Centers Plan for Nursing Home Care (HMO SNP) 2018 Summary of Benefits

Transcription

1 Centers Plan for Nursing Home Care (HMO SNP) 2018 Summary of Benefits H6988_003_ENR1099_CY2018 Accepted

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3 Centers Plan for Nursing Home Care (HMO SNP) Summary of Benefits January 1, December 31, 2018 Bronx, Erie, Kings, New York, Niagara, Queens, Richmond, and Rockland Counties. H6988_003_ENR1099_CY2018 Accepted

4 My Primary Care Provider is: Name: Address: Phone number: My CPHL Representative is: Name: Phone number: IMPORTANT CONTACT INFORMATION Member Services is available 8:00 AM to 8:00 PM, seven days a week: PHONE: TTY users MAIL: Centers Plan for Healthy Living 75 Vanderbilt Avenue Suite 700 Staten Island, NY Memberservices@centersplan.com WEBSITE: 4

5 Table of Contents Section I: Introduction to the Summary of Benefits Section II: Summary of Benefits

6 Language Assistance Services Notification ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: ). KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në (TTY: ). ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم )رقم هاتف الصم والبكم : (. লক ষ য কর ন যদ আপদন ব ল, কথ বলত প ত ন, হতল দন খ চ য় ভ ষ সহ য় পদ তষব উপলব ধ আত ফ ন কর ন ১ (TTY: ১ ) 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: ) ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : ). ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε (TTY: ). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: ). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: ). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: ) 번으로전화해주십시오. UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: ). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). 6

7 PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). -خبردار :اگر آپ اردو بولتے ہيں تو آپ کو زبان کی مدد کی خدمات مفت ميں دستياب ہيں کال کريں (TTY: ). אויפמערקזאם :אויב איר רעדט אידיש,זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל.רופט (TTY: ) 7

8 Centers Plan for Nursing Home Care (HMO SNP) is designed to meet the needs of people who need a level of care that is usually provided in a nursing home. To be eligible for our plan you must live in one of our network nursing homes. We welcome all eligible individuals into our health care program. Anyone entitled to Medicare Parts A and B may apply. Discrimination is Against the Law Centers Plan for Healthy Living complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Centers Plan for Healthy Living does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Centers Plan for Healthy Living provides: Free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters. Written information in other formats (large print, audio, accessible electronic formats, other formats) Free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages If you need these services, contact Member Services at (TTY users please call ( or 711). If you believe that Centers Plan for Healthy Living 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 Grievances and Appeals Department: By Mail: Centers Plan for Healthy Living Attn: G&A Department 75 Vanderbilt Avenue Staten Island, NY By Phone: (TTY users call ) By Fax: By GandA@centersplan.com 8

9 You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Participant Services is available to help you seven days a week from 8am to 8pm. 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 https: /ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C , (TDD) Complaint forms are available at http: / 9

10 SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS 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 (like Centers Plan for Nursing Home Care (HMO SNP)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what Centers Plan for Nursing Home Care (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 Benefits booklets. Or, use the Medicare Plan Finder on http: / 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 http: / or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Sections in this booklet Things to Know About Centers Plan for Nursing Home Care (HMO SNP) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits This document is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call us at (877) (TTY/TDD ). Esta información está disponible gratis en otros idiomas. Comuníquese con nuestro Servicio para Miembros at para obtener información adicional, (los usuarios de TTY deben llamar al ) de 8:00 am a 8: pm siete días a la semana. Los Servicios para Miembros también tienen servicios de intérpretes de idiomas gratis disponibles para las personas que no hablan inglés. También podemos darles información en sistema Braille, en letra grande u otros formatos. Things to Know About Centers Plan for Nursing Home Care (HMO SNP) Hours of Operation You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. 10

11 Centers Plan for Nursing Home Care (HMO SNP) Phone Numbers and Website If you are a member of this plan, call toll-free (877) (TTY/TDD ). If you are not a member of this plan, call toll-free (877) (TTY/TDD ). Our website: http: / Who can join? To join Centers Plan for Nursing Home Care (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and, live in a nursing home and in our service area, in one of our network nursing home. Our service area includes the following counties in New York: Bronx, Erie, Kings, New York, Niagara, Queens, Richmond, and Rockland. Which doctors, hospitals, and pharmacies can I use? Centers Plan for Nursing Home Care (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 and pharmacy directory at our website ( com). Or, call us and we will send you a copy of the provider and pharmacy directories. 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. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. 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, http: / Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? The amount you pay for drugs depends on the drug you are taking 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, Coverage Gap, and Catastrophic Coverage. 11

12 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the monthly premium? $39.00 per month. In addition, you must keep paying your Medicare Part B premium. How much is the deductible? This plan has deductibles for some hospital and medical services, and Part D prescription drugs. $405 per year for Part D prescription drugs. Is there any limit on how much I will pay for my covered services? 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. Your yearly limit(s) in this plan: $6,700 for services you receive from innetwork 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. Please note that you will still need to pay your monthly premiums and costsharing for your Part D prescription drugs. Is there a limit on how much the plan will pay? Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. 12

13 SECTION II - SUMMARY OF BENEFITS Covered Medical and Hospital Benefits Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Benefit Category Monthly Plan Premium, including Part C and Part D Premium Medical deductible $0 Pharmacy (Part D) deductible Maximum Out-of-Pocket Responsibility (does not include prescription drugs) Nursing Home Care (HMO SNP) $39.00 per month for your Part D premium. $0.00 per month for your Part C premium. In addition, you must keep paying your Medicare Part B premium. $405 $6,700 Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 13

14 Benefit Category Inpatient Hospital Care 1 Outpatient Hospital Coverage Doctor Visits Primary Care Physician Specialists Nursing Home Care (HMO SNP) The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. 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. In 2017 the amounts for each benefit period were: $1,316 deductible for days 1 through 60 $329 coinsurance per day for days 61 through 90 $658 for days 91 and beyond per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime) These amounts may change for % of the cost Prior Authorization Required $0 copay Specialist visit: You pay 20% Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 14

15 Benefit Category Preventive Care Emergency Care Urgently Needed Services Nursing Home Care (HMO SNP) You pay nothing 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 (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screenings HIV screening 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. $75 copay If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. $30 copay If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for urgently needed services. Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 15

16 Benefit Category Diagnostic Services/Labs/ Imaging Hearing Services Dental Services Vision Services Nursing Home Care (HMO SNP) Diagnostic radiology services (such as MRIs, CT scans): 20% of the cost Diagnostic tests and procedures: $0 copay Lab services: $0 copay Outpatient x-rays: $0 copay (authorization required) Therapeutic radiology services (such as radiation treatment for cancer): 20% of the cost Exam to diagnose and treat hearing and balance issues: $0 copay Routine hearing exam (for up to 1 every year): $0 copay Hearing aid fitting/evaluation (for up to 1 every three years): $0 copay Hearing aid: $0 copay Our plan pays up to $600 per ear every three years for hearing aids. Not covered Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0 copay Routine eye exam (for up to 1 every year): $0 copay Eyeglasses (frames and lenses) (for up to 1 every two years): $0 copay Eyeglasses or contact lenses after cataract surgery: $0 copay Our plan pays up to $150 every two years for eyeglasses (frames and lenses). Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 16

17 Benefit Category Mental Health Services (including inpatient) Skilled Nursing Facility Rehabilitation Services Physical Therapy and Speech-language Pathology Services 1 Ambulance Transportation Nursing Home Care (HMO SNP) 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. The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. 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. In 2017 the amounts for each benefit period were: $1,316 deductible for days 1 through 60 $329 coinsurance per day for days 61 through 90 $658 for days 60 and beyond per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime) These amounts may change for Outpatient group therapy visit: $0 copay Outpatient individual therapy visit: $0 copay Medicare covered. $0 copay (Prior authorization required) $0 copay 20% of the cost If you are admitted to the hospital within 24 hours, you do not have to pay for the ambulance services. Prior authorization required for non-emergency services Not covered Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 17

18 Benefit Category Medical Part B Drugs Nursing Home Care (HMO SNP) For Part B drugs such as chemotherapy drugs 1 : 20% of the cost Other Part B drugs 1 : 20% of the cost Foot Care (podiatry services) Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $0 copay Routine foot care (for up to 4 visit(s) every year): $0 copay Medical Equipment/ Supplies Wellness Programs (e.g. Fitness) 20% of the cost Not Covered OUTPATIENT PRESCRIPTION DRUG Deductible $405 Initial Coverage Coverage Gap Catastrophic Coverage After you pay your yearly deductible, you pay 25% of the cost for all drugs covered by this plan until your total yearly drug costs reach $3,750. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. 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 at the same cost as an in-network pharmacy. Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,750. After you enter the coverage gap, you pay 45% of the plan's cost for covered brand name drugs and 44% of the plan's cost for covered generic drugs until your costs total $5,000, which is the end of the coverage gap. Not everyone will enter the coverage gap. After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $5,000, you pay the greater of: 5% of the cost, or $3.35 copay for generic (including brand drugs treated as generic) and a $8.35 copayment for all other drugs. Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 18

19 Benefit Category ADDITIONAL BENEFITS Chiropractic Care 1,2 Diabetes Supplies and Services 1 Home Health Care 1 Outpatient Rehabilitation 1 Outpatient Substance Abuse 1 Outpatient Surgery 1 Over-the-Counter Items Prosthetic Devices (braces, artificial limbs, etc.) 1 Renal Dialysis 1 Hospice Nursing Home Care (HMO SNP) Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $0 copay Prior authorization is required Diabetes monitoring supplies: 20% of the cost Diabetes self-management training: $0 copay Therapeutic shoes or inserts: 20% of the cost $0 copay Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $0 copay Occupational therapy visit: $0 copay Physical therapy and speech and language therapy visit: $0 copay Group therapy visit: 20% of the cost Individual therapy visit: 20% of the cost Ambulatory surgical center: 20% of the cost Outpatient hospital: 20% of the cost $10 monthly OTC debit card Prosthetic devices: 20% of the cost Related medical supplies: 20% of the cost 20% of the cost You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. Hospice is covered outside our plan. Please contact us for more details. Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 19

20 For more information, please contact us at the phone number listed below or visit us at You can see plan's Provider and Pharmacy Directory on our website You can also see our complete plan formulary (list of Part D prescription drugs) and any restrictions on our website at To contact the Member Services Department, call: If you re hearing impaired, call TTY: Department hours are 8 a.m. 8 p.m., 7 days a week. Centers Plan for Nursing Home Care (HMO SNP) is an HMO plan with a Medicare contract. Enrollment in Centers Plan for Nursing Home Care (HMO SNP) is dependent upon contract renewal. Benefits, formulary, pharmacy network, provider network, and co-payments/coinsurance may change on January 1 of each year. This information is not a complete description of benefits. Contact the plan for more information. Enrolled members must continue to pay their Medicare Part B premium if not otherwise paid for under Medicaid. You can read the Medicare & You 2018 Handbook. Every year in the fall, this booklet is mailed to people with Medicare. It has a summary of Medicare benefits, rights and protections, and answers to the most frequently asked questions about Medicare. If you don t have a copy of this booklet, you can get it at the Medicare website (http: / or by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call

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24 For More Information or to Enroll Call (toll free) TTY Users Seven days a week, 8am-8pm MemberServices@centersplan.com