2017 Summary of Benefits

Transcription

1 Kaiser Permanente 2017 Summary of Benefits Kaiser Permanente Senior Advantage Medicare Medi-Cal South Plan (HMO SNP) Kaiser Foundation Health Plan, Inc. Southern California Region A nonprofit corporation Health Maintenance Organization (HMO) PBP 029 H0524_17SB029 accepted S 029

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3 Summary of Benefits for Kaiser Permanente Senior Advantage Medicare Medi-Cal South Plan January 1, 2017 December 31, 2017 Kaiser Permanente Senior Advantage is a Medicare Advantage Health Maintenance Organization (HMO) offered by Kaiser Foundation Health Plan, Inc. This document is a summary and does not include all plan rules, benefits, limitations, and exclusions. For complete details, refer to the Evidence of Coverage (EOC), which we will send you after you enroll. If you would like to review the EOC before you enroll, you can view it online at kp.org/medicare or request a copy from Member Services by calling , seven days a week, 8 a.m. to 8 p.m. (TTY 711). Benefits Monthly plan premium You must continue to pay your Medicare Part B premium and any other applicable Medicare premium(s), if not otherwise paid by Medi-Cal or another third party. Medicare Medi-Cal South Plan You pay nothing unless you are no longer eligible for Extra Help, in which case you would pay $32.00 per month. Deductible None. Your maximum out-of-pocket responsibility If you pay $3,400 in copays (a set amount you pay for covered services) or coinsurance (a percentage of the charges that you pay for covered services) during 2017 for services subject to the out-of-pocket maximum, you will not have to pay any more copays or coinsurance for those services for the rest of the year. Inpatient hospital coverage There is no limit to the number of medically necessary inpatient hospital days. Doctor's visits Primary and specialty care kp.org/medicare 1

4 Benefits Medicare Medi-Cal South Plan Preventive care Please see the EOC to learn which services are covered. Emergency care Our plan covers emergency care anywhere in the world. Urgently needed services Our plan covers urgent care anywhere in the world. Diagnostic services, lab, and imaging Hearing services Exams to diagnose and treat hearing and balance issues Routine hearing exams Dental services Preventive and comprehensive dental coverage is provided by DeltaCare USA dentists. Please see the Evidence of Coverage for benefit information. Vision services Visits to diagnose and treat diseases and conditions of the eye Routine eye exams Preventive glaucoma screening Eyeglasses or contact lenses after cataract surgery Other eyeglasses or contact lenses (covered once every 12 months) You pay nothing up to Medicare's limit and you pay any amounts that exceed Medicare's limit. If the eyewear you purchase costs more than $300, you pay the difference , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

5 Benefits Medicare Medi-Cal South Plan Mental health services Inpatient care (there is no limit to the number of medically necessary hospital days for specified conditions, see the EOC for details.) Outpatient group therapy Outpatient individual therapy Skilled Nursing Facility Our plan covers up to 100 days per benefit period. A benefit period begins the day you go into a hospital or skilled nursing facility. The benefit period ends when you haven't received any inpatient hospital care (or skilled care in a SNF) for 60 days in a row. Rehabilitation services Occupational, speech, or physical therapy Ambulance Transportation Not covered. Foot care (podiatry services) Office visits to diagnose and treat injuries and diseases of the feet Routine foot care for certain medical conditions affecting the lower limbs Outpatient surgery for treatment of injuries and diseases of the feet Medical equipment and supplies kp.org/medicare 3

6 Benefits Wellness programs Health education program Medicare Part B drugs A limited number of Medicare Part B drugs are covered when you get them from a network provider (see the EOC for details). Medicare Medi-Cal South Plan Medicare Part D prescription drug coverage Most persons who are entitled to Medicaid benefits also qualify for and are already getting Extra Help from Medicare to pay for their prescription drug plan costs. Medicare provides Extra Help to pay prescription drug costs for people who have limited income and resources. If you are entitled to Extra Help, the copayments and coinsurance discussed below do not apply to you; instead please refer to the Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs. Initial Coverage Stage If you are not entitled to Extra Help, the amount you pay for drugs differs depending upon the following: The drug tier that your drug is in. There are a total of six tiers, please refer to our Part D formulary to locate your drug's tier on our website at kp.org/seniorrx or call Member Services to request a copy at , seven days a week, 8 a.m. to 8 p.m. (TTY 711). The day supply you receive. For a 100-day supply, the type of network pharmacy that fills your prescription (network retail pharmacy or our mail-order pharmacy). See the Pharmacy Directory for our list of network pharmacies at kp.org/directory. The coverage stage you are in (initial, coverage gap, or catastrophic coverage stages). If you lose eligibility for Extra Help, you pay the following copays and coinsurance shown in the chart below until your total yearly drug costs reach $3,700. Total yearly drug costs are the total drug costs paid by both you and any Part D plan during a calendar year , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

7 Tier You pay the following if you are not entitled to Extra Help Tier 1 (Preferred Generic) Tier 2 (Generic) Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier) $8 (up to a 30-day supply). $20 (up to a 30-day supply). $47 (up to a 30-day supply). $100 (up to a 30-day supply). 33% coinsurance. Tier 6 (Vaccines) $0. You can get up to a 100-day supply for many drugs, but you will pay more (a 100-day supply is not available for all drugs). For a 100-day supply of drugs in Tiers 1-4 that you get from a network retail pharmacy, you pay the copay listed above multiplied by three. For example, if you get a 100-day supply of a Tier 1 drug from a retail network pharmacy, you will pay $24 (3 x $8 copay). For a 100-day supply of drugs in Tiers 1-4 that you get from our network mail-order pharmacy, you pay the copay listed above multiplied by two. For example, if you get a 100-day supply of a Tier 1 drug from our mail-order pharmacy, you will pay $16 (2 x $8 copay). Many drugs can be mailed to you through our network mail-order pharmacy (not all drugs can be mailed). If you reside in a long-term care facility, you pay the same as at a network retail pharmacy. Coverage gap and catastrophic coverage stages The information above shows the copays and coinsurance for the Initial Coverage Stage for persons not entitled to Extra Help. Most members do not reach the other two stages Coverage Gap Stage or the Catastrophic Coverage Stage. If you lose eligibility for Extra Help, the Coverage Gap Stage begins if your total yearly drug costs in a calendar year (including what any plan has paid and what you have paid) reaches $3,700. During the Coverage Gap Stage, you pay 51% coinsurance for generic drugs and you pay 40% coinsurance and a portion of the dispensing fee for brand-name drugs. You will stay in the Coverage Gap Stage for the remainder of the year unless you pay $4,950 for your Part D prescription drugs during that year. In which case, you will enter the Catastrophic Coverage Stage and your copays will change. For copay information, please refer to the Evidence of Coverage. kp.org/medicare 5

8 Important coverage rules We cover the services and items listed in this Summary of Benefits and the Evidence of Coverage, subject to exclusions and limitations, only if all of the following conditions are satisfied: The services or items are medically necessary (a service or item is medically necessary if it is medically appropriate and required to prevent, diagnose, or treat your condition or clinical symptoms in accord with generally accepted professional standards of practice that are consistent with a standard of care in the medical community). For services and items covered by Original Medicare, the service or item must be considered reasonable and necessary according to the standards of Original Medicare. You must receive all covered services and items from network providers, except as follows (see the Evidence of Coverage for details): Covered care from network providers in another Kaiser Permanente region s service area or providers in Group Health Cooperative s service area. Emergency care. Out-of-area dialysis care. Out-of-area urgent care (covered inside the service area from network providers and in limited situations from out-of-network providers). Referrals to out-of-network providers if our plan has provided you with prior authorization in writing. Note: You pay in-network copays and coinsurance when you get covered care listed above from out-of-network providers. Eligibility You are eligible for membership if you: Have both Medicare Part A and Medicare Part B and full Medicaid benefits. Are a citizen or lawfully present in the United States. Do not have end-stage renal disease (ESRD), with limited exceptions, such as if you developed ESRD when you were already a member of one of our plans or you were a member of a different plan that was terminated. Live inside our service area. Our service area includes all of Orange County and these parts of counties in these ZIP codes only: Kern County: 93203, , , 93220, 93222, , 93238, , 93243, , 93263, 93268, 93276, 93280, 93285, 93287, , , 93380, , , , , 93531, 93536, , and Los Angeles County: , , , 90099, 90189, , , , , , 90245, , , , 90270, 90272, , , 90280, , , , , , 90623, , , , , , , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

9 03, , , 90723, , , 90755, , , 90822, , 90840, 90842, 90844, , 90853, 90895, 90899, 91001, 91003, , , , , , , 91046, 91066, 91077, , , 91121, , 91129, 91182, , , 91199, , 91214, , , , 91313, 91316, , , , 91337, , , , , 91367, , 91376, , 91390, , , 91416, 91423, 91426, 91436, 91470, 91482, , 91499, , 91510, , 91526, , , 91702, 91706, 91709, 91711, , , , , , , 91759, , , 91778, 91780, , , 91896, 91899, 93243, 93510, 93532, , 93539, , , 93560, 93563, 93584, 93586, , and Riverside County: 91752, , , 92220, 92223, 92230, , , , 92253, 92255, 92258, , 92270, 92276, 92282, 92320, 92324, 92373, 92399, , , , , , 92548, , , 92567, , , , , 92599, 92860, and San Bernardino County: 91701, , , 91737, 91739, 91743, , , 91766, , 91792, 92305, , , , , 92329, 92331, , , , 92350, 92352, 92354, , 92369, , 92382, , , 92397, 92399, , , 92413, 92415, 92418, 92423, 92427, and San Diego County: , , 91921, , 91935, , , , , 91987, , , , , 92033, , 92046, 92049, , , , , , , , , , 92096, , , , , 92145, 92147, , , , 92163, , 92182, , , and Ventura County: 90265, 91304, 91307, 91311, , , 91377, , , , , , , , 93094, 93099, and Getting care from network providers At most of our network facilities, you can usually receive all the covered services you need, including specialty care, pharmacy, and lab work. You are not restricted to a particular network facility or pharmacy, and we encourage you to use the network facility or pharmacy that will be most convenient for you. For network facility and pharmacy locations, please refer to the Provider Directory, Pharmacy Directory, or call Member Services at , seven days a week, 8 a.m. to 8 p.m. (TTY 711). You can also find a current listing at kp.org/directory. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Your primary care provider will provide your primary care and play an important role in coordinating care, including hospital stays, referrals to specialists, and requesting prior authorization from us kp.org/medicare 7

10 as needed. Most primary care providers are physicians who are generalists in internal medicine or family practice. You may choose an available network provider to be your primary care provider. You can change your primary care provider at any time and for any reason. After you become a member, you can choose a provider by calling Member Services or on our website at kp.org/finddoctors. Except for the following services, your network provider must make a referral before you can obtain services or items (refer to the Evidence of Coverage for details): Emergency Flu shots, Hepatitis B vaccinations, and pneumonia vaccinations provided by a network provider. Kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside our service area. Mental health and substance abuse services provided by a network provider. Optometry services provided by a network provider. Routine women's health care provided by a network provider. Second opinions from another network provider except for certain specialty care. Urgently needed services from network providers or from out-of-network providers when network providers are temporarily unavailable or inaccessible; for example, when you are temporarily outside of our service area. Some services or items are covered only if your network provider gets approval in advance (sometimes called prior authorization ) from our plan. The following are some services that require prior authorization (please refer to the Evidence of Coverage for a complete list): Durable medical equipment. Nonemergency ambulance Post-stabilization care following emergency care from out-of-network providers. Prosthetic and orthotic devices. Referrals to out-of-network providers if services are not available from network providers. Skilled nursing facility care. Transplants. Note: We have case management programs for members who have difficulty managing multiple chronic conditions. This program partners with nurses, social workers, and your primary care provider to address your needs. It provides education and teaches self-care skills to properly manage your chronic conditions. If you are interested in these programs, please ask your primary care provider for more information , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

11 Grievances and appeals You can ask us to provide or pay for an item or service you think should be covered. If we deny your request, you can ask us to reconsider. You may ask for a fast decision if you think waiting could put your health at risk. If your doctor makes or supports the fast request, we will expedite our decision. If you have an issue unrelated to coverage, you can file a grievance with us. Please see the Evidence of Coverage for details. Notice of nondiscrimination Kaiser Permanente complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kaiser Permanente does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We also: Provide no cost aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters. Written information in other formats, such as large print, audio, and accessible electronic formats. Provide no cost language services to people whose primary language is not English, such as: Qualified interpreters. Information written in other languages. If you need these services, call Member Services at (TTY 711), 8 a.m. to 8 p.m., seven days a week. If you believe that Kaiser Permanente 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 our Civil Rights Coordinator by writing to One Kaiser Plaza, 12th Floor, Suite 1223, Oakland, CA or calling Member Services at the number listed above. You can file a grievance by mail or phone. If you need help filing a grievance, our Civil Rights Coordinator 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 Privacy We protect the privacy of protected health information. Please see the Evidence of Coverage or view our Notice of Privacy Practices on kp.org to learn more. kp.org/medicare 9

12 Summary of Medicaid-Covered Benefits The benefits described below are covered by Medicaid. For each benefit listed below, you can see what Medi-Cal covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. Benefit Inpatient hospital services Outpatient hospital services Rural health clinic services Federally qualified health center services Laboratory services X-rays Skilled nursing facility care for over 21 years of age - Subacute care Pediatric nursing facility care for under 21 years of age - Subacute services (Early & periodic screening, diagnosis, and treatment supplemental services) Family planning services & supplies Physician services Medicaid State Plan Senior Advantage Medicare Medi-Cal South Plan Not covered unless covered emergency or out of area urgent care. Not covered unless covered emergency or out of area urgent care. services (no age limit). Plan covers up to 100 days each benefit period. skilled nursing facility care (no age limit). Plan covers up to 100 days each benefit period , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

13 Benefit Medical & surgical dental services Ophthalmologist services Podiatry services Optometry services Chiropractic services Psychology services Nurse anesthetist services Optician and optical fabricating lab services Medical supplies (Does not include incontinence creams and washes) Incontinence creams and washes Durable medical equipment Hearing aids Enteral formulae Medicaid State Plan services Senior Advantage Medicare Medi-Cal South Plan services (see "Dental services" for comprehensive dental benefits). $0 copay for Optician (see "Eyeglasses, other eye appliances" for lab services). supplies. Not covered. items. Not covered. kp.org/medicare 11

14 Benefit Acupuncture services Licensed midwife services Home health services through a home health agency (Including home health nursing and aide services, physical and occupational therapy, speech pathology and audiology services, intermittent nursing, home health aide care, medical supplies, equipment and appliances) Physical therapy and related services Rehabilitation facilities Private duty nursing (Waiver only) Clinic (Organized outpatient clinic, Indian Health Services, alternate birthing centers, ambulatory surgical centers) Dental services Occupational therapy Speech pathology/ Speech therapy Medicaid State Plan Senior Advantage Medicare Medi-Cal South Plan $0 copay when determined medically necessary by a plan provider. services provided by plan providers. Not covered. services provided by a network provider. services provided by your assigned DeltaCare dentist , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

15 Benefit Audiology services Pharmaceutical services and prescribed drugs Dentures Prosthetic appliances (Orthotic appliances) prosthetic eyes Eyeglasses, other eye appliances Comprehensive Perinatal Services Program (Preventive services) Community-Based Adult Services (CBAS) (Waiver only) Chronic dialysis services Rehabilitation services (Chronic dialysis, outpatient heroin detoxification, rehabilitative mental health, drug Medi-Cal, independent rehabilitation centers) Medicaid State Plan $0 copay for drugs excluded from Medicare Part D coverage. Senior Advantage Medicare Medi-Cal South Plan Medicare Part B drugs: $0 copay for drugs covered by Medicare Part B. Medicare Part D drugs: See the "Medicare Part D prescription drug coverage" section for information about Medicare Part D prescription drug cost sharing. $0 for covered 0% of the cost for Medicarecovered $0 up to a $300 limit for eyewear every year. $0 copay for one pair of eyeglasses or contact lenses covered by Medicare after cataract surgery. prenatal care. Not covered. substance abuse kp.org/medicare 13

16 Benefit Institutes for Mental Diseases (For under 21 years of age and over 65 years of age, including inpatient psychiatric care) Intermediate Care Facility Nurse midwife Hospice TB-related services Respiratory care for ventilator-dependent patients Family nurse practitioner Home and community care for functionally disabled elderly (Waiver only) Community-supported living arrangements (Waiver only) Personal care services Rural primary care hospital Medicaid State Plan Senior Advantage Medicare Medi-Cal South Plan services (no age limits). Not covered. services provided by plan providers. services provided by plan providers. Not covered. Not covered. Not covered. emergency care , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

17 Benefit Nonmedical health facilities Emergency hospital services Transportation (State provides emergency and non-emergency medical transportation. Meets federal requirement for assurance of transportation to medically necessary services) Services for pregnant women that treat a condition that may impact the woman and/or the fetus (Not specifically stated as a benefit but is a mandated provision under federal regulations) Marriage and family counselor services (Early & periodic screening, diagnosis, and treatment services & waiver only) Licensed clinical social worker services (Early & periodic screening, diagnosis, and treatment services & waiver only) Medicaid State Plan Senior Advantage Medicare Medi-Cal South Plan Not covered except for services of a religious nonmedical health care institution covered by Medicare. emergency care. ambulance medically-necessary $0 copay only when part of Medicare-covered mental health services benefit. kp.org/medicare 15

18 Benefit Case management (Early & periodic screening, diagnosis, and treatment services & waiver only) Private duty nursing agency services (Early & periodic screening, diagnosis, and treatment services & waiver only) Individual nurse provider services (Early & periodic screening, diagnosis, and treatment services & waiver only) Nonmedical services (Waiver only) Medicaid State Plan Senior Advantage Medicare Medi-Cal South Plan Not covered. Not covered. Kaiser Permanente is an HMO SNP plan with a Medicare contract and a contract with the Medi-Cal program. Enrollment in Kaiser Permanente depends on contract renewal. This contract is renewed annually by the Centers for Medicare & Medicaid Services (CMS). By law, our plan or CMS can choose not to renew our Medicare contract. Benefits, premiums, deductibles, copayments, and coinsurance may change on January 1, The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. If you receive Extra Help to pay for Medicare Part D prescription drug coverage, premiums and cost-sharing will vary based on the level of Extra Help you receive. Please contact the plan for further details. 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 medicare.gov or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call This information is available for free in other languages. Please call Member Services at (seven days a week, 8 a.m. to 8 p.m.). TTY users should call 711. Esta información está disponible gratis en otros idiomas. Por favor llame a nuestra Servicio a los Miembros al (los siete días de la semana, de 8 a. m. a 8 p. m.). Los usuarios de TTY deben llamar al , seven days a week, 8 a.m. to 8 p.m. (TTY 711)

19 Multi-language Interpreter Services English ATTENTION: If you speak [insert language], 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). Chinese 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: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). Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). Korean 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Armenian ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք (TTY (հեռատիպ) 711): Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). Japanese 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY:711) まで お電話にてご連絡ください Punjabi ਧਆਨ ਦਓ: ਜ ਤ ਸ ਪ ਜ ਬ ਬ ਲਦ ਹ, ਤ ਭ ਸ਼ ਵ ਚ ਸਹ ਇਤ ਸ ਵ ਤ ਹ ਡ ਲਈ ਮ ਫਤ ਉਪਲਬਧ ਹ (TTY: 711) 'ਤ ਕ ਲ ਕਰ H0524_H6050_H6052_17MLI accepted CA

20 Cambodian របយ ត ប ស ន អ កន យ ខ រ, ស ជ ន យ ផ ក យម នគ តឈ ល គ ច នស ប ប រ អ ក ច រ ទ រស ព (TTY: 711) Hmong LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau (TTY: 711). Hindi 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: 711) पर क ल कर Thai เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: 711). Farsi توجھ: اگر بھ زبان فارسی گفتگو می کنید تسھیلات زبانی باشد. با (711 (TTY: تماس بگیرید. بصورت رایگان برای شما می فراھم Arabic ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم: -117).

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24 Kaiser Foundation Health Plan, Inc. 393 E. Walnut St. Pasadena, CA Have questions? If you are not a member, please call (TTY 711) toll free. If you are a member, please call Member Services at (TTY 711) toll free, seven days a week, 8 a.m. to 8 p.m. kp.org/medicare Please recycle.