SUMMARY OF BENEFITS. Cigna-HealthSpring. TotalCare (HMO SNP) H January 1, December 31, Cigna H5410_16_32684 Accepted

Transcription

1 SUMMARY OF BENEFITS January 1, December 31, 2016 Cigna-HealthSpring TotalCare (HMO H Cigna H5410_16_32684 Accepted

2 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. Sections in this booklet Things to Know About Cigna-HealthSpring TotalCare (HMO Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Cigna-HealthSpring TotalCare (HMO ). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what Cigna- HealthSpring TotalCare (HMO covers and what you pay. 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 and large print. If you want to compare our plan with other Medicare health plans, This document may be available in a ask the other plans for their Summary non-english language. For additional of Benefits booklets. Or, use the information, call us at Medicare Plan Finder on Este documento puede estar disponible en un idioma distinto al inglés. Para obtener información adicional, llámenos al

3 THINGS TO KNOW ABOUT CIGNA-HEALTHSPRING TOTALCARE (HMO Hours of Operation Which doctors, hospitals, and You can call us 7 days a week from pharmacies can I use? 8:00 a.m. to 8:00 p.m. Local time. Cigna-HealthSpring TotalCare (HMO has a network of doctors, Cigna-HealthSpring TotalCare hospitals, pharmacies, and other (HMO Phone Numbers providers. If you use the providers that and Website If you are a member of this plan, call toll-free If you are not a member of this plan, call toll-free Our website: 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. You can see our plan s provider and pharmacy directory at our website ( Who can join? Or, call us and we will send you a copy To join Cigna-HealthSpring TotalCare of the provider and pharmacy directories. (HMO, you must be entitled to Medicare Part A, be enrolled in Medicare What do we cover? Part B and Florida Department of Children Like all Medicare health plans, we cover and Families, and live in our service area. everything that Original Medicare covers - Our service area includes the following and more. counties in Florida: Bay, Escambia, Our plan members get all of Okaloosa, Santa Rosa, and Walton. the benefits covered by Original Medicare. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet.

4 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, 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. Or, call us and we will send you a copy of the formulary. SECTION II - SUMMARY OF BENEFITS Benefit Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the monthly premium? How much is the deductible? Is there any limit on how much I will pay for my covered services? Is there a limit on how much the plan will pay? $28.10 per month. In addition, you must keep paying your Medicare Part B premium. $0 to $74 per year for Part D prescription drugs. 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. In this plan, you may pay nothing for Medicare-covered services, depending on your level of Florida Department of Children and Families eligibility. Your yearly limit(s) in this plan: $6,700 for services you receive from in-network 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. Refer to the Medicare & You handbook for Medicare-covered services. For Florida Department of Children and Families-covered services, refer to the Medicaid Coverage section in this document. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal.

5 Benefit 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. Outpatient Care and Services Acupuncture Ambulance 1 Chiropractic Care 2 Dental Services 1 Diabetes Supplies and Services 2 Diagnostic Tests, Lab and Radiology Services, and X-Rays (Costs for these services may vary based on place of service) 1,2 Doctor s Office Visits 1,2 Not covered $0 or $225 copay or 0% or 20% of the cost, depending on the service Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): You pay nothing Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $0 copay Preventive dental services: Cleaning (for up to 1 every six months): $0 copay Dental x-ray(s) (for up to 1 every year): $0 copay Oral exam (for up to 1 every six months): $0 copay Comprehensive services: Restorative Fillings, Crowns: $10-$195 copay Periodontics: $10-$75 copay Extractions: $10-$75 copay Prosthodontics: $25-$195 copay Oral Surgery: $25-$195 copay Endodontics is not covered. Please see your EOC for plan coverage details. $1,000 plan coverage limit for comprehensive dental benefits every year. Diabetes monitoring supplies: 0-20% of the cost, depending on the supply Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: 0% or 20% of the cost Diagnostic radiology services (such as MRIs, CT scans): 0% or 20% of the cost Diagnostic tests and procedures: 0-20% of the cost, depending on the service Lab services: You pay nothing Outpatient x-rays: 0% or 20% of the cost Therapeutic radiology services (such as radiation treatment for cancer): 0% or 20% of the cost Primary care physician visit: You pay nothing Specialist visit: You pay nothing

6 Benefit Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Emergency Care Foot Care (podiatry services) 2 Hearing Services 2 Home Health Care 1 Mental Health Care 1 Outpatient Rehabilitation 1,2 Outpatient Substance Abuse 1 0% or 20% of the cost $0 or $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. See the Inpatient Hospital Care section of this booklet for other costs. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing 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 $500 every three years for hearing aids. Please see your EOC for plan coverage details. You pay nothing 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. 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. $0 or $245 copay per day for days 1 through 6 You pay nothing per day for days 7 through 90 Outpatient group therapy visit: You pay nothing Outpatient individual therapy visit: You pay nothing Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $0 or $10 copay Occupational therapy visit: You pay nothing Physical therapy and speech and language therapy visit: You pay nothing Group therapy visit: You pay nothing Individual therapy visit: You pay nothing

7 Benefit Outpatient Surgery 1,2 Over-the-Counter Items Prosthetic Devices (braces, artificial limbs, etc.) 1 Renal Dialysis 1,2 Transportation Urgently Needed Services Vision Services Ambulatory surgical center: $0 or $175 copay Outpatient hospital: $0 or $250 copay Please visit our website to see our list of covered over-the-counter items. Limited to $10 per month for specific over the counter drugs and other healthrelated pharmacy products, as listed in the OTC catalog. Prosthetic devices: 0% or 20% of the cost Related medical supplies: 0% or 20% of the cost 0% or 20% of the cost Not Covered You pay nothing 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 Contact lenses: $0 copay Eyeglasses (frames and lenses) (for up to 1 every year): $0 copay Eyeglass frames (for up to 1 every year): $0 copay Eyeglass lenses (for up to 1 every year): $0 copay Eyeglasses or contact lenses after cataract surgery: $0 copay Our plan pays up to $200 every year for eyewear. $0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance. Please see your EOC for plan coverage details.

8 Benefit Preventive Care Hospice 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. Annual physical exam: You pay nothing 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 of our plan. Please contact us for more details. Inpatient Care Inpatient Hospital Care 1,2 Inpatient Mental Health Care 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. $0 or $265 copay per day for days 1 through 6 You pay nothing per day for days 7 through 90 For inpatient mental health care, see the Mental Health Care section of this booklet.

9 Benefit Skilled Nursing Facility (SNF) 1 Our plan covers up to 100 days in a SNF. You pay nothing per day for days 1 through 20 $0 or $160 copay per day for days 21 through 100 Prescription Drug Benefits How much do I pay? Initial Coverage Catastrophic Coverage For Part B drugs such as chemotherapy drugs 1 : 0% or 20% of the cost Other Part B drugs 1 : 0% or 20% of the cost Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs, either: $0 copay; or $3.60 copay; or $7.40 copay. 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. After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay nothing for all drugs. Additional Plan Benefits 24-hour Nurse Line $0 copay for 24-hour Nurse Line Caring registered nurses are available by phone 24 hours a day, 7 days a week to answer your health questions in a confidential and convenient service. This plan is available to anyone who has both Medical Assistance from the State and Medicare. For full dual-eligible members the state will continue to pay your Medicare Part B premium. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

10 SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H5410, PLAN 013 This section demonstrates the Medicaid benefit package for full benefit dual-eligible recipients in the state of Florida. The services offered in your Medicaid benefit package are based on your Medicaid eligibility level (Categorically Needy or Medically Needy). Medicare coverage must be used first and the Medicaid Program may cover payment of Medicare Part A and B deductible and coinsurance for all Medicare covered services. The services listed below are available only to those SNP members eligible under Medicaid for medical services. If you are eligible for both Medicare and Medicaid, you will not be held liable for Medicare Part A and B cost sharing when the state is responsible for paying these amounts. For more information about your Medicaid benefits and copayments, please contact the State Medicaid Office. The benefits described below are covered by Medicaid. 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 Florida Medicaid covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. The Florida Department of Children and Families (DCF) ACCESS Program phone number: and the Florida Agency for Health Care Administration: Benefit Category (Excludes Assistive Care Assistive care services (ACS) provides Authorization rules may apply. Services care to eligible recipients living in In-Network congregate living facilities and requiring integrated services on a 24- hour per Plan covers up to 100 days each benefit day basis. period This includes residents of licensed No prior hospital stay is required. assisted living facilities (ALFs), adult For Medicare-covered SNF stays, $0 to family care homes (AFCHs) and Days 1-20: $0 copay per day residential treatment facilities (RTFs). Days : $160 copay per day $0 copay.

11 Birth Center Services Birth centers are licensed facilities that This benefit is not covered. provide obstetrical, gynecological, and family planning services. There is a $2 recipient copayment for gynecological services, per provider, per day, unless the recipient is exempt. Chiropractic Services Chiropractic services include a new In-Network patient visit, manual manipulation of the Referral from your Primary Care spine, and spinal X-rays. The new Physician (PCP) is required. patient visit consists of a screening and any required manual manipulation of the $0 copay for each Medicare-covered spine. chiropractic visit There is a $1 recipient copayment for Medicare-covered chiropractic visits are chiropractic services, per provider, per for manual manipulation of the spine to day, unless the recipient is exempt. correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor.

12 Community Community behavioral health services Inpatient Mental Health: Behavioral Health include mental health and substance In-Network Services abuse services and are provided for the maximum reduction of the recipient s Authorization rules may apply. mental health or substance abuse You get up to 190 days of inpatient disability and restoration to the best psychiatric hospital care in a lifetime. possible functional level. Services can Inpatient psychiatric hospital services reasonably be expected to improve the count toward the 190-day lifetime recipient s condition or prevent further limitation only if certain conditions are regression so that the services will no met. This limitation does not apply to longer be needed. inpatient psychiatric services furnished Community behavioral health services in a general hospital. include assessments, treatment For Medicare-covered hospital stays, $0 planning, medical and psychiatric to services, individual, group and family Days 1-6: $245 copay per day therapies, community support and Days 7-90: $0 copay per day rehabilitative services, therapeutic Except in an emergency, your doctor behavioral onsite services for children must tell the plan that you are going to and adolescents, as well as therapeutic be admitted to the hospital. foster care and group care services. Outpatient Mental Health: Access to these services for recipients in managed care does not require a In-Network referral from a PCP. $0 copayment for each Medicare- There is a $2 recipient copayment for covered individual therapy visit. community behavioral health services, $0 copayment for each Medicareper provider, per day, unless the covered group therapy visit. recipient is exempt. $0 copayment for each Medicarecovered individual therapy visit with a psychiatrist. $0 copayment for each Medicarecovered group therapy visit with a psychiatrist. $0 copay for Medicare-covered partial hospitalization program services Outpatient Substance Abuse: In-Network $0 copayment for Medicare-covered individual substance abuse outpatient treatment visits. $0 copayment for Medicare-covered group substance abuse outpatient treatment visits.

13 County Health County health departments (CHDs) are In-Network Department (CHD) administered by the Department of Authorization rules may apply. Clinic Services Health for the purpose of providing public health services. CHD Referral from your Primary Care clinics may also provide medically necessary Physician, (PCP) may be required. primary and preventative outpatient $0 copay for each Medicare-covered health care depending on the location of primary care doctor visit. the CHD. Services are performed by $0 copay for each Medicare-covered physicians, dentists, dental hygienists, specialist visit. registered nurses, advanced registered nurse practitioners, and physician assistants. $0 copay Dental Services Medicaid reimburses for limited adult In-Network dental services when rendered by a Authorization rules may apply. dentist enrolled in Medicaid. Acute emergency dental procedures to $0 copay for Medicare-covered dental alleviate pain or infection, dentures and benefits denture-related procedures are provided Preventive dental services: to recipients 21 years of age and older. Cleaning (for up to 1 every six Adult dental services include: months): $0 copay Comprehensive oral evaluation Dental X-ray(s) (for up to 1 every Denture-related procedures year): $0 copay Full dentures and removable partial Oral exam (for up to 1 every six dentures months): $0 copay Incision and drainage of an abscess Comprehensive services: Necessary radiographs to make a Restorative Fillings, Crowns: $10- diagnosis $195 copay Problem-focused oral evaluation Periodontics: $10-$75 copay Adult Medicaid recipients are Extractions: $10-$75 copay responsible for a five percent Prosthodontics: $25-$195 copay coinsurance charge for all procedures Oral Surgery: $25-$195 copay related to denture services, unless Endodontics is not covered. exempt. Please see your EOC for plan coverage details. $1,000 plan coverage limit for dental benefits every year

14 Durable Medical Durable Medical Equipment (DME) is In-Network Equipment (DME) and equipment that can be used repeatedly, Authorization rules may apply. Medical Supplies serves a medical purpose, and is 0% to 20% of the appropriate for use in the patient s cost for Medicare- home. covered durable medical equipment Medical supplies are medical or surgical items that are consumable, expendable, disposable or non-durable, and are appropriate for use in the patient s home. $0 copay Federally Qualified A federally qualified health center In-Network Health Center (FQHC) (FQHC) is a clinic that is receiving a Authorization rules may apply. grant from the Public Health Service to provide medical care in a medically Referral from your Primary Care underserved population. The clinic may Physician, (PCP) may be required. be located in either a rural or urban $0 copay for each Medicare-covered area. FQHCs provide primary and primary care doctor visit. preventive outpatient health care. $0 copay for each Medicare-covered FQHC services are performed by specialist visit. advanced registered nurse practitioners, chiropractors, clinical psychologists, clinical social workers, dentists, optometrists, physicians, physician assistants, and podiatrists. There is a $3 recipient copayment for FQHC services, per clinic, per day, unless the recipient is exempt. Freestanding Dialysis Freestanding dialysis center services In-Network Center Services include in-center hemodialysis, in-center Authorization rules may apply. administration of the injectable medication Erythropoietin (Epogen or Referral from your Primary Care EPO), other Agency approved drugs, Physician (PCP) may be required. and home peritoneal dialysis. These 0% to 20% of the cost for Medicareservices must be provided under the covered renal dialysis supervision of a physician licensed to $0 copay for Medicare-covered kidney practice allopathic or osteopathic disease education services medicine in Florida. The dialysis treatment includes routine laboratory tests, dialysis-related supplies, and ancillary and parenteral items. $0 copay.

15 Hearing Services Medicaid reimburses for hearing In-Network services rendered by licensed, Referral from your Primary Care Medicaid-participating otolaryngologists, Physician may be required. otologists, audiologists, and hearing aid specialists. Exam to diagnose and treat hearing and balance issues: $0 copay Medicaid reimbursable hearing services include: Routine hearing exam (for up to 1 every year): $0 copay Cochlear implant services. Diagnostic audiological testing. Hearing aid fitting/evaluation (for up to 1 Hearing aid fitting and dispensing. every three years): $0 copay Hearing aid repairs and accessories. Hearing aid: $0 copay Hearing aids. Our plan pays up to $500 every three Hearing evaluations to determine years for hearing aids. hearing aid candidacy. Please see your EOC for plan coverage Mandatory newborn hearing details. screening. $0 copay Home Health Home Health Services are provided in a In-Network Services recipient s home or other authorized Authorization rules may apply. setting to promote, maintain or restore health, or to minimize the effects of $0 copay for Medicare-covered home illness and disability. Medicaid health visits reimburses for home health services rendered by licensed, Medicaidparticipating home health agencies. Medicaid reimbursable services include: Home visit services provided by a registered nurse or a licensed practical nurse. Home visits provided by a qualified home health aide. Medical supplies, appliances, and durable medical equipment. Private duty nursing. Personal care services. Therapy services (occupational and physical therapy and speechlanguage pathology). There is a $2 recipient copayment for home health services, per provider, per day, unless the recipient is exempt.

16 Hospice Services Hospice Services are forms of palliative You must get care from a Medicarehealth care and supportive services for certified hospice. terminally ill patients and their families. You must consult with your plan before The services are administered by a you select hospice. hospice agency and coordinated by the hospice nurse assigned to the patient. Hospice employs an interdisciplinary team to meet the special needs arising out of the physical, emotional, spiritual, and social stresses associated with the final stages of illness, during end of life, and bereavement. Medicaid reimburses Medicaidparticipating hospice providers who are licensed by the Agency and meet the requirements to participate in Medicare. Medicaid-covered services include: Hospice care provided by the designated hospice. Direct care services of a hospice physician. Nursing facility room and board. Patient responsibility depends on the amount of income and spouse/dependent(s). Hospital Services Medicaid reimburses licensed, Medicaid- In-Network Inpatient participating hospitals for inpatient Authorization rules may apply. services. The services must be provided under the direction of a licensed Referral from your Primary Care physician or dentist. Physician, (PCP) may be required. Medicaid reimbursement for inpatient For Medicare-covered hospital stays, $0 hospital services include room and to board, medical supplies, diagnostic and Days 1-6: $265 copay per day therapeutic services, use of hospital Days 7-90: $0 copay per day facilities, drugs and biological, nursing Except in an emergency, your doctor care, and all supplies and equipment must tell the plan that you are going to necessary to provide the appropriate be admitted to the hospital. care and treatment of patients. There is a $3 recipient copayment for each admission to a hospital, unless the recipient is exempt.

17 Hospital Services Outpatient hospital services are Authorization rules may apply. Outpatient preventive, diagnostic, therapeutic or Referral from your Primary Care palliative care, and service items Physician, (PCP) may be required. provided in an outpatient setting. The $0 to $175 copay for each Medicareservices must be provided under the direction of a licensed physician or dentist. Medicaid reimburses licensed, Medicaidparticipating hospitals for outpatient services. Medicaid reimbursement includes medical supplies, nursing care, therapeutic services, and pharmacy services. Primary care services provided in an outpatient hospital setting, hospital-owned clinic, or satellite facility are not considered outpatient hospital services and are not reimbursable under the Florida Medicaid (Title XIX) Outpatient Hospital Reimbursement Plan. There is a five percent coinsurance on the first $300 of a Medicaid payment for an emergency room visit to receive nonemergency services not to exceed $15, unless the recipient is exempt. covered ambulatory surgical center visit $0 to $250 copay for each Medicarecovered outpatient hospital facility visit Independent Independent laboratory services are In-Network Laboratory Services clinical laboratory procedures performed Authorization rules may apply. in freestanding laboratory facilities. A physician or other licensed health care Referral from your Primary Care practitioner authorized within the scope Physician, (PCP) may be required. of practice to order clinical laboratory 0% of the cost for Medicare-covered lab tests must authorize the services. services There is a $1 recipient copayment for independent laboratory services, per provider, per day, unless the recipient is exempt.

18 Intermediate Care Medicaid reimburses for services This benefit is not covered. Facility Services for rendered by state owned and operated the Developmentally intermediate care facilities for the Disabled developmentally disabled (ICF/DD). Medicaid reimbursement for ICF/DD services includes the following: Basic wardrobe Dental care Food and food supplements Medical supplies, durable medical equipment, eyeglasses, and hearing aids Nursing services Rehabilitative care Room and board Training and help with daily living skills Therapy Transportation The per diem includes all services and items necessary to ensure appropriate care. The amount paid by Medicaid is the difference between the ICF/DD facility s Medicaid rate and the resident s patient responsibility. The patient responsibility is prorated on a daily basis. The facility may charge the recipient the difference in cost between a stocked and requested item.

19 Licensed Midwife Medicaid reimburses Medicaid- This benefit is not covered. Services participating, licensed midwives for obstetrical care services rendered to women during the antepartum and postpartum phases of pregnancy and home deliveries. Medicaid reimbursable services include the following: Initial comprehensive and prenatal examinations Labor management for recipients who transfer to a hospital Newborn assessment Post delivery examinations Post delivery recovery Related pregnancy services Vaginal delivery $0 copay

20 Mental Health The purpose of mental health targeted Inpatient Mental Health: Targeted Case case management is to assist recipients In-Network Management in gaining access to needed medical, Services social, educational, and other services. Authorization rules may apply $0 copay You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. For Medicare-covered hospital stays, $0 to Days 1-6: $245 copay per day Days 7-90: $0 copay per day Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. Outpatient Mental Health: In-Network $0 copayment for each Medicarecovered individual therapy visit. $0 copayment for each Medicarecovered group therapy visit. $0 copayment for each Medicarecovered individual therapy visit with a psychiatrist. $0 copayment for each Medicarecovered group therapy visit with a psychiatrist. $0 copay for Medicare-covered partial hospitalization program services

21 Nursing Facility Nursing facility services are 24-hour-a- In-Network Services day nursing and rehabilitation services Authorization rules may apply. provided in a facility that is licensed and certified by the Agency to participate in Plan covers up to 100 days each benefit the Medicaid program. The nursing period facility must have their beds certified by No prior hospital stay is required. the Agency to participate in the Medicaid For Medicare-covered SNF stays, $0 to program. Nursing facility services may Days 1-20: $0 copay per day include reimbursement for swing bed services provided in a rural acute care Days : $160 copay per day hospital, and skilled nursing services provided in a hospital-based, skilled nursing unit. Based upon the recipient s income, each recipient may have a patient responsibility amount determined by DCF. Optometric Services Medicaid reimburses for optometric In-Network services rendered by licensed, $0 copay for Medicare-covered Medicaid-participating optometrists and diagnosis and treatment for diseases ophthalmologists. and conditions of the eye Medicaid reimbursable services include: $0 copay for up to 1 supplemental Consultation and referral services. routine eye exam every year Evaluation and management services. $0 copay for Eye examinations, when there is a reported vision problem, illness, one pair of Medicare-covered disease, or injury. eyeglasses or contact lenses after General and special ophthalmologic cataract surgery services. up to 1 pair of glasses every year Medical and surgical services within contacts the optometrist s scope of practice. $200 plan coverage limit for eye wear Pathology and laboratory services. every year. Post-operative management. Services provided in a custodial care $0 copays for supplemental eyewear facility. (except after cataract surgery) apply up Services provided in a nursing facility. to the plan allowance. Please see your EOC for plan coverage details. There is a $2 recipient copayment for optometric services, per provider, per day, unless the recipient is exempt.

22 Physician Services Medicaid reimburses for services In-Network rendered by licensed, Medicaid- Authorization rules may apply. participating doctors of allopathic or osteopathic medicine. Services may be Referral from your Primary Care rendered in the physician s office, the Physician, (PCP) may be required. patient s home, a hospital, a nursing $0 copay for each Medicare-covered facility, or other approved place of primary care doctor visit. service as necessary to treat a particular $0 copay for each Medicare-covered injury, illness, or disease. specialist visit. There is a $2 recipient copayment for physician services, per provider, per day, unless the recipient is exempt. Physician Assistant Medicaid reimburses for services In-Network Services provided by licensed, Medicaid- Authorization rules may apply. participating physician assistants. Referral from your Primary Care There is a $2 recipient copayment for Physician, (PCP) may be required. physician assistant services, per provider, per day, unless the recipient is $0 copay for each Medicare-covered exempt. primary care doctor visit. $0 copay for each Medicare-covered specialist visit. Podiatry Services Medicaid reimburses for podiatry In-Network services rendered by licensed Referral from your Primary Care podiatrists, as defined in Chapter 461, Physician, (PCP) may be required. Florida Statutes, who are participating in Medicaid. $0 copay for Medicare-covered podiatry visits Medicare-covered podiatry visits Services can be provided in the are for medically-necessary foot care. podiatrist s office, inpatient hospital, outpatient or emergency department of a hospital, ambulatory surgical center, nursing facility, intermediate care facility for the developmentally disabled, boarding home, recipient s home, or other custodial facility. There is a $2 recipient copayment for podiatry services, per provider, per day, unless the recipient is exempt.

23 Portable X-ray Portable X-ray services are interpretive This benefit is not covered. Services and technical mobile X-ray services that are provided at the recipient s residence. A physician or other licensed health care practitioner authorized within the scope of practice to order X-rays must authorize the services. There is a $1 recipient copayment for portable X-ray services, per provider, per day, unless the recipient is exempt. Prescribed Drug Medicaid reimburses licensed, Medicaid Drugs covered under Medicare Part B Services enrolled pharmacy providers for most Authorization rules may apply. prescription drugs used in outpatient settings. Prescribed Drug Services also $0 yearly deductible for Medicare Part B reimburses for some injectable drugs drugs. and specific over-the-counter medications. Most drugs included on the Medicaid Preferred Drug List (PDL) are available without prior authorization (PA). However, some drugs listed on the PDL require a clinical PA. Drugs not listed on the PDL require prior authorization and may involve step therapy trials of PDL products. Over-the-counter drugs include: Aluminum and calcium products used as phosphate binders and multivitamin supplements for dialysis patients. Aspirin when prescribed as an antiinflammatory agent. Guaifenesin as a single entity expectorant, in either liquid or solid dosage form. Insulin. Sodium chloride solution for inhalation. Specified iron supplements. Specified smoking cessation products. Vaginal antifungal creams. 0% to 20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs. Drugs covered under Medicare Part D In-Network Deductible: $0 to $74 per year for Part D prescription drugs. Initial Coverage Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: A $0 copay or A $1.20 copay or A $2.95 copay For all other drugs, either: A $0 copay or A $3.60 copay or A $7.40 copay.

24 Prescribed Drug For institutionalized recipients, all over- Services the-counter drugs, supplies, food (continued) supplements, and vitamins are considered nursing home floor stock and are not reimbursable under Medicaid prescribed drug services. Medicaid does not reimburse pharmacies for the following products: Appetite suppressants (unless prescribed for an indication other than obesity). Cough and cold combination medications for recipients 21 years of age and older. Drug Efficacy Study Implementation ineffective drugs as designated by the Centers for Medicare and Medicaid Services. For more information, visit the Agency s Medicaid website at com/medicaid/prescribed_ Drug/current_info.shtml. Drugs for patients who are hospitalized or being treated in outpatient hospital facilities or ambulatory surgical centers. Drugs to treat the terminal condition of hospice recipients. Drugs used to treat infertility. Experimental drugs. Erectile dysfunction drugs. Floor stock items required to be furnished by institutions.

25 Prescribed Drug Services (continued) Hair growth restorers and other drugs for cosmetic use. Immunizations for non-child Health Check-Up recipients 21 years of age and older, except for influenza, herpes zoster virus (shingles), and pneumococcal vaccines for institutionalized recipients. Prostheses, appliances and devices. Vitamins (except prenatal vitamins for pregnant and lactating women and folic acid as a single entity, one vitamin or vitamin/mineral prescription monthly for dialysis patients, and fluoridated pediatric vitamins for children 12 years of age or younger) and prescribed ferrous sulfate, gluconate, or fumarate for noninstitutionalized patients (ferrous sulfate, gluconate, or fumarate are available as floor stock to institutionalized patients). All other over-the-counter products not specified above. Medicaid does not reimburse for drugs not included in a manufacturer s rebate agreement. Drugs must be prescribed for medically accepted indications. $0 copay Program of All- The Program of All-Inclusive Care for This benefit is not covered. Inclusive Care for the Elderly (PACE) provides a the Elderly (PACE) comprehensive range of medical and home and community-based services for individuals who would otherwise qualify for placement in a nursing home. PACE was established in 2002 and is operated by the Department of Elder Affairs (DOEA).

26 Registered Nurse Medicaid reimburses for services In-Network First Assistant provided by licensed, Medicaid- Authorization rules may apply. (RNFA) Services participating registered nurse first assistants (RNFA). Referral from your Primary Care Physician, (PCP) may be required. There is a $2 recipient copayment for RNFA services, per provider, per day, $0 copay for each Medicare-covered unless the recipient is exempt. primary care doctor visit. $0 copay for each Medicare-covered specialist visit. Rural Health Clinic A rural health clinic (RHC) is a clinic that This benefit is not covered. (RHC) Services is located in a rural area with a shortage of health care providers. RHCs provide medically necessary primary and preventive outpatient health care. RHC services are performed by advanced registered nurse practitioners, chiropractors, clinical psychologists, clinical social workers, optometrists, physicians, physician assistants, and podiatrists. Medicaid reimburses RHCs for the following services: Adult health screening services Chiropractic services Family planning services and family planning waiver services Immunizations Medical primary care services, including obstetrical care Mental health services Optometric services Podiatry services There is a $3 recipient copayment for RHC services, per clinic, per day, unless the recipient is exempt. School-Based School districts may enroll as providers This benefit is not covered. Services Programs of a variety of Medicaid services. When School District the school district employs or contracts Program with staff who provide health care, the school district can enter into a provider agreement with Medicaid and receive the federal share of Medicaid payments for providing Medicaid-covered services to Medicaid eligible children. $0 copay.

27 School-Based County health departments (CHDs) may This benefit is not covered. Services Programs enroll as providers of a variety of nursing County Health and master s degree level social work Department services in public schools. A CHD that (CHD) Program employs or contracts with nurses who provide nursing services, and master s level degree social workers who provide social work services, can receive reimbursement for the federal share of Medicaid payments. $0 copay. State Mental Health The purpose of the Medicaid State In-Network Hospital Services Mental Health Hospital Program is to Authorization rules may apply. provide medically necessary, long-term inpatient mental health services to You get up to 190 days of inpatient recipients 65 years of age or older. psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services Residents of state mental health count toward the 190-day lifetime hospitals receive physician, nursing, limitation only if certain conditions are dietary, pharmaceutical, personal care, met. This limitation does not apply to rehabilitative, and restorative services. inpatient psychiatric services furnished Specific service criteria must be met in a general hospital. prior to the services being rendered. Each service must be medically For Medicare-covered hospital stays, $0 necessary. to $0 copay. Days 1-6: $245 copay per day Days 7-90: $0 copay per day Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.

28 Therapy Services Occupational therapy addresses the In-Network - Occupational functional needs of an individual related Authorization rules may apply. to the performance of self-help skills, adaptive behavior, and sensory, motor, Referral from your Primary Care and postural development. Physician, (PCP) may be required. Medicaid reimburses for occupational $0 copay for Medicare-covered therapy services provided by licensed, Occupational Therapy visits Medicaid-participating occupational therapists and by supervised, occupational therapy assistants. Medicaid reimbursable services include evaluation and treatment to prevent or correct physical and emotional deficits, or to minimize the disabling effect of these deficits. Typical activities are perceptual motor activity exercises to enhance functional performance, kinetic movement, guidance in the use of adaptive equipment, and other techniques related to improving motor development. Services are available in the home or other appropriate setting. $0 copay.

29 Therapy Services Physical therapy addresses the In-Network - Physical development, improvement, or Authorization rules may apply. restoration of neuromuscular or sensory Referral from your Primary Care motor function, relief of pain, or control of postural deviation to attain maximum performance. Medicaid reimburses for physical therapy services provided by licensed, Medicaid-participating physical therapists, and by supervised physical therapy assistants. Medicaid reimbursable services include the evaluation and treatment related to range-of-motion, muscle strength, functional abilities, and the use of adaptive or therapeutic equipment. Activities include rehabilitation through exercises, massage, the use of equipment, and rehabilitation through therapeutic activities. These services are available in the home or other appropriate setting for children 20 years of age or younger. Services for adults are only available in a hospital outpatient setting. $0 copay Physician, (PCP) may be required. $0 copay for Medicare-covered Physical Therapy and/ or Speech and Language Pathology visits Therapy Services Respiratory therapy is the evaluation Authorization rules may apply. - Respiratory and treatment of pulmonary dysfunction. Referral from your Primary Care Medicaid reimbursable services include Physician, (PCP) may be required. ventilator support, therapeutic use of medical gases, respiratory rehabilitation, $0 to $10 copayment for each Medicare- covered pulmonary rehabilitative therapy management of life support systems, bronchopulmonary drainage, breathing visit exercises, and chest physiotherapy. Medicaid reimburses for respiratory therapy services that are personally rendered by licensed registered respiratory therapists. These services are available in the home or other appropriate setting. $0 copay

30 Therapy Services Speech-language pathology services In-Network Speech-Language involve the evaluation and treatment of Authorization rules may apply. Pathology speech-language disorders. Medicaid reimburses for speech-language Referral from your Primary Care pathology services provided by licensed, Physician, (PCP) may be required. Medicaid-participating speech-language $0 copay for Medicare-covered Physical pathologists, and by supervised speech- Therapy and/ or Speech and Language language pathologist assistants. Pathology visits These services are available in the home or other appropriate setting. Speech-language pathology services may be rendered to a group of children. $0 copay. Transplant Services Bone marrow transplantation is Authorization rules may apply. Organ and performed for the treatment of certain Referral from your Primary Care Bone Marrow types of cancers and aplastic anemias. Physician, (PCP) may be required. Solid organ transplantation is performed for failure of the organ due to illness. Under certain conditions, the following Medicaid reimburses for organ and bone types of transplants are covered: marrow transplantation provided by corneal, kidney, kidney-pancreatic, transplant physicians in designated heart, liver, lung, heart/lung, bone transplant centers. marrow, stem cell, and intestinal/multivisceral. Medicaid coverage of transplant procedures is established in consultation If our plan provides transplant services with the Organ Transplant Advisory at a distant location (outside of the Council, the Bone Marrow Transplant service area) and you chose to obtain Advisory Panel, and Medicaid medical transplants at this distant location, we consultants. will arrange or pay for appropriate lodging and transportation costs for you Acceptance as a candidate for covered and a companion. transplant services is determined by the designated transplant hospital, not by Medicaid. Pre-transplant and posttransplant care, including immunosuppressive medications, is reimbursed even if the transplant is not a Medicaid-covered transplant. $0 copay

31 Transportation Non-emergency medical transportation Non-Emergency Transportation: Services (NEMT) services are defined as This benefit is not covered. medically necessary transportation for a recipient and a personal care attendant Medical Emergency Transportation: or escort, if required, who have no other In-Network means of transportation available to any Authorization rules may apply. Medicaid compensable service location 0% to 20% coinsurance for each oneto receive treatment, medical evaluation, way Medicare-covered air ambulance or therapy. trip Medicaid emergency transportation $0 to $225 copay for each one-way services provide medically necessary Medicare-covered ground ambulance emergency ground or air ambulance trip transportation to Medicaid eligible recipients. Necessary emergency transportation services are reimbursed as Medicaid fee-for service for all recipients not enrolled in a health plan that covers transportation. There is a $1 recipient copayment for transportation services for each one-way trip, unless the recipient is exempt. Round trips require two copayments. There is no copay for Medicaid emergency transportation services. Visual Services Medicaid reimburses for medically In-Network necessary visual services rendered by $0 copay for Medicare-covered licensed, Medicaid-participating diagnosis and treatment for diseases ophthalmologists, optometrists, and and conditions of the eye opticians enrolled as visual services providers. $0 copay for up to 1 supplemental routine eye exam every year Medicaid reimbursable services include eyeglasses, eyeglass repairs as $0 copay for required, prosthetic eyes, and medically one pair of Medicare-covered necessary contact lenses. Providers eyeglasses or contact lenses after may use the Central Optical Laboratory, cataract surgery managed by Prison Rehabilitative up to 1 pair of glasses every year Industries and Diversified Enterprises contacts (PRIDE), for services to Medicaid $200 plan coverage limit for eye wear recipients. every year. For visual services rendered by an optometrist or ophthalmologist, a copayment of $2 per day, per provider, per recipient is required, unless otherwise exempt.