benefits Summary of FHCP s Medvantage Plan (HMO-POS) A Medicare Advantage HMO Plan Flagler, Volusia, and Seminole Counties

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1 Summary of benefits FHCP s Medvantage Plan A Medicare Advantage HMO Plan Flagler, Volusia, and Seminole Counties H1035_NR770 (09/09/2016) H1035_NR531 FYI (08/17/2015)

2 NOTES H1035_NR770 (09/09/2016)

3 FHCP s Medvantage Plan H1035, Plan 007 Summary of Benefits January 1, December 31, 2017 This booklet gives you a summary of health plan services that 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". Who can join? To join FHCP s Medvantage Plan, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in Florida: Flagler, Seminole, and Volusia. Which doctors and hospitals can I use? FHCP s Medvantage Plan has an extensive network of doctors, hospitals, and other providers. If you use the providers in our network, you may pay less for your covered services. If you use providers that are not in our network, the plan may not pay for these services. You can see our plan's provider directory at our website Or, call us and we will send you a copy of the provider directory. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers and more. Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. FHCP s Medvantage Plan covers Part B drugs including chemotherapy and some drugs administered by your provider. However, this plan does not cover Part D prescription drugs. Things to Know About FHCP Hours of Operation You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern Standard time. FHCP s Phone Numbers and Website If you are a member of this plan, call toll-free Hearing Impaired call TRS Relay 711. If you are not a member of this plan, call toll-free Go2FHCP ( ). Hearing Impaired call TRS Relay 711. Our website: 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 Florida Health Care Plans (FHCP) is an HMO with a Medicare contract. Enrollment in Florida Health Care Plans depends on contract renewal. This information is not a complete description of benefits. Contract the plan for more information. Limitation, copayments and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. The provider network may change at any time. You will receive notice when necessary. This document is available in other formats such as Braille and large print. H1035_FA1816 CMS Accepted (09/13/2016)

4 Premiums and Benefits Monthly Plan Premium SUMMARY OF BENEFITS January 1, 2017 December 31, 2017 FHCP s Medvantage Plan $0 per month. Florida Health Care Plan, Inc. will reduce your Medicare Part B premium by up to $15. You must keep paying your Medicare Part B premium. Deductible $0 per year This plan does not have a deductible Maximum Out-of-pocket Responsibility $6,700 annually The most you pay for copays, coinsurance and other costs for medical services for the year. Inpatient Hospital $295 copay per day for days 1 Coverage through 6 $0 copay per day for days 7 through 90 $0 copay per day for days 91 and beyond Our plan covers an unlimited number of days for an inpatient hospital stay. You pay the Inpatient Hospital copayments each time you're admitted to a hospital, no matter how many days have passed since your last admission. Doctor Visits Primary Specialists $5 copay per visit $40 copay per visit A copay will apply for No-show PCP and/or Specialist visits. Preventive Care $0 copay Any additional preventive services approved by Medicare during the contract year will be covered. There are some items not covered at $0 cost. Our plan covers many preventive services, including: Abdominal Aortic Aneurysm Screening Annual Wellness Visit Bone Mass Measurement Breast Cancer Screening (mammograms) Cardiovascular Disease Risk Reduction Visit Page 2

5 Premiums and Benefits Preventive Care, continued FHCP s Medvantage Plan Cardiovascular Disease Testing Cervical and Vaginal Cancer Screening Colorectal Cancer Screening Depression Screening Diabetes Screening Diabetes Self-Management Training HIV Screening Immunizations (Influenza, Pneumonia, Hepatitis B) Lung Cancer Screening Medical Nutrition Therapy Obesity Screening and Therapy Prostate Cancer Screening Screening and Counseling to Reduce Alcohol Misuse STI/STD Screening Smoking and Tobacco Use Cessation Welcome to Medicare Preventive Visit Preventive Services are covered in full when received by an FHCP participating provider Emergency Care $75 copay 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. Emergency care is available worldwide. Urgently Needed Services FHCP Extended Hours Care Center Urgent Care Center Diagnostic Services/Labs/Imaging Diagnostic Radiology services (such as MRIs, CT scans) $5 copay per visit $40 copay per visit $ copay, depending on the service Urgently needed services are available worldwide. Please contact FHCP s Marketing Department and ask for a copy of Chapter 4 from the 2017 Evidence of Coverage. Page 3

6 Premiums and Benefits Diagnostic Services/Labs/Imaging, continued Diagnostic tests and procedures Lab Services Outpatient x-rays FHCP s Medvantage Plan $0-175 copay, depending on the service $0 copay $10-25 copay, depending on the service Therapeutic radiology services (such as radiation treatment for cancer) Hearing Services Exam to diagnose and treat hearing and balance issues $10-50 copay, depending on the service $0 copay per visit Routine hearing exam Hearing aid fitting/evaluation Dental Services Preventive Dental $0 copay per visit $0 copay per visit Not covered Routine hearing exam up to 1 every year. Hearing aid fitting/evaluation up to 1 every year. Limited Dental Services $40 copay per visit Limited dental services do not include services in connection with care, treatment, filling, removal, or replacement of teeth. Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) Eyeglasses or contact lenses after cataract surgery $15-40 copay, depending on the service $0 copay Please contact FHCP s Marketing Department and ask for a copy of Chapter 4 from the 2017 Evidence of Coverage. Page 4

7 Premiums and Benefits Vision Services, continued Routine eye exam Eyeglasses (frames and lenses) Mental Health Services Outpatient therapy visits Group Individual Inpatient visit Skilled Nursing Facility (SNF) Outpatient Rehabilitation Services Occupational therapy visit Physical therapy and speech and language therapy visit Pulmonary rehab services FHCP s Medvantage Plan $15 copay per visit Plan pays up to $90 every two years toward the purchase of eyeglasses (lenses and frames) from a participating Optometrist. $40 copay per visit $40 copay per visit $295 copay per day for days 1 through 5 $0 copay per day for days 6 through 90 $0 copay per day for days 91 and beyond $0 copay per day for days 1 through 20 $160 copay per day for days 21 through 100 $30 copay per visit $30 copay per visit $30 copay per session Up to 1 Routine eye exam every year when performed by an Optometrist. Eyeglasses (frames & lenses) up to 1 every two years Our plan covers an unlimited number of days for an inpatient hospital stay. You pay the Inpatient Hospital Psychiatric copayments each time you're admitted to a hospital, no matter how many days have passed since your last admission. Our plan covers up to 100 days in a SNF. No prior hospital stay required. When admitted to a Skilled Nursing Facility (SNF), you're covered as defined by Original Medicare guidelines. FHCP does not cover custodial care. FHCP follows Original Medicare guidelines in determining authorization and benefit period for SNF services. Page 5

8 Premiums and Benefits Outpatient Rehabilitation Services, continued Cardiac (heart) rehab services FHCP s Medvantage Plan $30 copay per session For a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks. Ambulance $175 copay Non-emergency transportation must Transportation Foot Care (podiatry services) Not covered be pre-authorized by FHCP. Medicare-covered foot exams and treatment Routine foot care Medical Equipment/Supplies Durable Medical Equipment (e.g., wheelchairs, oxygen, etc.) $40 copay per visit $10 copay per visit Routine foot care is covered for individuals with diabetes or other conditions that result in damage to the nerve and blood supply of their feet, or poor circulation in the feet (i.e. cutting or removal or corns, warts, calluses or nails). Limited to 6 visits per year. 20% of the cost Prosthetic Devices (braces, artificial limbs, etc.) and related medical supplies Diabetic supplies: 50 Test Strips/sensors Lancets Glucometer Therapeutic shoes or inserts 20% of the cost $10 copay $10 copay $0 copay 20% of the cost Diabetic Supplies/Services are limited to specific manufacturers, products and/or brands issued by participating pharmacies and DME suppliers. Contact FHCP for additional information. Page 6

9 Premiums and Benefits Wellness Programs (e.g. fitness) Preferred Fitness Program Telemedicine (Doctor on Demand) Primary Care Psychologist Acute Low Back and Neck Pain Program Medicare Part B Drugs Chemotherapy drugs Other Part B drugs When administered in a Dialysis Center FHCP s Medvantage Plan $0 copay per visit $10 copay per visit $30 copay per visit $30 copay per visit 20% of the cost 20% of the cost 20% of the cost For additional Wellness programs, please contact FHCP s Marketing Department and ask for a copy of Chapter 4 from the 2017 Evidence of Coverage. Part B drugs are available at FHCP Innetwork Preferred Retail Pharmacies only, up to a 31-day supply, OR when administered by an in-network physician or an out-of-network physician. Page 7

10 FHCP s Medvantage Plan OPTIONAL SUPPLEMENTAL BENEFITS (YOU MUST PAY AN ADDITIONAL PREMIUM EACH MONTH FOR THESE BENEFITS) Optional Point of Service Benefit Premium and Other Important Information Maximum Out-of-Pocket responsibility Inpatient Hospital Acute (out-of-network) Inpatient Psychiatric Hospital (out-of-network) Skilled Nursing Facility (out-of-network) Group 1 (out-of-network) Group 2 (out-of-network) $70 monthly premium, in addition to your $0 monthly plan premium and monthly Medicare Part B premium. Florida Health Care Plan, Inc. will reduce your Medicare Part B premium by up to $15. $8,000 Annually - Out-of-Network $200 copay per day for days 1-10 $0 copay per day beginning on day 11 $200 copay per day for days 1-10 $0 copay per day beginning on day 11 $175 copay per day for days 1-58 $0 copay per day for days % coinsurance $40 copay The Optional Point of Service (POS) benefit is Open Access meaning you do not need a referral if you need specialized treatment. The Optional POS benefit is limited to contract HMO participating providers or facilities AND Medicare participating providers and facilities outside of FHCP s network. Coinsurance is based on the Medicare Fee Schedule in effect at the time of service. Under this benefit you pay the following for Medicare-covered services. Service categories include: Home Health Services All Outpatient Procedures/Tests, Lab & Radiology Services, and X- rays Outpatient Surgery (Hospital Services & Ambulatory Surgical Centers) Durable Medical Equipment Prosthetics/Medical Supplies Diabetic Supplies/Services Medicare Part B Drugs Preventive Services Service categories include: Primary Care or Specialty physicians Outpatient Rehab (Cardiac, Pulmonary, Occupational, Physical & Speech-Language Pathology Therapy) Podiatry Chiropractic Mental Health Outpatient Substance Abuse Comprehensive Dental Page 8

11 MULTI-LANGUAGE INSERT ENGLISH: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: TRS Relay 711). SPANISH: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: TRS Relay 711). FRENCH CREOLE: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: TRS Relay 711). VIETNAMESE: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: TRS Relay 711). PORTUGUESE: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: TRS Relay 711). CHINESE: 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY:TRS Relay 711) FRENCH : ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : TRS Relay 711). TAGALOG: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: TRS Relay 711). RUSSIAN: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: TRS Relay 711). ARABIC: ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم:.(TRS Relay 711 ITALIAN: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: TRS Relay 711). GERMAN: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: TRS Relay 711). KOREAN: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: TRS Relay 711) 번으로전화해주십시오. POLISH: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: TRS Relay 711). GUJARATI: ચન : જ તમ જર ત બ લત હ, ત ન: લ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર (TTY: TRS Relay 711). THAI: เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: TRS Relay 711). Page 9

12 Discrimination is Against the Law Florida Health Care Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Florida Health Care Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Florida Health Care Plans: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o 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 Daria Siciliano, RN-BC, CCM. If you believe that Florida Health Care Plans 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: Daria Siciliano, RN-BC, CCM, Manager of Member Services, 1340 Ridgewood Avenue, Holly Hill, FL , TTY: TRS Relay 711, , rights@fhcp.com. You can file grievance in person or by mail, fax, or . If you need help filing a grievance, Daria Siciliano, RN-BC, CCM Manager of Member Services 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 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 Page 10

13 FOR MORE INFORMATION ABOUT FLORIDA HEALTH CARE PLANS, PLEASE CALL: Go2FHCP ( ) (TTY# TRS Relay 711) Hours of operation: 7 days a week, 8 a.m. to 8 p.m. Service Area: Flagler, Seminole and Volusia Counties, Florida This brochure is for information only and does not constitute an agreement. Florida Health Care Plans is an HMO plan with a Medicare contract. Enrollment in Florida Health Care Plans depends on contract renewal. Page 11