2018 SUMMARY OF BENEFITS. january 1, december 31, 2018 ALOHACARE ADVANTAGE PLUS (HMO SNP)

Transcription

1 ALOHACARE ADVANTAGE PLUS 2018 SUMMARY OF BENEFITS january 1, december 31, 2018 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. H5969_109901_18 ACCEPTED

2 Summary of Benefits AlohaCare Advantage Plus H5969, Plan 002 This is a summary of drug and health services covered by AlohaCare Advantage Plus (HMO-SNP). January 1, 2018 December 31, 2018 AlohaCare Advantage Plus is an HMO SNP with a Medicare contract and a contract with the Hawaii Medicaid program. Enrollment in AlohaCare Advantage Plus depends on contract renewal. This plan is available to anyone who has both Medical Assistance from the State and Medicare. To join AlohaCare Advantage Plus, you must be entitled to Medicare Part A, be enrolled in Medicare Part B and QUEST Integration Program (Medicaid), and live in our service area. The islands in our service area include the following: Hawaii, Oahu, Lanai, Molokai, Kauai, and Maui. You must continue to pay your Medicare Part B premium. Premiums, copayments, coinsurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. To get a complete list of services we cover, please request the Evidence of Coverage. You can view the Evidence of Coverage at our website ( Or, call us and we will send you a copy of the Evidence of Coverage. H5969_109901_18 Page 1

3 Monthly Premium, Deductible, and Maximum Out-of-Pocket Monthly Plan Premium You pay $0. You must continue to pay your Medicare Part B Premium. Deductible You pay nothing. This plan does not have a deductible. Maximum Out-of-Pocket Responsibility (does not include prescription drugs) $6,700 annually. The most you pay for copays, coinsurance and other costs for medical services for the year. Services that are covered for you Inpatient Hospital Coverage* What you must pay when you get these services You pay nothing. What you should know Plan covers 90 days each benefit period. Outpatient Hospital Coverage Doctor Office Visits Primary Specialists You pay nothing. You pay nothing. Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor s order. The day before you are discharged is your last inpatient day. We cover medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. Preventive Care You pay nothing. Any additional preventive services approved by Medicare during the contract year will be covered. Emergency Care You pay nothing. A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse. World-wide benefit You pay $0 copay and any amounts over $1000 Services with an * may require a prior authorization. Page 2 An annual maximum benefit limit of $1000 is covered for emergency or urgent care services you receive

4 Services that are covered for you Urgently Needed Services World-wide benefit Diagnostic Tests, Lab and Radiology Services, and x-rays* (Costs for these services may vary based on place of service) Hearing Services* Dental Services What you must pay when you get these services You pay nothing. You pay $0 copay and any amounts over $1000 You pay nothing. $0 copay. $0 copay for preventive dental benefits. What you should know outside of the U.S. You will have to pay the facility or provider for Receipts must be in English with billed charges in U.S. dollars. AlohaCare Advantage Plus will reimburse you up to your benefit limit. Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services may be furnished by network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible. An annual maximum benefit limit of $1000 is covered for emergency or urgent care services you receive outside of the U.S. You will have to pay the facility or provider for Receipts must be in English with billed charges in U.S. dollars. AlohaCare Advantage Plus will reimburse you up to your benefit limit. Diagnostic radiology services (such as MRIs, CT scans). Diagnostic tests and procedures. Lab Service. Outpatient x-rays. Therapeutic radiology services (such as radiation treatment for cancer). Exam to diagnose and treat hearing and balance issues. $2000 plan coverage limit for preventive and restorative dental services each year Preventive dental benefits: - Cleaning (for up to 2 every year); - Dental x-ray(s) (for up to 2 every year; - Oral exam (for up to 2 every year); $0 copay for restorative dental benefits. Services with an * may require a prior authorization. Restorative dental services: - Endodontics (root canals) - Extractions (removal of teeth) Page 3

5 Services that are covered for you What you must pay when you get these services What you should know - Prosthodontics (dentures, crowns, veneers) - Periodontics (implants) - Other (oral/maxillofacial surgery) Vision Services You pay nothing. Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening). Mental Health Care* You pay nothing. Eyeglasses or contact lenses after cataract surgery. Inpatient Visit: Plan covers up to 190 day lifetime limit for inpatient services in a psychiatric hospital. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. The 190-day limit does not apply to mental health services provided in a psychiatric unit of a general hospital. Outpatient group therapy visit. Outpatient Individual therapy visit. Skilled Nursing Facility (SNF)* Physical Therapy (Outpatient Rehabilitation Services) You pay nothing. You pay nothing. You pay nothing. You pay nothing. Services with an * may require a prior authorization. Page 4 Outpatient Visit: Covered services include mental health services provided by a state-licensed psychiatrist or doctor, clinical psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or other Medicare-qualified mental health care professional as allowed under applicable state laws. Our plan covers up to 100 days in a SNF. Outpatient Rehabilitation Services includes physical therapy, occupational therapy, and speech and language therapy. Ambulance* You pay nothing. Covered ambulance services include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide care only if they are furnished to a member whose medical condition is such that other means of transportation could endanger the person s health or if authorized by the plan.

6 Services that are covered for you Transportation What you must pay when you get these services Not Covered. What you should know Non-emergency transportation by ambulance is appropriate if it is documented that the member s condition is such that other means of transportation could endanger the person s health and that transportation by ambulance is medically required. Medicare Part B Drugs You pay nothing. For Part B drugs such as chemotherapy drugs * Foot Care (podiatry services)* You pay nothing. Other Part B drugs * Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: Routine foot care (for up to 8 visit(s) every year) Over-the-Counter Items You pay nothing. The plan provides $75 credit every three months. Delivery services may be available when medically necessary and prior authorized. Services with an * may require a prior authorization. Please visit our website to see our list of covered over-the-counter items. Page 5

7 Prescription Drug Benefits Stage 1 Yearly Deductible Stage Because there is no deductible for the plan, this payment stage does not apply to you. If you receive Extra Help to pay your prescription drugs, this payment stage does not apply to you. Stage 2 Initial Coverage Stage You begin in this stage when you fill your first prescription of the year. During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost. You stay in this stage until your year-to-date out-of-pocket costs (your payments) reach $5,000. Stage 3 Coverage Gap Stage Because there is no coverage gap for the plan, this payment stage does not apply to you. Stage 4 Catastrophic Coverage Stage During this stage, the plan will pay all of the costs of your drugs for the rest of the calendar year (through December 31, 2018) Cost Sharing Generic Drugs Standard retail cost-sharing (innetwork) (up to a 30-day supply) $0 copay or $1.25 copay or $3.35 copay Mail-order costsharing (up to a 90-day supply) $0 copay or $3.75 copay or $10.05 copay Long-term care (LTC) costsharing (up to a 31-day supply) $0 copay or $1.25 copay or $3.35 copay Out-of-network cost-sharing (Coverage is limited to certain situations) (up to a 30-day supply) $0 copay or $1.25 copay or $3.35 copay Cost-Sharing Brand Drugs $0 copay or $3.70 copay or $8.35 copay $0 copay or $11.10 copay or $25.05 copay $0 copay or $3.70 copay or $8.35 copay $0 copay or $3.70 copay or $8.35 copay Cost-Sharing may change depending on the pharmacy you choose and when you enter another phase of the Part D benefit. For more information on the additional pharmacy specific cost-sharing and the phases of the benefit, please call us to access our Evidence of Coverage online. Page 6

8 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 AlohaCare Advantage Plus has a network of doctors, hospitals, pharmacies, and other providers. If you use providers that are not in our network, the plan may not pay for these You can see our plan s Provider & Pharmacy directory at our website ( Or, call us and we will send you a copy of the Provider & Pharmacy directory. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, Or, call us and we will send you a copy of the formulary. AlohaCare Advantage Plus Phone Numbers, Hours of Operation, and Website Toll-free TTY/TDD users call days a week, 8:00 a.m. to 8:00 p.m. Page 7

9 Summary of Medicaid-Covered Benefits AlohaCare Advantage Plus, H5969, Plan 002 The following section will describe benefits that you are entitled to as a recipient of Medicaid benefits, in the State of Hawaii. You will also receive Extra Help from Medicare to pay for the costs of your Medicare prescription drugs. Medicare members, who also qualify for Medicaid, are eligible for additional benefits, including assistance with paying for their Medicare premiums, deductibles and cost sharing, such as copays and coinsurance. You will also receive Extra Help from Medicare to pay for the costs of your Medicare prescription drugs. The Medicaid benefits available to you are managed under the QUEST Integration Program. This document does not describe all of the details of your Medicaid benefits. Please contact your QUEST Integration plan for a complete listing. As a QUEST Integration beneficiary, you can access these benefits through one of five health plans handbooks; AlohaCare, HMSA, Kaiser Foundation Health Plan, Ohana Health Plan, or United Healthcare Community Plan. You can also get more information from Med-QUEST: Med-QUEST Enrollment Services Section Oahu: Neighbor Islands: 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 QUEST Integration covers and what our plan covers. IMPORTANT INFORMATION Premium and Other Important Information There are no co-pays and no coinsurance for this plan $0 monthly plan premium. $6,700 out-of-pocket limit for Medicare-covered Doctor and Hospital Choice Once you have paid $6,700 outof-pocket for covered Part A and Part B services, you will pay nothing for your covered Part A and Part B services for the rest of the calendar year. Page 8

10 (For more information, see Emergency Care You must go to network doctors, specialists, and hospitals. and Urgently Needed Care.) SUMMARY OF BENEFITS Inpatient Hospital Care (Includes Substance Abuse and Rehabilitation Services) Inpatient Mental Health Care INPATIENT CARE No limit on number of days of service. Includes the cost of room and board for Inpatient stays for: Nursing care Medical supplies Equipment Drugs Diagnostic services Physical and occupational therapy Audiology Speech-language pathology services No limit on number of days of service. Covered services include all medically necessary behavioral health These services include: Ambulatory services, including 24-hours-a-day, 7-days-a-week crisis services 24-hour-a-day care for acute psychiatric illnesses, including: - Room and board - Nursing care - Medical supplies and equipment - Diagnostic services - Physician services - Other practitioner services, as needed $0 copay. Plan covers 90 days each benefit period. You will not be charged additional cost sharing for professional Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. $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. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. Page 9

11 - Other medically necessary services Skilled Nursing Facility (SNF) (In a Medicare-certified skilled nursing facility) Home Health Care (Includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.) Hospice No limit on number of days of service. Covered for members who need 24-hour-a-day help with activities of daily living (ADLs) and instrumental activities of daily living (IADLs.) These members need regular, long-term care from licensed nurses and paramedical personnel. The care that is provided in a nursing facility includes: Independent and group activities Meals and snacks Housekeeping and laundry services Nursing and social work services Nutritional monitoring and counseling Pharmaceutical services and rehabilitative services Some home health services included are: Skilled nursing Home health aides Medical supplies Physical and occupational Therapy Audiology and speechlanguage pathology Provides care to terminally ill patients who have 6 months or less to live. $0 copay for SNF Plan covers up to 100 days each benefit period. No prior hospital stay is required. You will not be charged additional cost sharing for professional $0 copay for Medicare-covered home health visits. When you enroll in a Medicarecertified hospice program, your hospice services and your Part A and Part B services related to your terminal prognosis are paid for by Original Medicare, not AlohaCare Advantage Plus. Page 10

12 OUTPATIENT CARE Doctor Office Visits Cornea Transplants and Bone Graft Services Services include: Initial and interval histories Comprehensive physical examinations (including developmental services) Immunizations Diagnostic and screening laboratory X-ray services (including screening for tuberculosis) $0 copay for each Medicarecovered primary care doctor visit. $0 copay for each Medicarecovered specialist visit. Cornea transplants (keratoplasty) and Bone graft. Chiropractic Services Not a covered benefit. 20% coinsurance for each Medicare-covered chiropractic service Podiatry Services Medically necessary foot care. Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). $0 copay for Medicare-covered podiatry visits. You pay nothing for up to 8 supplemental routine podiatry visit(s) every year. Medicare-covered podiatry visits are for medically necessary foot care. Page 11

13 Outpatient Mental Health Care Outpatient Substance Abuse Care Covered services include all medically necessary behavioral health These services include: Ambulatory services, including 24-hours-a-day, 7-days-a-week crisis services Acute day hospital/partial hospitalization, including: Medication management psychiatrist* Prescribed drugs Medical supplies Diagnostic tests Therapeutic services, including individual, and group therapy and aftercare Other medically necessary services Covered services include all medically necessary behavioral health These services include: Methadone treatment services, which include the provision of methadone or a suitable alternative (e.g. LAAM), as well as outpatient counseling services Prescribed drugs including medication management and patient counseling Diagnostic/laboratory services, including: - Psychological testing - Screening for drug and alcohol problems $0 copay for: - each Medicare-covered individual therapy visit. - each Medicare-covered group therapy visit. $0 copay for Medicare-covered partial hospitalization program $0 copay for: - each Medicare-covered individual substance abuse outpatient treatment visit. - each Medicare-covered group substance abuse outpatient treatment visit. Page 12

14 - Other medically necessary diagnostic services Psychiatric or psychological evaluation Physician services Rehabilitation services Occupational therapy Other medically necessary therapeutic services Outpatient Services $0 co-pay per visit for Medicaidcovered Ambulance Services (medically necessary ambulance services) This service includes 24-hour-aday, 7-days-per-week care for: Emergency services Ambulatory center services Urgent care services Medical supplies Equipment and drugs Diagnostic services Therapeutic services (including chemotherapy and radiation therapy) $0 co-pay per trip for Medicaidcovered $0 copay for each Medicarecovered ambulatory surgical center visit. $0 copay for each Medicarecovered outpatient hospital facility visit. $0 copay for Medicare-covered ambulance benefits. Page 13

15 Emergency Care $0 co-pay per visit for Medicaidcovered (You may go to any emergency room if you reasonably believe you need emergency care.) Covered for medically necessary No prior authorization is required. $0 copay for Medicare-covered emergency room visits. If you are admitted to the hospital within 3-day(s) for the same condition, you pay $0 for the emergency room visit. World Wide Benefit for Emergency Care and Urgent Care Urgently Needed Care Covered as medically necessary. No prior authorization is required. Outside the U.S., there is a plan annual maximum covered benefit limit of $1,000. You pay $0 copay for services up to the $1,000 benefit maximum. Amounts that you pay above the $1,000 are excluded from your annual maximum out-of-pocket costs, and are not covered by the plan. You will have to pay the facility or provider directly for To file a claim, bring your itemized list and receipts of services received to AlohaCare Advantage Plus. Receipts must be in English with billed charges in U.S. dollars. AlohaCare Advantage Plus will reimburse you up to your benefit limit. $0 copay for Medicare-covered urgently-needed-care visits. World Wide Benefit for Emergency Care and Urgent Care Outside the U.S., there is a plan annual maximum covered benefit limit of $1,000. You pay $0 copay for services up to the $1,000 benefit maximum. Amounts that you pay above the Page 14

16 $1,000 are excluded from your annual maximum out-of-pocket costs, and are not covered by the plan. You will have to pay the facility or provider directly for To file a claim, bring your itemized list and receipts of services received to AlohaCare Advantage Plus. Receipts must be in English with billed charges in U.S. dollars. AlohaCare Advantage Plus will reimburse you up to your benefit limit. Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy, Audiology) Covered services include: Physical and occupational therapy Audiology and speechlanguage pathology $0 copay for Medicare-covered Occupational Therapy visits. $0 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits. Durable Medical Equipment (Includes wheelchairs, oxygen, etc.) Prosthetic Devices Covered services include but are not limited to the following: Oxygen tanks and concentrators Ventilators Wheelchairs Crutches and canes Eyeglasses Orthotic devices Prosthetic devices Hearing aids Pacemakers Medical supplies such as surgical dressings and ostomy supplies Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered. $0 copay for Medicare-covered durable medical equipment. Page 15

17 (Includes braces, artificial limbs and eyes, etc.) Covered as medically necessary. $0 co-pay for Medicare-covered: prosthetic devices medical supplies related to prosthetics, splints, Diabetes Programs and Supplies Diagnostic Tests, X- Rays, Lab Services, and Radiology Services Cardiac Pulmonary Rehabilitation Services Covered services include: Coverage for glucose monitors Test strips Lancets Screening tests Diabetes selfmanagement Training $0 co-pay per visit for Medicaidcovered Covered services include: Diagnostic Therapeutic radiology and imaging Screening and diagnostic laboratory tests Laboratory and diagnostic exclusions: Experimental Investigational or generally unproven Chromosomal evaluations IgG4 testing Covered as medically necessary. and other devices $0 copay for Medicare-covered: - Diabetes monitoring supplies. - Therapeutic shoes or inserts. - Diabetes self-management training $0 copay for Medicare-covered: lab services diagnostic procedures and tests X-rays diagnostic radiology services (not including X- rays) therapeutic radiology services $0 copay for: - Medicare-covered Cardiac Rehabilitation Services - Medicare-covered Intensive Cardiac Rehabilitation Services - Medicare-covered Pulmonary Rehabilitation Services Page 16

18 PREVENTIVE SERVICES Preventive Services Health Education and Counseling $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Bone Mass Measurement (for people with Medicare who are at risk) Colorectal Screening Exams (for people with Medicare age 50 and older) Immunizations (Flu vaccine; Pneumonia vaccine; Hepatitis B vaccine- for people with Medicare who are at risk) Mammograms (Annual Screening) (for women with Medicare age 40 and older) Substance use (including Alcohol) Diet and exercise Injury prevention Sexual behavior Annually One sigmoidoscopy or annual fecal occult blood test Every 10 years after initial screening Initial screening completed at age 50 $0 co-pay for Medicare-covered Tetanus-diphtheria (td) booster, Rubella, Hepatitis B in high risk - household and contacts with HBsAg positive person Mammography and clinical breast exam every year. A woman of any age with a history of breast cancer, or whose mother or sister has a history of breast cancer, is eligible for a screening Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. Plan covers a physical exam annually. You pay nothing. You pay nothing. You pay nothing. You pay nothing. Page 17

19 mammography when authorized by a physician. Pap Smears and Pelvic Exams You pay nothing. (for women with Medicare) Prostate Cancer Screening Exams Annually One Pap Test and pelvic exam You pay nothing. (for men with Medicare age 50 and older) Kidney Disease and Conditions Outpatient Prescription Drugs $0 co-pay per visit for Medicaidcovered Dialysis Services and Epogen Injections. Acute hospital admissions solely to provide chronic dialysis are not covered PRESCRIPTION DRUG BENEFITS Covers drugs listed on the Drugs covered under Medicare Part B Plan s Preferred Drug List (PDL). This list will also have drugs that may have limits such as prior authorization, quantity limits, step therapy, age limits, or gender limits. Alternate Drugs may be covered with prior authorization. OTC drugs may be covered by the Plan when physician prescribed and medically necessary at $0 co-pay. $0 copay for Medicare-covered renal dialysis. $0 copay for Medicare-covered kidney disease education Drugs covered under Medicare Part B $0 yearly deductible for Medicare Part B drugs. $0 copay for Part B chemotherapy drugs and other Part-B drugs. Drugs covered under Medicare Part D This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at on the web. For generic drugs (including brand drugs treated as generic), either: - A $0 copay; or - A $1.25 copay; or - A $3.35 copay Page 18

20 For all other drugs, either: - A $0 copay; or - A $3.70 copay; or - A $8.35 copay. Cost-Sharing may change depending on the pharmacy you choose and when you enter another phase of the Part D benefit. This list will also have drugs that may have limits such as prior authorization, quantity limits, step therapy, age limits, or gender limits. Alternate Drugs may be covered with prior authorization. For more information on the additional pharmacy specific cost-sharing and the phases of the benefit, please call us and request the Evidence of Coverage. Dental Services OUTPATIENT MEDICAL SERVICES AND SUPPLIES $0 co-pay for medically related Medicaid-covered For adults, emergency-only dental services are also covered under the QUEST Integration dental plan. Dental services are coordinated through Community Case Management Corporation (CCMC). CCMC will help members: Find a dentist Make an appointment You can view the Evidence of Coverage at our website ( are/acap/memberdocuments.a spx). Or, call us and we will send you a copy of the Evidence of Coverage $0 copay for Medicare-covered dental benefits. $0 copay for the following preventive dental benefits: - up to 2 oral exam(s) every year - up to 2 cleaning(s) every year - up to 2 dental x-ray(s) every year $0 copay for the following restorative dental benefits: -Endodontics (root canals) Page 19

21 Coordinate transportation and translation Call from Oahu or toll-free Extractions (removal of teeth) -Prosthodontics (dentures, crowns, veneers) Periodontics (implants) -Other (oral/maxillofacial surgery) $ plan coverage limit for preventive and restorative dental services each year. Hearing Services Hearing/Audiology Services - $0 co-pay per visit for Medicaidcovered Hearing Evaluation - one per 12 month period (Hearing Aid Suppliers will not be paid for a hearing evaluation) Hearing Services - Ear Plugs (Custom-made earplugs can be prescribed only by ENT specialists for individuals with recurrent middle ear infections) Hearing Aids one per 24 month period - $0 per item prescribed by an ENT specialist Hearing aid check, examination and fitting, monaural or binaural - one per 36 month period No additional comprehensive dental benefits covered beyond $ max coverage. $0 copay for: Medicare-covered diagnostic hearing exams. In general, supplemental routine hearing exams and hearing aids not covered. Page 20

22 Vision Services The Plan provides eye and vision exam and services: once every 24 month period More visits may be allowed, depending on the symptoms or medical condition. Covered services include: Vision examinations Prescription lenses Cataract removal Prosthetic eyes Ophthalmologic exam with refraction Visual aids (eyeglasses) Contact lenses and miscellaneous vision supplies (if medically necessary). $0 copay for exams to diagnose and treat diseases and conditions of the eye. $0 copay for one Medicarecovered glaucoma screening each year for persons at high risk. $0 copay for one pair of eyeglasses (lenses and frames) or contact lenses after cataract surgery. Over-the-Counter Items Transportation (Routine) This includes the costs for the lens, frames, or other parts of the glasses. Fittings and adjustments are also covered. Not Covered. The Plan provides both emergency and non-emergency ground and air services to and from medically necessary medical appointments for members who: - Have no means of transportation - Reside in areas not served The plan provides $75 credit every three months. Delivery services may be available when medically necessary and prior authorized. Please visit our website to see our list of covered over-thecounter items. Page 21

23 by public transportation - Cannot access public transportation due to their medical condition Acupuncture and Other Alternative Therapies Not covered Methadone maintenance Treatment Program (MMTP) Long-Term Care Services (Institutional) Nursing Facility services Page 22 Medication management, prescribed drugs, medical supplies, diagnostic tests, therapeutic services, (individual, family, group and after care), and other medically necessary Includes the provision of methadone or suitable alternatives, as well as outpatient counseling $0 copay for Medicaid-covered Cost sharing amounts from members who have cost-sharing requirements may apply. $0 copay for up to 15 visit(s) for acupuncture and other alternative therapies every year. $1000 plan coverage limit for acupuncture and other alternative therapies every year. At-Risk Services At-risk services are certain Home and Community-based Services (HCBS) which are listed below and that are provided to you if an assessment of your health by your QUEST Integration Service Coordinator indicates that you are at-risk for worsening and going into a nursing home or other type of care outside of your home. Adult Day Care Services include: Observation and supervision by center staff Coordination of behavioral, medical and

24 social plans and implementation of the instructions as listed in the participant s care plan Therapeutic, social, educational, recreational activities Adult day care staff may not perform healthcare related services such as medication administration Adult Day Health Adult day health services are organized day programs for therapeutic, social and health services for individuals that require nursing oversight or care. Home-Delivered Meals Services include: Emergency care Dietetic services Occupational therapy Physical therapy Physician services Pharmaceutical services Psychiatric or psychological services Recreational and social activities Social services Speech-language pathology Transportation services Includes nutritious meals delivered to a location where an individual resides (excluding residential or institutional settings). The meals will not replace or substitute for a full day s nutrition (i.e., no more than 2 meals per day). Page 23

25 Personal Assistance Services Level 1 Personal Assistance Services Level 2 Services may include: Routine housekeeping Meal preparation Laundry Shopping Errands Covered for those that require assistance with their activities of daily living (ADL). This level of service is to be provided by a Home Health Aide (HHA), Personal Care Aide (PCA), Certified Nurse Aide (CNA) or Nurse Aide (NA) with applicable skills. Some activities include: Personal hygiene and grooming, including bathing, skin care, oral hygiene, hair care and dressing Help with bowel and bladder care Help with mobility Help with transfers Help with medications Help with routine or maintenance health care services by a personal care provider Help with feeding, nutrition, meal preparation and other dietary activities Help with exercise, positioning and range of motion Taking and recording vital signs, including blood pressure Page 24

26 Personal Emergency Response Services (PERS) Skilled Nursing Services PERS services are limited to those individuals: Who live alone Who are alone for significant parts of the day Who have no regular caregiver for extended periods Who would otherwise need extensive routine supervision PERS services will only be offered to a member living in a non-licensed setting. Covered for those who need ongoing nursing care. The service is provided by licensed nurses within the scope of state law. Home and Community-Based Services You must meet certain level of care requirements and have an assessment performed by your QUEST Integration Service Coordinator. Your Service Coordinator will determine what services you need based on your assessment. Please contact your for details on this benefit. Adult Day Care Services include: Observation and supervision by center staff Coordination of behavioral, medical and social plans and implementation of the instructions as listed in the participant s care plan Therapeutic, social, educational, recreational activities Page 25

27 Adult day care staff may not perform healthcare related services such as medication administration Adult Day Health Assisted Living Services Adult day health services are organized day programs for therapeutic, social and health services for individuals that requires nursing oversight or care). This also includes: Emergency care Dietetic services Occupational therapy Physical therapy Physician services Pharmaceutical services Psychiatric or psychological services Recreational and social activities Social services Speech-language pathology Transportation services Assisted living services include: Personal care Supportive care services (homemaker, chore, attendant services and meal preparation) Community Care Management Agency (CCMA) The QUEST Integration health plan is not responsible for payment for room and board. Covered for members living in Community Care Foster Family Homes and other community settings, as required. Page 26

28 Community Care Foster Family Home (CCFFH) Services Covered services include: Personal care Supportive services Homemaker services Attendant care Companion services Local transportation Day programming Medication oversight (to the extent permitted under state law) All services must be provided in a certified private home by a principal care provider who lives in the home. Counseling and Training The QUEST Integration health plan is not responsible for payment for room and board. Counseling and training activities include the following: Member care training for members, family and caregivers regarding the nature of the disease and the disease process Methods of transmission and infection control measures Biological, psychological care and special treatment needs/regimens Use of equipment specified in the care and service plan Skills updates, as necessary, to safely maintain the individual at home Some services may be covered by Medicare such as: Psychological services including family therapy (under Outpatient Mental Health Care) Substance abuse service (under Outpatient Substance Abuse care) Equipment (under Durable Medical Equipment (DME)) Nutritional assessment (under Medical Nutrition Therapy) For counseling and training services that are not covered by Medicare, please contact your Page 27

29 Crisis intervention Supportive counseling Family therapy Suicide risk assessments and intervention Death and dying counseling Substance abuse counseling Nutritional assessment and counseling for details on how to receive Environmental Accessibility Adaptations Home-Delivered Meals Counseling and training services may be provided to: Members Families/caregivers on behalf of the member Professional and paraprofessional caregivers on behalf of the member Covered services to safely maintain the individual at home include: The installation of ramps and grab-bars Widening of doorways Modification of bathroom facilities Installation of specialized electric and plumbing systems (must be necessary to accommodate the medical equipment and supplies that are necessary for the welfare of the individual) All services shall comply with state or local building codes. Page 28

30 Includes nutritious meals delivered to a location where an individual resides (excluding residential or institutional settings). The meals will not replace or substitute for a full day s nutrition (i.e., no more than 2 meals per day). Home Maintenance Home maintenance services are those services not included as a part of personal assistance and include: Heavy-duty cleaning to bring a home up to acceptable standards of cleanliness at the start of service to a member Minor repairs to essential appliances, limited to stoves, refrigerators and water heaters Fumigation or extermination services Moving Assistance This benefit is provided to individuals who cannot perform these services without assistance and are determined, through assessment, to require the service to prevent institutionalization. This benefit is provided in the rare instances when it is determined through an assessment that an individual needs to move to a new home. This benefit is not utilized when the individual has family members, a landlord, and other community members who can provide this service. Situations Page 29

31 for which this benefit may be used include: Unsafe home due to deterioration The individual is wheelchair bound, living in a building with no elevator, multistory building with no elevator or where the client lives above the first floor Member is evicted from his or her current home Member can no longer afford the home due to a rent increase Non-Medical Transportation Personal Assistance Services Level 1 Moving expenses include packing and moving of belongings. This service helps members travel as specified by the member care plan. It helps members get to community services, activities and resources. Whenever possible, those who can offer this service without cost will be used. They include family, neighbors, friends or community agencies. Exclusion: Members living in a residential care setting or a CCFFH are not eligible for this service. Services may include: Routine housekeeping Meal preparation Laundry Shopping Errands Page 30

32 Personal Assistance Services Level 2 Covered for those that require assistance with their activities of daily living (ADL). This level of service is to be provided by a Home Health Aide (HHA), Personal Care Aide (PCA), Certified Nurse Aide (CNA) or Nurse Aide (NA) with applicable skills. Some activities include: Personal hygiene and grooming, including bathing, skin care, oral hygiene, hair care and dressing Help with bowel and bladder care Help with mobility Help with transfers Help with medications Help with routine or maintenance health care services by a personal care provider Help with feeding, nutrition, meal preparation and other dietary activities Help with exercise, positioning and range of motion Taking and recording vital signs, including blood pressure Page 31

33 Personal Emergency Response Services (PERS) PERS services are limited to those individuals: Who live alone Who are alone for significant parts of the day Who have no regular caregiver for extended periods Who would otherwise need extensive routine supervision Skilled or Private-Duty Nursing Licensed Residential Care PERS services will only be offered to a member living in a non-licensed setting Covered for those who need ongoing nursing care. The service is provided by licensed nurses within the scope of state law. Residential care is provided in a licensed private home by a principle care provider who lives in the home. He or she gives the following services to members: Personal care services Homemaker, chore, attendant care and companion services Medication oversight (to the extent allowed by law) Transportation to medical appointments The QUEST Integration health plan is not responsible for payment for room and board. Page 32

34 Respite Care Respite care is short-term caregiving support and relief provided to caregivers of members who are unable to care for themselves. It may be provided hourly, daily and overnight. Respite care may be provided in the following locations: Member s home or place of residence Foster home or expanded-care adult residential care home Medicaid-certified nursing facility Licensed respite day care facility Other community care residential facility approved by the Plan Specialized Medical Equipment Warranty and Supplies Respite care services are authorized by the member s PCP as part of the member s care plan. Refers to the purchase, rental, lease, costs, installation, repairs and removal of devices, controls or appliances specified in the care plan. This also includes: Items necessary for life support Supplies and equipment needed for the proper functioning of such items Durable and non-durable medical equipment not available under the Medicaid state plan Examples include: Page 33

35 Shower seat Portable humidifiers Electric bills specific to electrical life support devices (ventilator, oxygen concentrator) Medical supplies Page 34

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37 AlohaCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. AlohaCare does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. AlohaCare 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) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact AlohaCare s Compliance Officer. If you believe that AlohaCare 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: You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, AlohaCare s Compliance Officer 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 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 AlohaCare Attn: Compliance Officer 1357 Kapiolani Blvd., Ste Honolulu, HI Phone: Toll-free: TTY/TDD: Fax: Compliance@alohacare.org