same drug is available in injectable form. Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen. Inhalation and infusion drugs provided through durable medical equipment (DME). Page 1 of 18

2 IMPORTANT INFORMATION 1 - Premium and Other Important Information You pay the $96.40 Medicare Part B premium each month. You pay the Medicare Part B premium each month. Most people will pay the standard monthly Part B premium. For more information on Part B premiums based on income, call Social Security at 1 (800) TTY users should call 1 (800) Deductible $135 yearly Medicare Part B deductible. 3 - Out-of-Pocket Maximum There is no limit to what you could potentially spend out-ofpocket. 4 - Lifetime Maximum There is no lifetime maximum for Medicare covered services. Retirees that retired on or after 7/1/05 will continue to pay their employee contribution. Most people will pay the standard monthly Part B premium. For more information on Part B premiums based on income, call Social Security at 1 (800) TTY users should call 1 (800) $100 calendar year deductible, excluding inpatient facility services, home health agency care, labs and some preventative services. $380 per year for plan approved services not covered by Medicare in addition to the $100 calendar year deductible. There is no lifetime maximum for Medicare covered services. $500,000 lifetime maximum for plan approved services not covered by Medicare. Page 2 of 18

3 5 - Doctor and Hospital Choice You may go to any doctor, specialist or hospital that accepts Medicare. You may go to any doctor, specialist or hospital that agrees to accept Advantra Freedom s terms and conditions of payment. 6 - Plan Approved Services Not Covered by Medicare You pay 100% for non- Medicare covered services. You pay 20% coinsurance for plan approved services not covered by Medicare. Page 3 of 18

4 INPATIENT SERVICES 7 - Inpatient Hospital Care You pay for each benefit period: (includes Substance Abuse and Rehabilitation Services) Days 1-60: an initial deductible of $1,024 Days 61-90: $256 each day Days : $512 each lifetime reserve day Please call Medicare at 1 (800) for information about lifetime reserve days. Medicare covered Inpatient Hospital services received at a hospital for inpatient stays up to 90 days. the one time usage of the lifetime reserve days, inpatient care for days 91 to 150. These days are optional and nonrenewable. Medicare covered Inpatient Hospital services received at a hospital for inpatient stays days 151 to 180, only available if lifetime reserve days have been exhausted and are non-renewable. You pay 20% coinsurance for plan approved Inpatient Hospital services not covered by Medicare received at a hospital for inpatient stays greater than 180 days. You may go to any doctor, specialist, or hospital that agrees to accept Advantra Freedom s terms and conditions of payment. Deductible does not apply. Page 4 of 18

5 8 - Inpatient Mental Health Care You pay the same deductible and copayments as inpatient hospital care (above) except Medicare beneficiaries may only receive 190 days in a psychiatric hospital in a lifetime. See Inpatient Hospital Care. 30 additional nonrenewable days are not dependent on the usage of the 60 lifetime reserve days. For Inpatient Mental Health Care only, after 190 days in a lifetime have been used, you pay 20% coinsurance for plan approved Inpatient Mental Health Care Services. Deductible does not apply. Page 5 of 18

6 9 - Skilled Nursing Facility (SNF) Care (in a Medicare certified Skilled Nursing Facility) You pay for each benefit period following at least a 3- day covered hospital stay: Days 1-20: $0 for each day Days : $128 for each day You are covered for 100 days each benefit period. A benefit period begins the day you go to a hospital or SNF. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. Medicare covered Skilled Nursing Facility services received at a Medicare certified Skilled Nursing Facility up to 100 days. If skilled care is still required you may use 2 days for each of the 30 unused nonrenewable additional hospital days. Medicare covered Skilled Nursing Facility services received at a Medicare certified Skilled Nursing Facility for stays day 101 to 160. These 60 days are non-renewable. You pay 20% coinsurance for plan approved services not covered by Medicare Skilled Nursing Facility services received at a Medicare certified Skilled Nursing Facility for stays greater than 160 days. No prior hospital stay is required. Deductible does not apply. Page 6 of 18

7 (includes medically necessary intermittent skilled nursing care, home health aid services, rehabilitation services, etc.) Summary of Benefits 10 - Home Health Agency Care all covered home health visits. Medicare covered home health visits. You pay 20% coinsurance for plan approved services not covered by Medicare Hospice Care You pay part of the cost for outpatient drugs and inpatient respite care. Deductible does not apply. You must receive care from a Medicare certified hospice. You must receive care from a Medicare certified hospice. Page 7 of 18

8 OUTPATIENT SERVICES 12 - Physician Services (including doctor office visits) approved amounts. each primary care doctor office visit for Medicare covered services. each specialist visit for Medicare covered services. You may go to any doctor, specialist, or hospital that agrees to accept Advantra Freedom s terms and conditions of payment. See 34 - Physical Exams for more information Chiropractic Services You are covered for manual manipulation of the spine to correct subluxation, provided by chiropractors or other qualified providers. You pay 100% for routine care. approved amounts. visit (manual manipulation of the spine to correct subluxation). You pay 20% coinsurance for plan approved services not covered by Medicare. Page 8 of 18

9 14 - Podiatry Services approved amount. You are covered for medically necessary foot care, including care for medical conditions affecting the lower limbs. You pay 100% for routine care. Medicare covered podiatry services (medically necessary foot care) Outpatient Mental Health Care You pay 50% of Medicare approved amounts with the exception of certain situations and services for which you pay 20% of approved charges. individual/group therapy visit performed by a Medicare participating provider Outpatient Substance Abuse Services approved amounts. individual/group therapy visit performed by a Medicare participating provider Outpatient Surgery approved amounts for the doctor. You pay 20% of outpatient facility charges. services to an ambulatory surgical center. services to an outpatient hospital facility. Page 9 of 18

10 18 - Ambulance Services (medically necessary ambulance services) approved amounts or applicable fee schedule charge. medically necessary covered ambulance services Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care.) 20 - Urgently Needed Care (This is NOT emergency care) You pay 20% of the facility charge or applicable copayment for each emergency room visit; you do NOT pay this amount if you are admitted to the hospital for the same condition within 3 days of the emergency room visit. You pay 20% of doctor charges. NOT covered outside the U.S. except under limited circumstances. approved amounts or applicable copayment. NOT covered outside the U.S. except under limited circumstances. emergency room visit. If the deductible has not been met the maximum amount you pay is $50. Worldwide coverage. urgently needed care visit. Worldwide coverage. Page 10 of 18

11 21 - Outpatient Rehabilitation Services approved amounts. (Occupational Therapy, Physical Therapy, Speech and Language Therapy) occupational therapy visit. physical therapy and/or speech/language therapy visit. You pay 20% coinsurance for plan approved services not covered by Medicare Durable Medical Equipment (DME) and Related Supplies (such as wheelchairs, oxygen equipment, etc.) 23 - Prosthetic Devices and Related Supplies (includes braces, artificial limbs and eyes, etc.) 24 - Diabetes Self-Monitoring Training and Supplies (includes coverage for blood glucose monitors, syringes, blood glucose test strips, lancet devices and lancets, and self-management training) approved amounts. approved amounts. approved amounts. Medicare covered items. You pay 20% coinsurance for plan approved services not covered by Medicare. Medicare covered items. diabetes self-monitoring training. diabetes supplies. Page 11 of 18

12 25 - Outpatient Prescription Drug Benefit Drugs covered under Medicare Part B (Original Medicare) Drugs covered under Medicare Part D (Prescription Drug Benefit) You pay 100% for most prescription drugs, unless you enroll in the Medicare Part D Prescription Drug program. Medicare Part B covered drugs. This Plan does not cover Medicare Part D prescription drugs. Prescription drugs are covered under the REHP Prescription Drug Plan Outpatient Diagnostic Tests and Therapeutic Services and Supplies approved amounts, except for approved lab services. There is no copayment for Medicare approved lab services. clinical/diagnostic lab service. radiation therapy service. X- ray visit. Deductible does not apply to lab services. Page 12 of 18

13 PREVENTIVE CARE AND SCREENING TESTS 27 - Bone Mass Measurement (for people who are at risk) approved amounts. bone mass measurement Colorectal Screening (for people age 50 or older or who are at high risk) approved amounts Hepatitis B Vaccine approved amounts for the Hepatitis B vaccine Pneumonia and Flu Vaccine the pneumonia and flu vaccines. You may only need the pneumonia vaccine once in your lifetime. Medicare covered colorectal screening exams. Deductible does not apply. the Hepatitis B vaccine. the pneumonia and flu vaccines. Deductible does not apply Mammography Screening (for women age 40 and older) Please contact your doctor for further details. approved amounts. No referral necessary for Medicare covered screenings. Medicare covered screening mammograms. Deductible does not apply. Page 13 of 18

14 32 - Pap Tests, Pelvic Exams and Clinical Breast Exams (for women) There is no copayment for a pap test once every 2 years, annually for beneficiaries at high risk. Medicare covered annually for pap tests, pelvic exams and clinical breast exams Prostate Cancer Screening Exams (for men age 50 and older) approved amounts for pelvic exams. There is no copayment for approved lab services and a copayment of 20% of Medicare approved amounts for other related services. Deductible does not apply. Medicare covered prostate cancer screening exams. Deductible does not apply Physical Exams If your coverage to Medicare Part B begins on or after January 1, 2005, you may receive a one time physical exam within the first six months of your new Part B coverage. Medicare covered physical exams. You are covered for an annual exam. This will not include laboratory tests. You pay 20% of the Medicare approved amount. Page 14 of 18

15 ADDITIONAL BENEFITS 35 - Hearing Services You pay 100% for routine hearing exams and hearing aids. approved amounts for diagnostic hearing exams Vision Care You are covered for one pair of eyeglasses or contact lenses after each cataract surgery. For people with Medicare who are at risk, you are covered for annual glaucoma screenings. hearing exam (diagnostic hearing exams). Medicare covered eye wear (one pair of eyeglasses or contact lenses after each cataract surgery). annual glaucoma screenings. approved amounts for diagnosis and treatment of diseases and conditions of the eye. Medicare approved amounts for diagnosis and treatment of diseases and conditions of the eye. You pay 100% for routine eye exams and glasses Dental In general, you pay 100% for preventive dental services. In general, you pay 100% for preventive dental services. Page 15 of 18

16 38 - Health and Wellness Education Programs You pay 100%. approved health education classes. Weight management health education classes are limited to $150 per year. access to approved fitness facilities. Page 16 of 18

17 Advantra Freedom - PEBTF Important Plan Information Prior Notification Is Requested for Inpatient and Outpatient Procedures by calling 1 (866) These must be performed in a Medicare-approved facility. These procedures include: Transplants Carotid Artery Stenting Ventricular Assist Device (VAD) Destination Therapy Bariatric Surgery Lung Volume Reduction Therapy (LVRT) National Oncological PET Registry (NOPR) You may contact Advantra Freedom or dial MEDICARE for more information. The list of CMS approved facilities is also posted on-line at ApprovedFacilities. Approved transplant facilities are listed at ApprovedTransplantCenters. Neither Medicare nor Advantra Freedom will pay for procedures that are performed by facilities that have not been approved by CMS for that specific purpose. You do not need to request prior notification for other inpatient and outpatient procedures. Part B Prescription Drugs Prior notification is requested. In some situations, specific Part B drugs may be covered under your prescription drug plan. Advantra Freedom needs to be able to make a decision before services are rendered so that claims are processed appropriately. Additional Information about the Advantra Freedom Plan Advantra Freedom provides coverage when you are sick or injured. But as we get older, preventive care becomes even more important. You can count on Advantra Freedom for preventive care and wellness benefits. Page 17 of 18

18 Preventive Care and Screening Tests It has been well documented that early detection is the key to successful treatment of many medical conditions. Advantra Freedom makes it easy and affordable to get the essential screening exams and tests you need to maintain good health. You can go directly to any doctor who accepts Medicare and Advantra Freedom s terms and conditions of payment with no referrals for covered preventive services. What s more, there are NO COPAYMENTS for the following preventive care services: Annual routine physical exams Immunizations Gynecological exams Screening mammograms Bone mass measurements Colorectal screening exams Prostate screening exams Vision and Hearing Services Advantra Freedom s additional benefits help keep your vision and hearing sharp. Vision You are covered for Medicare covered vision services at a $0 copayment. Hearing You are covered for Medicare covered hearing services at a $0 copayment. Nurse Information Line As a member of Advantra Freedom, medical advice is always just a quick phone call away even in the middle of the night. Nurses are on call 7 days a week, 24 hours a day, even on holidays. You can call the Nurse Information Line at 1 (800 ) to get answers to health-related questions, better understand your doctor s instructions, or review your medications. Should you be faced with a serious medical condition, you can use the Nurse Information Line to discuss treatment options and get the information you need to make an informed medical decision about which option is best for you. Page 18 of 18