VNSNY CHOICE. Monthly Premium, Deductible, and Limits on how much you pay for Covered Services

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1 Medicare Advantage-Classic Program (HMO): The Medicare Classic service area includes the following counties in New York: Albany, Bronx, Kings (Brooklyn), Nassau, New York, Queens, Rensselaer, Richmond (Staten Island), Saratoga, Schenectady, Suffolk and Westchester. Like all Medicare health plans, Medicare covers everything that Original Medicare covers - and more. Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. also covers Part D drugs. We also cover Part B drugs such as chemotherapy and other drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) along with any limitations on our website, vnsnychoice.org. Or, call us and we will send you a copy of the formulary. If you are a member of this plan, call toll-free TTY users please call 711. If you are not a member of this plan, call toll-free TTY users please call 711. Covered Services Monthly Premium, Deductible, and Limits on how much you pay for Covered Services Medicare Classic (HMO) How much is the monthly premium? How much is the deductible? $39.00 per month. In addition, you must keep paying your Medicare Part B premium. $405 per year for Part D prescription drugs.

2 Is there any limit on how much to pay for covered services? Yes, like all Medicare health plans, our plan protects you having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers. Is there a limit on how much the plan will pay? If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain innetwork benefits. Contact us for services that apply Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and What you should I know about CHOICE Classic Services *Doctor s Office Visits Primary Care and Specialists Primary Care physician visit: The member does not pay Specialist Visit: $25 copay

3 Outpatient Care and Services Preventive Care What you should I know about CHOICE Classic The member does not pay anything The plan covers many preventive services including: Annual physician visit Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cervical and vaginal cancer screening Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible Sigmoidoscopy) Depression screening Diabetes screenings HIV Screenings Obesity screening and counseling Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Abdominal aortic aneurysm screening Cardiovascular disease (behavioral therapy) Medicinal nutrition therapy services Prostate cancer screenings (PSA) Sexually transmitted infections screenings and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Welcome to Medicare preventive visit (one-time) Yearly Wellness visit

4 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services What you should I know about CHOICE Classic Preventive Care (continued) Emergency Care Worldwide coverage includes any country outside the United States and its territories. Coverage includes emergency and urgent care and is limited to $50,000 US per year. Contact Member Services for more information. Any additional preventive services approved by Medicare during the contract year will be covered. The plan also covers the following supplemental education/wellness programs: Health Club Membership Fitness Classes Nursing Hotline- 24 hours a day, 7 days a week $75 copay If the member is admitted to the hospital within 24 hours, the member does not have to pay their share of the emergency care. (See Inpatient Hospital Care below for other costs.) $295 copay per day for days 1 through 6 Member pays nothing per day for days 7 through 90 Member pays nothing per day for days 91 and beyond. Urgently needed Care Worldwide includes any country outside the United States and its territories. Coverage and urgent care and is limited to $50,000 US per year. Contact the plan for more information. $20 copay

5 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services *Hearing Services Services provided by our HearUSA vendor *Diagnostic Tests, Lab and Radiology Services, and X- Rays Services provided by our Care to Care vendor Costs for these services may vary based on the place of service *Dental Services Services provided by our Healthplex vendor What you should I know about CHOICE Classic The member pays nothing for Medicare-covered hearing benefits. One routine hearing exam every year Two fitting evaluations for a supplemental hearing aid limited to one per ear (one right, one left) every three (3) years. $1,000 plan coverage limit for supplemental hearing aids limited to $500 per ear (one right, one left) every three years. Diagnostic radiology services (such as MRI s, CT scans) $50 copay Diagnostic tests and procedures / member pays nothing Lab services / member pays nothing Outpatient x-rays / member pays nothing Therapeutic radiology services ( such as radiation treatment for cancer) 20% of the cost The plan covers comprehensive dental services including diagnostic services, restorative services, and prosthodontics, other maxillofacial surgery, comprehensive oral evaluation, standard fillings, crowns and posts, dentures; extractions and local anesthesia are covered with a maximum benefit of $1,000 per year for combined preventive and comprehensive care: - Member pays a $5 copay per preventive dental visit - Member pays a $5 copay diagnostic services. - Member pays a $30 copay restorative services. - Member pays a $100 copayment for prosthodontics or oral/maxillofacial surgery

6 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and What you should I know about CHOICE Classic Services *Dental Services (continued) Services provided by our Healthplex vendor Vision Services Services provided by our Superior Vision vendor Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) Routine eye exam (for up to 1 every year) Contact lenses or Eyeglasses (frames and lenses) For up to 1 every year. Eyeglasses or contact lenses after cataract surgery Preventive dental services: - Cleaning (for up to 2 every year) / Member pays nothing - Dental x-ray(s) (for up to 2 every year) / Member pays nothing - Fluoride treatment (for up to 2 every year) / Member pays nothing - Oral exam (for up to 2 every year) / Member pays nothing General anesthesia is covered as medically necessary in conjunction with surgical extractions only. Member pays nothing Member pays nothing Member pays nothing Member pays nothing - The cost of standard lenses and frames is limited to $200 for one set of eye-glasses or contact lenses, but not both. - Standard lenses include single, bifocal, trifocal; does not include specialty lens (i.e. transition, tints, progressives, polycarbonate). - Standard contact lenses include: extended daily wear, disposables, standard daily wear, toric, or rigid gas permeable.

7 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services What should I know about CHOICE Classic *Mental Health Care Services provided by our Beacon Health vendor The plan covers 90 days for an inpatient hospital stay. The 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. $265 copay per day for days 1 through 6 Member pays nothing per day for days 7 through 90 Outpatient group therapy visit: $20 copay *Skilled Nursing Facility (SNF) *Outpatient Rehabilitation Outpatient individual therapy visit: $20 copay The plan covers up to 100 days in a SNF The member pays nothing per day for days 1 through 20 $ co-pay per day for days 21 through 100 No prior hospital stay is required. Plan covers up to 100 days in a skilled nursing facility per benefit period. Cardiac (heart) rehab services (for a maximum of 2 onehour sessions per day for up to 36 sessions up to 36 weeks): $20 copay Occupational therapy visit: $20 copay Physical therapy and speech and language therapy visit: $20 copay

8 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services *Outpatient Substance Abuse *Ambulance (Emergency and Non-Emergency) *Foot Care (Podiatry Services) *Durable Medical Equipment/Supplies (wheelchairs,oxygen,etc.) Prosthetic Devices (braces, artificial limbs, etc.) *Diabetes self-management training, Diabetes Supplies, and Services *Chiropractic Care Services provided by our Triad vendor What should I know about CHOICE Classic Groups therapy visit: 20% of the cost Individual therapy visit: 20% of the cost $200 copay Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $20 copay 20% of the cost Prosthetic Devices: 20% of the cost Related Medical Supplies: 20% of the cost *Home Health Care Member pays nothing Diabetes monitoring supplies: 20% of the cost of Medicare covered Diabetes self-management training: Member pays nothing Therapeutic shoes or inserts: Member pays nothing Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): Member pays nothing *Hospice Member pays nothing for hospice care from a Medicare certified hospice. The member may have to pay part of the costs for drugs and respite care. *Outpatient Surgery Ambulatory surgical center: $170 copay Outpatient hospital: $170 copay *Renal Dialysis 20% of the cost

9 Medicare Advantage-Preferred Program (HMO SNP): The Preferred program is for Medicare beneficiaries who are eligible for some level of assistance from New York State Medicaid. Medicare Preferred includes the following counties in New York: Albany, Bronx, Kings, Nassau, New York, Queens, Rensselaer, Richmond, Saratoga, Schenectady, Suffolk and Westchester. Like all Medicare health plans, Medicare covers everything that Original Medicare covers - and more. The plans members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. The plan cover Part D drugs. We also cover Part B drugs such as chemotherapy and other drugs administered by the provider. You can see the complete plan formulary (list of Part D prescription drugs) along with any limitations on our website, vnsnychoice.org. Or, call us and we will send you a copy of the formulary. If you are a member of this plan, call toll-free TTY users please call 711. If you are not a member of this plan, call toll-free TTY users please call 711. Covered Services Monthly Premium, Deductible, and Limits on how much you pay for Covered Services Medicare Preferred (HMO SNP) How much is the monthly premium? How much is the deductible? $0 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a Part B deductible. $0-$83 per year for Part D prescription drugs.

10 Covered Services Covered Medical and Hospital (Note: Services with * may require prior authorization) Is there any limit on how much a member will pay for covered services? Is there a limit on how much the plan will pay? Like all Medicare health plans, protects you by having yearly limits on the 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 New York State Medicaid eligibility. Yearly limit in the Preferred plan: - $6,700 for services received from in-network provider. If the member reaches the limit on out of pocket costs, the plan will continue to cover hospital and medical services. In addition they will pay the full cost for the rest of the year. has a coverage limit every year for certain innetwork benefits. Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services What you should I know about CHOICE Preferred *Inpatient Hospital Care The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day the member is admitted as an inpatient and ends when they haven t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There s no limit to the number of benefit periods. The plan covers 90 days for an inpatient hospital stay. The 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.

11 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services What you should I know about CHOICE Preferred *Inpatient Hospital Care (continued) In 2018, the amount for each benefit period were $0 or: $1,340deductible for days 1 through 60 $335 copay per day for days 61 through 90 $670 copay per day for 60 lifetime reserve days *These amount may change for 2018 *Doctor s Office Visits Primary Care and Specialists Preventive Care 0% or 20% of the cost * The cost depends on the Medicaid Eligibility The member pays nothing. The plan covers many preventive services, including: Annual physical exam Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cervical and vaginal cancer screening Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible Sigmoidoscopy) Depression screening Diabetes screenings HIV screening Obesity screening and counseling Vaccines, including Flu shots, Hepatitis B shots Pneumococcal shots Abdominal aortic aneurysm screening Cardiovascular disease (behavioral therapy) Cardiovascular screenings Medical nutrition therapy services Prostate cancer screenings (PSA) Sexually transmitted infections screenings and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)

12 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services What you should I know about CHOICE Preferred Preventive Care (continued) Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Any additional preventive services approved by Medicare during the contract year will be covered The plan also covers the following supplemental education/wellness programs: Nutritional supplement benefit includes 3 one-on-one telephonic nutritional counseling by registered dietician's (RD). Health Club Membership/ Fitness Classes Emergency Care Worldwide coverage includes any country outside the United States and its territories. Coverage includes emergency and urgent care and is limited to $50,000 US per year. Contact the plan for more information Urgently needed Care Worldwide includes any country outside the United States and its territories. Coverage includes emergency and urgent care and is limited to $50,000 US per year. Contact the plan for more information. Nursing Hotline- 24 hours a day, 7 days a week O% or 20% of the cost (up to $75 per visit) If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. Your cost depends on the Medicaid eligibility. 0% or 20% of the cost (up to $65 per visit) The cost depends on the medicaid eligibility.

13 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services What you should I know about CHOICE Preferred *Diagnostic Tests, Lab and Radiology Services, and X-Rays Services provided by our Care to Care providers (Costs for these services may vary based on place of service.) Diagnostic radiology services (such as MRI s, CT scans) - 0% or 20% of the cost Diagnostic tests and procedures: - 0% or 20% of the cost Lab Services - Member pays 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 *Hearing Services Services provided by our HearUSA vendor *Dental Services Services provided by our Healthplex vendor The cost for members depends on the Medicaid eligibility Exam to diagnose and treat hearing and balance issues: - 0% or 20% of the cost The members cost will depend on the members Medicaid eligibility. Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): - Member pays nothing

14 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services What you should I know about CHOICE Preferred *Dental Services Services provided by our Healthplex vendor Preventive Dental Services: Cleaning (for up to 1 every six months): Dental x-ray(s) (for up to 1 every six months): Fluoride treatment (for up to 1 six months): Oral exam (for up to 1 every six months): Comprehensive Dental Services includes: (Non-Routine, Diagnostic, Restorative, Endodontic / Periodontics/Extractions, Prosthodontics, other Oral/Maxillofacial Surgery, other Services) - The member receives up to $500 per year. Authorization is required.

15 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services What you should I know about CHOICE Preferred Vision Services Services provided by our Superior Vision vendor Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) Routine eye exam (for up to 1 every year) Contact lenses or Eyeglasses (frames and lenses) For up to 1 every year. Eyeglasses or contact lenses after cataract surgery Member pays nothing Member pays nothing Member pays nothing Member pays nothing - The cost of standard lenses and frames is limited to $200 for one set of eye-glasses or contact lenses, but not both. - Standard lenses include single, bifocal, trifocal; does not include specialty lens (i.e. transition, tints, progressives, polycarbonate). - Standard contact lenses include: extended daily wear, disposables, standard daily wear, toric, or rigid gas permeable.

16 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services *Mental Health Care Services provided by our Beacon Health vendor What should I know about CHOICE Preferred The plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you re admitted as an inpatient and ends when you haven t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefits period has ended, a new benefit period begins. The member must pay the inpatient hospital deductible for each benefit period. There s no limit to the number of benefit periods. The plan covers 90 days for an inpatient hospital stay. The plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. In 2016 the amount for each benefit period were $0 or: $1,288 deductible for days 1 through 60 $322 copay per day for days 61 through copay per day for 60 lifetime reserve days These amounts may change for Outpatient group therapy visit: 0% or 20-40% of the cost, depending on the service. Outpatient Individual therapy visit: 0% or 20-40% of the cost, depending on the service. *The cost for the member may depend on Medicaid eligibility.

17 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services *Skilled Nursing Facility (SNF) What should I know about CHOICE Preferred The plan covers up to 100 days in a SNF The member pays nothing per day for days 1 through 20 $ co-pay per day for days 21 through 100 *Outpatient Rehabilitation The member pays for all costs each day after day 100 of the benefit period. Cardiac (heart) rehab services (for a maximum of 2 onehour sessions per day for up to 36 sessions up to 36 weeks): - 0% or 20% of the cost Occupational therapy visit: - 0% or 20% of the cost Physical therapy and speech and language therapy visit: - 0% or 20% of the cost The cost for the member depends on the Medicaid eligibility

18 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services What should I know about CHOICE Preferred *Outpatient Substance Abuse Groups therapy visit: 0% or 20% of the cost Individual therapy visit: 0% or 20% of the cost The cost for the member depends on Medicaid eligibility *Ambulance (Emergency and Non-Emergency) *Transportation Services provided by our National MedTrans vendor *Foot Care (Podiatry Services) *Durable Medical Equipment (wheelchairs, oxygen, etc.) *Prosthetic Devices (braces, artificial limbs, etc.) 0% or 20% of the cost The cost for the member depends on Medicaid eligibility The member pays nothing for up to 24 one-way trips per year with a Maximum of 3 round-trips every three months to plan approved locations. Car service or ambulette is the mode of transportation. *To schedule transportation, call member services 48 hours in advance. Foot exams and treatment if you have diabetesrelated nerve damage and/or meet certain conditions: 0% or 20% of the cost The cost of the member depends on Medicaid eligibility Prosthetic Devices: -0% or 20% of the cost Related medical supplies: -0% or 20% of the cost *Diabetes Supplies and Services Diabetes monitoring supplies: -0% or 20% of the cost Diabetes self-management training: -0% or 20% of the cost *The costs for depend on the Medicaid eligibility.

19 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services *Acupuncture and Other Alternative Therapies What should I know about CHOICE Preferred For up to 12 visit(s) every year: Member pays nothing *Chiropractic Care Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position) -The member pays nothing *Home Health Care The member pays nothing *Hospice The member pays nothing for hospice care from a Medicare certified hospice. The member may have to pay part of the costs for drugs and respite care. *Outpatient Surgery Ambulatory surgical center: -0% or 20% of the cost Outpatient hospital: -0% or 20% of the cost The cost depends on the Medicaid eligibility. Renal Dialysis 0% or 20% of the cost The cost depends on Medicaid eligibility.

20 Medicare Advantage-Maximum Program (HMO SNP): The Maximum program is for Medicare beneficiaries who are eligible for some level of assistance from New York State Medicaid. Medicare Preferred includes the following counties in New York: Albany, Bronx, Kings, Nassau, New York, Queens, Rensselaer, Richmond, Saratoga, Schenectady, Suffolk and Westchester. Like all Medicare health plans, Medicare covers everything that Original Medicare covers - and more. The plans members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. The plan cover Part D drugs. We also cover Part B drugs such as chemotherapy and other drugs administered by the provider. You can see the complete plan formulary (list of Part D prescription drugs) along with any limitations on our website, vnsnychoice.org. Or, call us and we will send you a copy of the formulary. If you are a member of this plan, call toll-free TTY users please call 711. If you are not a member of this plan, call toll-free TTY users please call 711. Covered Services Monthly Premium, Deductible, and Limits on how much you pay for Covered Services Medicare Maximum (HMO SNP) How much is the monthly premium? How much is the deductible? $0 per month. This plan does not have a Part B deductible. This plan does not have a deductible for Part D prescription drugs

21 Covered Services Covered Medical and Hospital (Note: Services with * may require prior authorization) Is there any limit on how much a member will pay for covered services? Is there a limit on how much the plan will pay? Like all Medicare health plans, protects you by having yearly limits on the out of pocket costs for medical and hospital care. In this plan, you may pay nothing for Medicare covered services. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. has a coverage limit every year for certain innetwork benefits. Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services *Inpatient Hospital Care What you should I know about CHOICE Maximum The plan covers an unlimited number of days for an inpatient hospital stay. The member pays nothing. *Doctor s Office Visits Primary Care and Specialists The member pays nothing.

22 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services What you should I know about CHOICE Maximum Preventive Care The member pays nothing. The plan covers many preventive services, including: Annual physical exam Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cervical and vaginal cancer screening Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible Sigmoidoscopy) Depression screening Diabetes screenings HIV screening Obesity screening and counseling Vaccines, including Flu shots, Hepatitis B shots Pneumococcal shots Abdominal aortic aneurysm screening Cardiovascular disease (behavioral therapy) Cardiovascular screenings Medical nutrition therapy services Prostate cancer screenings (PSA) Sexually transmitted infections screenings and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)

23 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services What you should I know about CHOICE Maximum Preventive Care (continued) Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Any additional preventive services approved by Medicare during the contract year will be covered The plan also covers the following supplemental education/wellness programs: Nutritional supplement benefit includes 3 one-on-one telephonic nutritional counseling by registered dietician's (RD). Health Club Membership/ Fitness Classes Emergency Care Worldwide coverage includes any country outside the United States and its territories. Coverage includes emergency and urgent care and is limited to $50,000 US per year. Contact the plan for more information Urgently needed Care Worldwide includes any country outside the United States and its territories. Coverage includes emergency and urgent care and is limited to $50,000 US per year. Contact the plan for more information. Nursing Hotline- 24 hours a day, 7 days a week The member pays nothing The member pays nothing

24 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services What you should I know about CHOICE Maximum *Diagnostic Tests, Lab and Radiology Services, and X-Rays Services provided by our Care to Care providers (Costs for these services may vary based on place of service.) Diagnostic radiology services (such as MRI s, CT scans) Diagnostic tests and procedures: Lab Services Outpatient x-rays: Therapeutic radiology services (such as radiation treatment for cancer): *Hearing Services Services provided by our HearUSA vendor Exam to diagnose and treat hearing and balance issues: Routine hearing exam (for up to 1 every year): Hearing aid fitting/evaluation (for up to 2 every three years): Hearing aid: Our plans coverage limit is: $1,000 for hearing aids limited to $500 per ear (one right, one left) every three years. Fitting/evaluation is limited to one per ear (one right, one left) every 3 years.

25 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services What you should I know about CHOICE Maximum *Dental Services Services provided by our Healthplex vendor Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): Preventive Dental Services: Cleaning (for up to 1 every year): Dental x-ray(s) (for up to 1 every year): Fluoride treatment (for up to 1 every year): Oral exam (for up to 1 every year): Additional coverage under Medicaid.

26 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services What you should I know about CHOICE Maximum Vision Services Services provided by our Superior Vision vendor Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) Routine eye exam (for up to 1 every year) Contact lenses or Eyeglasses (frames and lenses) For up to 1 every year. Eyeglasses or contact lenses after cataract surgery Member pays nothing Member pays nothing Member pays nothing Member pays nothing - The cost of standard lenses and frames is limited to $200 for one set of eye-glasses or contact lenses, but not both. - Standard lenses include single, bifocal, trifocal; does not include specialty lens (i.e. transition, tints, progressives, polycarbonate). - Standard contact lenses include: extended daily wear, disposables, standard daily wear, toric, or rigid gas permeable.

27 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services *Mental Health Care Services provided by our Beacon Health vendor What should I know about CHOICE Maximum The plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. The plan covers 90 days for an inpatient hospital stay. The plan also covers 60 lifetime reserve days. These are extra days that we cover. If the hospital stay is longer than 90 days, the member can use these extra days. But once the member has used up these extra 60 days, the inpatient hospital coverage will be limited to 90 days. Outpatient group therapy visit: Outpatient Individual therapy visit:

28 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services *Skilled Nursing Facility (SNF) What should I know about CHOICE Maximum The plan covers up to 100 days in a SNF *Outpatient Rehabilitation The member pays nothing Cardiac (heart) rehab services (for a maximum of 2 onehour sessions per day for up to 36 sessions up to 36 weeks):. Occupational therapy visit: Physical therapy and speech and language therapy visit:

29 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services What should I know about CHOICE Maximum *Outpatient Substance Abuse Groups therapy visit:: The member pays nothing Individual therapy visit: The member pays nothing *Ambulance (Emergency and Non-Emergency) *Transportation Services provided by our National MedTrans vendor *Foot Care (Podiatry Services) *Durable Medical Equipment (wheelchairs, oxygen, etc.) *Prosthetic Devices (braces, artificial limbs, etc.) The member pays nothing Not covered under Medicare. The medicaid benefit covers scheduled transportation that is necessary to get needed medical care and other health related services. Coverage includes ambulette, car service, and public transportation. Foot exams and treatment if you have diabetesrelated nerve damage and/or meet certain conditions: Routine foot care (for up to 4 visit(s) every year): The member pays nothing Prosthetic Devices: Related medical supplies: *Diabetes Supplies and Services Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts:

30 Covered Medical and Hospital (Note: Services with * may require prior authorization) Outpatient Care and Services *Acupuncture and Other Alternative Therapies What should I know about CHOICE Maximum For up to 12 visit(s) every year: Member pays nothing *Chiropractic Care Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position) -The member pays nothing *Home Health Care The member pays nothing *Hospice The member pays nothing for hospice care from a Medicare certified hospice. The member may have to pay part of the costs for drugs and respite care. *Outpatient Surgery Ambulatory surgical center: Outpatient hospital:. Renal Dialysis The member pays nothing.

31 Summary of Medicaid-Covered The benefits described below are covered by Medicaid. The benefits described in the Covered Medical and Hospital are covered by Medicare. For each benefit listed below, you can see what New York State Medicaid Plan covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. Coverage of the benefits described below depends upon your level of Medicaid eligibility. No matter what your level of Medicaid eligibility is, Medicare Maximum and Preferred (HMO SNP) will cover the benefits described in the Covered Medical and Hospital section of the Summary of. If you have questions about your Medicaid eligibility and what benefits you are entitled to call: TTY users please call 711. Summary of Medicaid-Covered Benefit NYS Medicaid Plan CHOICE Maximum CHOICE Preferred Adult Day Healthcare AIDS Adult Day Healthcare Covered by Medicaid Not covered by plan Not covered by plan Covered by Medicaid Not covered by plan Not covered by plan Ambulance Services Covers Medicare deductibles, copays and coinsurances $0 copayment for covered services $0 copayment for covered services Bone Mass Measurement Covers Medicare deductibles, copays and coinsurances $0 copayment for covered services $0 copayment for covered services Colorectal Screening Exams Covers Medicare deductibles, copays and coinsurances $0 copayment for covered services $0 copayment for covered services.

32 Summary of Medicaid-Covered (continued) Summary of Medicaid-Covered Benefit Certain Mental Health Services Including: Intensive Psychiatric Rehabilitation Treatment Programs Day Treatment Continuing Day Treatment Case Management for Seriously and Persistently Mentally ill (sponsored by state or local mental health units) Partial Hospitalizations Assertive Community Treatment (ACT) Personalized Recovery Oriented Services (PROS) NYS Medicaid Plan Covered by Medicaid CHOICE Maximum CHOICE Preferred Not covered by the plan Not covered by the plan

33 Summary of Medicaid-Covered (continued) Summary of Medicaid-Covered Benefit Consumer Directed Personal Care Services NYS Medicaid Plan New York State Medicaid covers self-directed home care services including personal care services, home health aide services or skilled nursing tasks. Services are provided by a consumer directed personal assistant under the instruction, supervision and direction of the enrollee or the enrollee's designated representative. There is no copayment for Medicaid covered services. CHOICE Maximum CHOICE Preferred Not covered by the plan Not covered by the plan

34 Summary of Medicaid-Covered (continued) Summary of Medicaid-Covered Benefit NYS Medicaid Plan Dental Covers Medicare deductibles, copays and coinsurances. Diabetes Self- Monitoring Training, Nutrition Therapy, and Supplies Diagnostic Tests, X- Rays, Lab Services and Radiology Services Medicaid covers dental services including necessary preventive, prophylactic and other routine dental care, services, and supplies and dental prosthetics to alleviate a serious health condition. Ambulatory or inpatient surgical dental services subject to prior authorization. Covers Medicare deductibles, copays and coinsurances Covered Medicare deductibles, copays and coinsurances CHOICE Maximum $0 copayment for covered services Covers dental services including necessary preventive, prophylactic and other routine dental care, services, and supplies and dental prosthetics to alleviate a serious health condition. Ambulatory or inpatient surgical dental services subject to prior authorization. $0 copayment for covered services $0 copayment for covered services CHOICE Preferred $0 copayment for Medicare covered services. $0 copayment for covered services $0 copayment for covered services

35 Summary of Medicaid-Covered (continued) Summary of Medicaid-Covered Benefit NYS Medicaid Plan CHOICE Maximum CHOICE Preferred Durable Medical Equipment (DME) and Medical Supplies Covers Medicare deductibles, copays and coinsurances. Medicaid covered durable medical equipment, including devices and equipment other than medical / surgical supplies, and prosthetic or orthotic appliances having the following: characteristics: can withstand repeated use for a protracted period of time; are primarily and customarily used for medical purposes are generally not useful to a person in the absence of illness or injury and are usually fitted, designed or fashioned for a particular individual s use. Must be ordered by a Practitioner. No homebound prerequisite and includes non- Medicare DME Covered by Medicaid (e.g. tub stool; grab bars). Medical/Surgical supplies, enteral/ parenteral formula and supplements, and hearing aid batteries. $0 copayment for covered services. The plan covers Medicaid durable medical equipment, including devices and equipment other than medical/surgical supplies, enteral formula, and prosthetic or orthotic appliances having the following characteristics: can withstand repeated use for a protracted period of time; are primarily and customarily used for medical purposes; are generally not useful to a person in the absence of illness or injury and are usually fitted designed or fashioned for a particular individual s use. Must be ordered by a Practitioner. No homebound prerequisite and includes non-medicare DME Covered by Medicaid (e.g. tub stool; grab bars) Medical/Surgical supplies, enteral/parenteral formula and supplements, and hearing aid batteries. $0 copayment for Medicare covered items

36 Summary of Medicaid-Covered (continued) Summary of Medicaid-Covered Benefit NYS Medicaid Plan CHOICE Maximum CHOICE Preferred Durable Medical Equipment (DME) and Medical Supplies There is no copayment for Medicaid-covered services. Coverage of enteral formula and nutritional supplements are limited to coverage only for nasogastric, jejunostomy, or gastrostomy tube feeding. Coverage of enteral formula and nutritional supplement is limited to individuals who cannot obtain nutrition through any other means, and to the following three conditions: 1) tube-fed individuals who cannot chew or swallow food and must obtain nutrition through formula via tube. 2) individuals with rare inborn metabolic disorders requiring specific medical formulas to provide essential nutrients not available through any other means. 3) Children who require medical formulas due to mitigating factors in growth and development. There is no copayment for Durable Medical Equipment (DME) and Medical Supplies. Coverage of enteral formula and nutritional supplements are limited to coverage only for nasogastric, jejunostomy, or gastrostomy tube feeding. Coverage of enteral formula and nutritional supplements is limited to individuals who cannot obtain nutrition through any other means, and to the following three conditions: 1) tube-fed individuals who cannot chew or swallow food and must obtain nutrition through formula via tube. 2) individuals with rare inborn metabolic disorders requiring specific medical formulas to provide essential nutrients not available through any other means. $0 copayment for Medicare covered items

37 Summary of Medicaid-Covered (continued) Summary of Medicaid-Covered Benefit NYS Medicaid Plan CHOICE Maximum CHOICE Preferred Durable Medical Equipment (DME) and Medical Supplies Coverage for certain inherited diseases of amino acid and organic acid metabolism shall include modified solid food products that are lowprotein or which contain modified protein. 3) Children who require medical formulas due to mitigating factors in growth and development. Coverage for certain inherited diseases of amino acid metabolism shall include modified solid food products that are lowprotein or which contain modified protein. $0 copayment for Medicare covered items Emergency Care Covers Medicare deductibles, copays and coinsurances $0 copayment for covered services $0 copayment for covered services End-Stage Renal Disease Home Delivered and Congregate Meals Covers Medicare deductibles, copays and coinsurances New York State Medicaid covers meals provided at home or in congregate settings, such as senior centers for individuals unable to prepare meals or have them prepared. There is no copayment for Medicaid covered services. $0 copayment for covered services. $0 copayment for covered services. Not covered by the plan Not covered by the plan

38 Summary of Medicaid-Covered (continued) Summary of Medicaid-Covered Benefit NYS Medicaid Plan CHOICE Maximum CHOICE Preferred Hearing Services Covers Medicare deductibles, copays and coinsurances. Covers Medicare deductibles, copays and coinsurances. Not covered by plan Medicaid covers hearing services and products when medically necessary to alleviate disability caused by the loss or impairment of hearing. Services include: - Hearing aid selecting - Fitting, and dispensing - Hearing aid checks following dispensing - Conformity evaluations and hearing aid repairs Audiology services including examinations and testing. Hearing aid evaluations and hearing aid prescriptions. Hearing aid products including hearing aids, ear molds, special fittings and replacement parts Medicaid covers hearing services and products when medically necessary to alleviate disability caused by the loss or impairment of hearing. Services include: - Hearing aid selecting - Fitting, and dispensing - Hearing aid checks following dispensing. - Conformity evaluations and hearing aid repairs. Audiology services including examinations and testing. Hearing aid evaluations and hearing aid prescriptions Hearing aid products including hearing aids, ear molds, special fittings and replacement parts.

39 Summary of Medicaid-Covered (continued) Summary of Medicaid-Covered Benefit NYS Medicaid Plan CHOICE Maximum CHOICE Preferred Home Health Services (Includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.) Covers Medicare deductibles, copays and coinsurances. Covers medically necessary intermittent skilled nursing care, home health aide services and rehabilitation services. Also includes non- Medicare covered home health services (e.g. home health aid services with nursing supervision to medically unstable individuals.) Hospice Covers Medicare deductibles, copays and coinsurances. Immunizations Covers Medicare deductibles, copays, and coinsurances Inpatient Mental Health Services (Over 190-day lifetime limit) Covers Medicare deductibles, copays and coinsurances. Covers all inpatient mental health services, including voluntary or involuntary admissions for mental health services over the Medicare 190-day lifetime limit. $0 copayment for covered services. Covers medically necessary intermittent skilled nursing care, home health aide services and rehabilitation services. Also includes non- Medicare covered home health services (e.g. home health aid services with nursing supervision to medically unstable individuals) $0 copayment for Medicare covered services. Not covered Not covered $0 copayment for covered services $0 copayment for covered services. Covers all inpatient mental health services, including voluntary or involuntary admissions for mental health services over the Medicare 190-day lifetime limit. $0 copayment for covered services. $0 copayment for covered services up to Medicare 190 day limit.

40 Summary of Medicaid-Covered (continued) Summary of Medicaid-Covered Benefit NYS Medicaid Plan CHOICE Maximum CHOICE Preferred Mammograms Covers Medicare deductibles, copays and coinsurances $0 copayment for covered services $0 copayment for covered services Medical Social Services Methadone Maintenance Treatment Programs New York State Medicaid covers an assessment, arranging and providing aid for social problem related to maintaining an individual at home. There is no copayment for Medicaid-covered services Not covered by the plan Covered by Medicaid Not covered by the plan Nutrition New York State Medicaid covers and assessment of nutritional status / needs, development and evaluation of treatment plans, nutritional education and counseling, in-service education. Includes cultural considerations. There is no copayment for Medicaid covered services. Out of Network family planning services Medicaid covers out of network family planning services provided under the direct access provisions of the waiver. Not covered by the plan Not covered by the plan. Not covered by the plan Not covered by the plan Not covered by the plan Not covered by the plan.

41 Summary of Medicaid-Covered (continued) Summary of Medicaid-Covered Benefit NYS Medicaid Plan CHOICE Maximum CHOICE Preferred Outpatient Mental Health Covers Medicare deductibles, copays and coinsurances $0 copayment for covered services. Enrollee may self-refer for one assessment from a network provider in a 12 month period. $0 copayment for covered services There is no copayment or deductible for each covered individual or group therapy visits, visit with a psychiatrist, partial hospitalization program services. Except in an emergency, authorization rules apply. Outpatient Services/Surgery Covers Medicare deductibles, copays and coinsurances. $0 copayment for covered services. $0 copayment for covered services Outpatient Substance Abuse Care Covers Medicare deductibles, copays and coinsurances. $0 copayment for covered services. Enrollee may self-refer for one assessment from a network provider in a 12 month period $0 copayment for covered services.

42 Summary of Medicaid-Covered (continued) Summary of Medicaid-Covered Benefit NYS Medicaid Plan CHOICE Maximum CHOICE Preferred Outpatient Rehabilitation Services Covers Medicare deductibles, copays and coinsurances Occupational, Physical and Speech therapies are limited to twenty (20) visits per therapy per year, except for children under age 21, or you have been determined to be developmentally disabled by the Office for People with Developmental Disabilities, or if you have a traumatic brain injury. $0 copayment for covered services. Occupational, Physical and Speech therapies are limited to twenty (20) visits per therapy per year, except for children under age 21, or you have been determined to be developmentally disabled by the Office for People with Developmental Disabilities, or if you have a traumatic brain injury. $0 copayment for Medicarecovered services. Outpatient Services/Surgery Covers Medicare deductibles, copays and coinsurances $0 copayment for covered services. $0 copayment for covered services Outpatient Substance Abuse Care Covers Medicare deductibles, copays and coinsurances $0 copayment for covered service. Enrollee may self-refer for one assessment from a network provider in a 12 month period. $0 copayment for covered services.

43 Summary of Medicaid-Covered (continued) Summary of Medicaid-Covered Benefit NYS Medicaid Plan CHOICE Maximum CHOICE Preferred Over-the- Counter Drugs Certain Over the Counter medications are covered. Covers up to $88 per month for over the counter products Covers up to $77 per month for over the counter products. Pap Smears and Pelvic Exams Personal Care Services Covers Medicare deductibles, copays and coinsurances. Some health products may be available to you through Medicaid using your Medicaid Benefit ID card. $0 copayment for covered services. Some health products may be available to you through Medicaid using your Medicaid Benefit ID card. $0 copayment for covered services. Covered by Medicaid Not covered by plan Not covered by plan Personal Emergency Response Services (PERS) New York State Medicaid covers electronic devices that enable individuals to secure help in a physical, emotional or environmental emergency. $0 copayment for PERS Unit. $0 copayment for PERS Unit. There is no copayment for Medicaid-covered services.