health. Our focus Summary of Benefits Health Partners Medicare Special (HMO SNP)

Transcription

1 Yur health. Our fcus Summary f Benefits Health Partners Medicare Special (HMO SNP)

2 2018 Summary f Benefits Health Partners Medicare (H9207) Health Partners Medicare Special (HMO SNP) (plan 004) This is a summary f drug and medical services cvered by Health Partners Medicare Special (HMO SNP) fr the plan year January 1, 2018 December 31, The benefit infrmatin prvided is a summary f what we cver and what yu pay. It des nt list every service that we cver r list every limitatin r exclusin. T get a cmplete list f the services we cver, please see the Evidence f Cverage. View it nline at r get a cpy by calling Member Relatins at (TTY 711), 24 hurs a day, seven days a week. Health Partners Medicare has a netwrk f dctrs, hspitals, pharmacies and ther prviders. If yu use prviders that are nt in ur netwrk, the plan may nt pay fr these services. Fr infrmatin abut prescriptin drugs cvered, please see the plan s Frmulary. Fr infrmatin abut prviders and pharmacies in ur netwrk, see ur Prvider & Pharmacy Directry. These dcuments are available at r by calling the plan at (TTY 711). Yu can call 24 hurs a day, seven days a week. T jin Health Partners Medicare Special, yu must be entitled t Medicare Part A, be enrlled in Medicare Part B, be eligible fr Medical Assistance frm the Pennsylvania State Medicaid prgram and live in ur service area. Our service area includes the fllwing cunties in Pennsylvania: Bucks, Chester, Delaware, Lancaster, Lehigh, Mntgmery, Nrthamptn and Philadelphia. If yu want t knw mre abut the cverage and csts f Original Medicare, lk in yur current Medicare & Yu handbk. View it nline at r get a cpy by calling MEDICARE ( ), 24 hurs a day, 7 days a week. TTY users shuld call Health Partners Medicare is an HMO plan with Medicare and Pennsylvania State Medicaid prgram cntracts. Enrllment in Health Partners Medicare depends n cntract renewal. Health Partners Medicare Special is available t anyne wh has bth Medical Assistance frm the State and Medicare. This infrmatin is nt a cmplete descriptin f benefits. Cntact the plan fr mre infrmatin. Limitatins, cpayments, and restrictins may apply. Benefits, premiums and/r cpayments/ cinsurance may change n January 1 f each year. Yu must cntinue t pay yur Medicare Part B premium (unless it is paid fr yu by Medicaid). Premium, cpays, cinsurance, and deductibles may vary based n the level f Extra Help yu receive. Please cntact the plan fr further details. Imprtant: Thrughut the fllwing benefit chart, where tw cst-sharing amunts are shwn fr the same benefit, yur cst sharing will depend n yur Medical Assistance (Medicaid) categry. Fr example, 0% r 20% indicates that yu will pay 0% if yu are in a Medical Assistance categry that cvers payment f Medicare cst sharing amunts, and yu will pay 20% if yu are in a Medical Assistance categry that des nt cver payment f Medicare cst-sharing amunts. Even if yu are therwise eligible fr 0% cst sharing, remember that yu must btain services nly frm Health Partners Medicare prviders wh als participate in the Medical Assistance prgram; if nt, Medical Assistance will nt pay the prvider and yu will be respnsible fr the higher cst-sharing amunt. Please cntact the Pennsylvania Medical Assistance prgram fr additinal infrmatin abut yur level f cst sharing. H9207_HPM Accepted 9/2017 1

3 Health Partners Medicare Special (HMO SNP) Mnthly Plan Premium Yu pay $37 r (if yu are fully dual eligible) $0. Yu must cntinue t pay yur Medicare Part B premium. Deductible Yu pay $0 r $183 a year. This amunt may change fr Maximum Out-f-Pcket Respnsibility (des nt include prescriptin drugs) $6,700 annually The mst yu pay fr cpays, cinsurance and ther csts fr medical services fr the year. OUTPATIENT PRESCRIPTION DRUG BENEFITS (PART D) Health Partners Medicare Special (HMO SNP) Deductible Stage Yu pay $0 r $83 r $405 per year fr Part D prescriptin drugs. Initial Cverage Stage (after yu pay yur deductible, if applicable) Generic Drugs All Other Drugs Standard Retail Rx 30-day supply Yu pay $0, $1.25 r $3.35 cpay; r 15% f the cst depending n yur incme level and institutinal status. Yu pay $0, $3.70 r $8.35 cpay; r 15% f the cst depending n yur incme level and institutinal status. Mail Order 90-day supply Yu pay $0, $1.25 r $3.35 cpay; r 15% f the cst depending n yur incme level and institutinal status. (A lng-term supply is nt available fr specialty drugs.) Yu pay $0, $3.70 r $8.35 cpay; r 15% f the cst depending n yur incme level and institutinal status. (A lng-term supply is nt available fr specialty drugs.) Cverage Gap Stage (after the ttal amunt fr the prescriptin drugs yu have filled and refilled reaches $3,750) When yu are in the Cverage Gap Stage, the Medicare Cverage Gap Discunt Prgram prvides manufacturer discunts n brand name drugs. Yu pay 35% f the negtiated price and a prtin f the dispensing fee fr brand name drugs. Bth the amunt yu pay and the amunt discunted by the manufacturer cunt tward yur ut-f-pcket csts as if yu had paid them and mve yu thrugh the cverage gap. Yu als receive sme cverage fr generic drugs. Yu pay n mre than 44% f the cst fr generic drugs and the plan pays the rest. Fr generic drugs, the amunt paid by the plan (56%) des nt cunt tward yur ut-f-pcket csts. Only the amunt yu pay cunts and mves yu thrugh the cverage gap. 2

4 Health Partners Medicare Special (HMO SNP) Catastrphic Cverage Stage (after yur ut-fpcket csts have reached the $5,000 limit fr the calendar year) Once yu are in the Catastrphic Cverage Stage, yu will stay in this payment stage until the end f the calendar year. During this stage, the plan will pay mst f the cst fr yur drugs. Yur share f the cst fr a cvered drug will be either cinsurance r a cpayment, whichever is the larger amunt: either cinsurance f 5% f the cst f the drug r $3.35 fr a generic drug r a drug that is treated like a generic and $8.35 fr all ther drugs Our plan pays the rest f the cst. Lng-Term Care Pharmacy and Outf-Netwrk Pharmacy Cverage Yur csts may vary in lng-term care r hme infusin settings. Fr mre infrmatin, please see the plan s Evidence f Cverage at r call us at (TTY 711). Yu can call 24 hurs a day, seven days a week. MEDICAL BENEFITS (PART C) Benefits Inpatient Hspital Cverage Health Partners Medicare Special (HMO SNP) In 2018, the amunt yu pay fr each admissin/stay is $0 r: $1,340 deductible fr days 1 60 $335 cpay fr days $670 cpay a day fr 60 lifetime reserve days Our plan cvers up t 90 days fr an inpatient hspital stay. Our plan als cvers 60 lifetime reserve days. These are extra days that we cver. If yur hspital stay is lnger than 90 days, yu can use these extra days. Once yu have used up these extra 60 days, yur inpatient hspital cverage will be limited t 90 days. A per admissin deductible is applied nce during each hspital admissin/stay. Cpays als apply t each hspital admissin/stay. All elective inpatient admissins require prir authrizatin. All ther admissins will be reviewed fr medical necessity and authrizatin. 3

5 Benefits Health Partners Medicare Special (HMO SNP) Outpatient Hspital Services/ Surgery Ambulatry surgical center Yu pay 0% r 20% f the ttal cst. Outpatient hspital Yu pay 0% r 20% f the ttal cst. Prir authrizatin is required. Dctr Visits Primary care prvider Yu pay 0% r 20% cinsurance each visit. Specialists Yu pay 0% r 20% cinsurance each visit. Referral is required fr specialist visits. Preventive Care Yu pay a $0 cpay. Any additinal preventive services apprved by Medicare during the cntract year will be cvered. There are sme services nt cvered at $0 cst. Authrizatin is required nly fr certain advanced radilgy tests, such as lw-dse CT scans fr lung cancer screening. Emergency Care Urgently Needed Services Yu pay 0% r 20% cinsurance (up t $80) each visit. Cinsurance is waived if yu are admitted t the same hspital within 24 hurs. Yu pay 0% r 20% cinsurance (up t $65) each visit. 4

6 Benefits Health Partners Medicare Special (HMO SNP) Diagnstic Services/Labs/ Imaging Lab services Yu pay 0% r 20% cinsurance. Medicare-cvered diagnstic tests and prcedures Outpatient diagnstic imaging tests (such as X- rays, ultrasund and mammgraphy) Advanced radilgy services (such as MRI, PET, CT, nuclear medicine) Therapeutic radilgy (such as radiatin treatment fr cancer) Yu pay 0% r 20% cinsurance. Yu pay 0% r 20% cinsurance. Yu pay 0% r 20% cinsurance. Yu pay 0% r 20% cinsurance. PCP r Specialist cinsurance als applies if service is prvided during an ffice visit. Prir authrizatin is required fr certain services prvided by yur dctr r ther netwrk prvider. Please cntact the plan fr mre infrmatin. Hearing Services Medicare-cvered hearing exam Yu pay 0% r 20% f the ttal cst. Rutine hearing exam Yu pay 0% cinsurance. Rutine hearing exams are cvered nce a year. Hearing aids $1,000 tward hearing aids every 3 years 5

7 Benefits Dental Services Preventive (such as ral exam & cleaning) Health Partners Medicare Special (HMO SNP) Yu pay $0 cpay fr 2 exams and cleanings per year, 1 set f X-rays per year and 1 fluride treatment per year. Medicare-cvered dental services Supplemental cmprehensive dental services Yu pay 0% r 20% f the ttal cst. The plan cvers $1,000 each year tward supplemental cmprehensive dental services. Visin Services Medicare-cvered visin services Medicare-cvered eyewear Yu pay 0% r 20% f the ttal cst. Yu pay $0 cpay fr ne pair f Medicare-cvered eyeglasses (lenses and frames) r cntact lenses after cataract surgery. Rutine visin exam Yu pay $0 cpay. Rutine exams are cvered nce a year. Supplemental eyewear $200 plan cverage limit every year fr cntact lenses r eyeglasses 6

8 Benefits Health Partners Medicare Special (HMO SNP) Mental Health Services Inpatient visit In 2018, the amunt yu pay fr each admissin/stay is $0 r: $1,340 deductible fr days 1 60 $335 cpay fr days $670 cpay a day fr 60 lifetime reserve days These amunts may change fr A per admissin deductible is applied nce during each hspital admissin/stay. Cpays als apply t each hspital admissin/stay. Prir authrizatin is required. Our plan cvers up t 190 days in a lifetime fr inpatient mental health care in a psychiatric hspital. The inpatient hspital care limit des nt apply t inpatient mental services prvided in a general hspital. Our plan cvers 90 days fr an inpatient hspital stay. Our plan als cvers 60 lifetime reserve days. These are extra days that we cver. If yur hspital stay is lnger than 90 days, yu can use these extra days. Once yu have used up these extra 60 days, yur inpatient hspital cverage will be limited t 90 days. Outpatient individual and therapy visits Yu pay 0% r 20% f the ttal cst fr each utpatient individual and grup therapy visit Prir authrizatin is required. Skilled Nursing Facility Our plan cvers up t 100 days in a skilled nursing facility during each benefit perid. In 2018, the amunt yu pay fr each benefit perid is: $0 cpay each day fr days 1 20 $ cpay each day fr days These amunts may change fr Prir authrizatin is required. 7

9 Benefits Health Partners Medicare Special (HMO SNP) Physical Therapy & Other Rehabilitatin Services Occupatinal therapy, physical therapy and speech and language therapy visit Medicare-cvered cardiac rehabilitatin Medicare-cvered pulmnary rehabilitatin Yu pay 0% r 20% f the ttal cst. Prir authrizatin is required. Yu pay 0% r 20% f the ttal cst. Yu pay 0% r 20% f the ttal cst. Ambulance Yu pay 0% r 20% f the ttal cst. Cst sharing applies t each ne-way: Emergency ambulance trip Cvered (medically necessary) nn-emergency ambulance trip Prir authrizatin is required n nn-emergency transprtatin nly. Transprtatin Up t 48 ne-way van r medical transprt trips each year t planapprved lcatins Transprtatin must be fr medical reasns. Trips must be arranged thrugh the plan s transprtatin vendr. Cntact plan fr details. Medicare Part B Drugs Acupuncture Yu pay 0% r 20% f the ttal cst fr chemtherapy drugs and ther Part B drugs. Prir authrizatin may be required. Yu pay a $5 cpay fr up t 20 visits each year. Services must be received frm netwrk prviders. Chirpractr Visits Medicare-cvered Yu pay 0% r 20% f the ttal cst. Rutine Yu pay a $0 cpay fr up t 20 visits each year. Prir authrizatin is required. Referral is required. 8

10 Benefits Health Partners Medicare Special (HMO SNP) Ft Care (pdiatry services) Medicare-cvered ft care Yu pay 0% r 20% cinsurance. Rutine ft care Yu pay a $20 cpay. Hme Health Care Up t 4 rutine ft care visits a year (ne every 3 mnths) Referral is required. Yu pay a $0 cpay. Prir authrizatin is required. Hspice Yu pay a $0 cpay. Services must be prvided by a Medicare-certified hspice. Yu may have t pay part f the csts fr drugs and respite care. Hspice is cvered utside f ur plan. Cntact the plan fr mre details. Meals Yu pay $0 cpay. Fur weeks f hme-delivered meals cvered fr members with uncntrlled diabetes r cngestive heart failure. Prir authrizatin is required. Medical Equipment/Supplies Durable Medical Equipment (such as wheelchairs, xygen) Yu pay 0% r 20% f the ttal cst. Prir authrizatin is required fr durable medical equipment csting mre than $500 and all rentals. Prsthetics (such as braces, artificial limbs) Yu pay 0% r 20% f the ttal cst. Prir authrizatin is required. Diabetes supplies Yu pay 0% r 20% f the ttal cst. 0% cinsurance will apply t diabetes mnitring supplies frm preferred manufacturers; 20% cinsurance will apply t these same supplies frm nn-preferred manufacturers; 20% cinsurance will apply t all ther Part B diabetic supplies. Prir authrizatin is required fr supplies frm nn-preferred manufacturers. 9

11 Benefits Health Partners Medicare Special (HMO SNP) Wellness Prgrams Fitness The plan pays fr annual membership at participating fitness centers. Teladc Yu pay a $0 cpay fr 24-hur health advice service. Bld pressure cuffs and scales T assist specific members with cngestive heart failure in mnitring and cntrlling their disease cnditin, a bld pressure cuff and/r scale will be ffered. Prir authrizatin is required fr bld pressure cuffs and scales. 10

12 Summary f Medicaid-Cvered Benefits T help yu better understand yur health care ptins, the fllwing chart describes the csts fr certain services as a Pennsylvania Medical Assistance (Medicaid) recipient and as a Health Partners Medicare Special member. T enrll in the Health Partners Medicare Special plan, yu must be dual eligible, meaning that yu qualify fr bth Medicare Part A and Part B and als receive Medicaid. Medicare cst sharing includes cpayments, cinsurance and deductibles. Yur Medicare cst-sharing respnsibility is based n yur level f Medicaid eligibility. Medicare cverage must be used first. Medicaid may then cver payment f yur cst sharing fr Medicare-cvered services, depending n yur level f Medicaid eligibility. If yur Medicaid categry is Qualified Medicare Beneficiary (QMB) r QMB Plus, yu will pay $0 fr thse services cvered by ur plan that shw 0% r 20% f the cst in this Summary f Benefits. Medicaid will cver cst-sharing amunts nly when yur primary care dctr and ther prviders participate in the Medicaid prgram. Our Prvider & Pharmacy Directry includes infrmatin t help yu chse netwrk prviders wh als accept Medicaid. T help avid errrs, always shw bth yur Health Partners Medicare member card and yur ACCESS card anytime yu receive health care services. It is imprtant t knw that Medicaid benefits and eligibility levels can change thrughut the year. Please cntact the Pennsylvania Medicaid prgram fr the mst current and accurate infrmatin regarding yur eligibility and benefits. The benefits described in the fllwing chart are cvered by Medicaid. The benefits described in the Cvered Medical and Hspital Benefits sectin f the Summary f Benefits are cvered by Medicare. Fr each benefit listed, yu can see what the Medical Assistance prgram cvers and what ur plan cvers. What yu pay fr cvered services may depend n yur level f Medicaid eligibility. 11

13 Summary f Medicaid-Cvered Benefits Benefit Categry Medicaid Health Partners Medicare Special (HMO SNP) In-Netwrk Acupuncture Nt cvered $5 cpay fr each visit, fr up t 20 visits a year Certified Registered Nurse Practitiner $0 $3.80 cpay (sliding scale based n Medical Assistance fee fr the service) N limits 0% r 20% f the cst fr each Medicare-cvered visit Chirpractic Services $0 $3.80 cpay (sliding scale based n Medical Assistance fee fr the service) N limits 0% r 20% f the cst fr each Medicare-cvered chirpractic visit Medicare-cvered chirpractic visits are fr manual manipulatin f the spine t crrect a subluxatin (when ne r mre f the bnes f yur spine mve ut f psitin). $0 cpay fr up t 20 supplemental rutine chirpractic visits every year 12

14 Summary f Medicaid-Cvered Benefits Benefit Categry Medicaid Health Partners Medicare Special (HMO SNP) In-Netwrk Dental Services $0 $3.80 cpay (sliding scale based n Medical Assistance fee fr the service) Dentures cvered nce a lifetime Exams/cleanings cvered nce every 180 days Crwns, peridntics and enddntics cvered nly with an apprved benefit limit exceptin 0% r 20% f the cst fr Medicarecvered dental benefits $0 cpay fr the fllwing preventive dental benefits: up t 2 ral exams every year up t 2 cleanings every year 1 fluride treatment every year 1 dental X-ray every year $1,000 plan cverage limit fr supplemental cmprehensive dental benefits every year Diagnstic Tests, X-rays, Lab Services and Radilgy Services $0 $1 cpay N limits 0% r 20% f the cst fr Medicarecvered diagnstic radilgy services (such as MRIs, CT scans, etc.) 0 20% f the cst fr diagnstic tests and prcedures, depending n the service 0 20% f the cst fr lab services, depending n the service 0% r 20% f the cst fr utpatient X-rays 0% r 20% f the cst fr therapeutic radilgy services (such as radiatin treatment fr cancer) 13

15 Summary f Medicaid-Cvered Benefits Benefit Categry Medicaid Health Partners Medicare Special (HMO SNP) In-Netwrk Dctr Visits $0 $3.80 cpay (sliding scale based n Medical Assistance fee fr the service) N limits 0% r 20% f the cst fr each Medicare-cvered primary care dctr visit 0% r 20% f the cst fr each Medicare-cvered specialist visit Durable Medical Equipment $0 $3.80 cpay (sliding scale based n Medical Assistance fee fr the service) 0% r 20% f the cst fr Medicarecvered durable medical equipment Emergency Care $0 cpay N limits 0% r 20% f the cst (up t $80) fr Medicare-cvered emergency rm visits If yu are admitted t the hspital within 24 hurs, yu d nt have t pay yur share f the cst fr emergency. Family Planning Services $0 cpay N limits Nt cvered 14

16 Summary f Medicaid-Cvered Benefits Benefit Categry Medicaid Health Partners Medicare Special (HMO SNP) In-Netwrk Health/Wellness Services Health advice line, fitness memberships and bld pressure cuff and/r scale fr recipients with cngestive heart failure nt cvered The plan cvers the fllwing supplemental health/wellness prgrams: Teladc 24-hur health advice line Fitness center membership Bld pressure cuff and/r scale fr certain members with cngestive heart failure Hearing Services $0 $3.80 cpay (sliding scale based n Medical Assistance fee fr the service) Hearing aids nt cvered fr adults 0% r 20% f the cst fr Medicare-cvered diagnstic hearing exams $0 cpay fr supplemental hearing aid(s) every 3 years ($1,000 plan cverage limit) $0 cpay fr 1 supplemental rutine hearing exam every year Hme Health Care $0 cpay N limit fr first 28 days, then up t 15 days are cvered each mnth $0 cpay fr Medicare-cvered hme health visits 15

17 Summary f Medicaid-Cvered Benefits Benefit Categry Medicaid Health Partners Medicare Special (HMO SNP) In-Netwrk Hspice $0 cpay Key limitatin: Respite care is cvered up t 5 days during each 60-day certificatin perid. Yu must get care frm a Medicare-certified hspice. Yu must cnsult with yur plan befre yu select hspice. Inpatient Hspital Care $3 each day up t $21 each admissin N limits The plan cvers up t 90 days fr each inpatient stay. In additin, there are 60 lifetime reserve days. In 2018, the amunt fr each inpatient stay is $0 r: Days 1 60: $1,340 deductible Days 61 90: $335 each day $670 cpay each day fr 60 lifetime reserve days Except in an emergency, yur dctr must tell the plan that yu are ging t be admitted t the hspital. 16

18 Summary f Medicaid-Cvered Benefits Benefit Categry Medicaid Health Partners Medicare Special (HMO SNP) In-Netwrk Inpatient Mental Health Care $3 each day up t $21 each admissin N limits Yu get up t 190 days f inpatient psychiatric hspital care in a lifetime. Inpatient psychiatric hspital services cunt tward the 190-day lifetime limitatin nly if certain cnditins are met. This limitatin des nt apply t inpatient psychiatric services furnished in a general hspital. In 2018, the amunt fr each inpatient stay is $0 r: Days 1 60: $1,340 deductible Days 61 90: $335 each day $670 each day fr up t 60 lifetime reserve days These amunts may change fr Except in an emergency, yur dctr must tell the plan that yu are ging t be admitted t the hspital. Medical Supplies $0 $3.80 cpay (sliding scale based n Medical Assistance fee fr the service) N limits 0% r 20% f the cst fr Medicare-cvered medical supplies 17

19 Summary f Medicaid-Cvered Benefits Benefit Categry Medicaid Health Partners Medicare Special (HMO SNP) In-Netwrk Nurse Midwife $0 cpay N limits 0% r 20% f the cst fr each Medicare-cvered visit Nursing Hme $0 cpay In rder t receive nursing hme services, individuals must meet clinical criteria t be cnsidered Nursing Facility Clinically Eligible (NFCE) by the lcal Area Agency n Aging Nt cvered Outpatient Mental Health Care $0.50 cpay each unit (individual r grup therapy) N limits 0% r 20% f the cst fr each Medicare-cvered individual therapy visit 0% r 20% f the cst fr each Medicare-cvered grup therapy visit 18

20 Summary f Medicaid-Cvered Benefits Benefit Categry Medicaid Health Partners Medicare Special (HMO SNP) In-Netwrk Outpatient Rehabilitatin Services $0 $3.80 cpay (sliding scale based n Medical Assistance fee fr the service) Cvered nly when prvided by a hspital, utpatient clinic r hme health prvider 0% r 20% f the cst fr Medicare-cvered ccupatinal therapy visits 0% r 20% f the cst fr Medicare-cvered physical therapy and speech and language therapy visits Outpatient Substance Abuse Treatment $0 $3.80 cpay (sliding scale based n Medical Assistance fee fr the service) N limits 0% r 20% f the cst fr Medicare-cvered individual therapy visit 0% r 20% f the cst fr Medicare-cvered grup therapy visit Outpatient Surgery $0 $3.80 cpay (sliding scale based n Medical Assistance fee fr the service) N limits 0% r 20% f the cst fr each Medicare-cvered ambulatry surgical center visits 0% r 20% f the cst fr each Medicare-cvered utpatient hspital facility visit 19

21 Summary f Medicaid-Cvered Benefits Benefit Categry Medicaid Health Partners Medicare Special (HMO SNP) In-Netwrk Over-the-Cunter Items Nt cvered $50 mnthly ver-the-cunter pharmacy allwance at participating pharmacies Nte: Unused prtins f the $50 mnthly benefit d nt carry ver mnth t mnth Physician apprval is required (such as with a written prescriptin). Visit t see the list f cvered ver-thecunter items. Pdiatry Services $0 $3.80 cpay (sliding scale based n Medical Assistance fee fr the service) N limits 0% r 20% f the cst fr each Medicare-cvered pdiatry visit Medicare-cvered pdiatry visits are fr ft exams and treatment if yu have diabetes-related nerve damage and/r meet certain cnditins $20 cpay fr 1 supplemental rutine pdiatry visit every 3 mnths 20

22 Summary f Medicaid-Cvered Benefits Benefit Categry Medicaid Health Partners Medicare Special (HMO SNP) In-Netwrk Prescriptin Drugs $1 generic / $3 brand fr Medicaid cvered prescriptin drugs Certain drug categries are excluded frm cpays If yu have Medicare, drugs cvered under Medicare Part D are usually nt cvered by Medicaid. Depending n yur incme and institutinal status, yu pay the fllwing during the Initial Cverage Perid: Fr generic drugs (including brand drugs treated as generic), either: $0 cpay r $1.25 cpay r $3.35 cpay r 15% f the cst Fr all ther drugs, either: $0 cpay r $3.70 cpay r $8.35 cpay r 15% f the cst Yu can get drugs the fllwing way(s): 1-mnth (30-day) supply 2-mnth (60-day) supply 3-mnth (90-day) supply Nte: Specialty drugs aren t available fr an extended day supply 21

23 Summary f Medicaid-Cvered Benefits Benefit Categry Medicaid Health Partners Medicare Special (HMO SNP) In-Netwrk Prsthetic Devices $0 $3.80 cpay (sliding scale based n Medical Assistance fee fr the service) Lw visin aids and eye prsthesis limited t 1 per beneficiary per 2 years Eye culars limited t 1 per year 0% r 20% f the cst fr Medicare-cvered prsthetic devices 0% r 20% f the cst fr Medicare-cvered medical supplies related t prsthetic devices Orthtic shes nt cvered 0% r 20% f the cst fr Medicarecvered therapeutic shes r inserts Psychiatric Partial Hspitalizatin $0 cpay N limits 0% r 20% f the cst fr Medicarecvered psychiatric partial hspitalizatin services Renal Dialysis $0 cpay N limit in freestanding dialysis center Initial training fr hme dialysis, prvided in a renal dialysis clinic, is limited t 24 sessins per beneficiary Backup visits t facility limited t 75 each year 0% r 20% f the cst fr Medicare-cvered renal dialysis 22

24 Summary f Medicaid-Cvered Benefits Benefit Categry Medicaid Health Partners Medicare Special (HMO SNP) In-Netwrk Skilled Nursing Facility (SNF) $0 cpay 365 days cvered yearly The plan cvers up t 100 days each benefit perid. N prir hspital stay is required. In 2018, the amunt fr each inpatient stay is $0 r: Days 1 20: $0 each day Days : $ each day These amunts may change fr Tbacc Cessatin $0 cpay Limited t minute units per calendar year $0 cpay fr up t 8 sessins per year. Transprtatin (rutine) Medical Assistance Transprtatin Prgram prvides special transprtatin r cvers public transprtatin csts t/frm Medical Assistancecvered services N limits $0 cpay fr up t 48 ne-way trips t plan-apprved lcatins each year 23

25 Summary f Medicaid-Cvered Benefits Benefit Categry Medicaid Health Partners Medicare Special (HMO SNP) In-Netwrk Urgently Needed Services $0 $3.80 cpay (sliding scale based n Medical Assistance fee fr the service) N limits 0% r 20% f the cst (up t $65) Visin Services $0 $3.80 cpay (sliding scale based n Medical Assistance fee fr the service) Tw rutine exams are cvered yearly. Glasses/cntacts limited t patients with aphakia: Up t 2 eyeglass frames Up t 4 eyeglass lenses r Up t 4 cntact lenses 0% r 20% f the cst fr Medicarecvered exams t diagnse and treat diseases and cnditins f the eye, including an annual glaucma screening fr peple at risk $0 cpay fr ne pair f Medicarecvered eyeglasses (lenses and frames) r cntact lenses after cataract surgery $0 cpay fr 1 supplemental rutine eye exam every year $200 plan cverage limit fr supplemental eyewear every year 24

26 Health Partners Medicare 901 Market Street, Suite 500 Philadelphia, PA (TTY 711) HPPMedicare.cm H9207_HPM Accepted 9/2017