Summary of Benefits. SCAN Connections at Home (HMO SNP) Los Angeles, Riverside and San Bernardino Counties. January 1, December 31, 2018

Transcription

1 2018 Summary of Benefits Connections at Home (HMO SNP) Los Angeles, Riverside and San Bernardino Counties January 1, December 31, 2018 Connections at Home (HMO SNP) is an HMO plan with a Medicare contract and a contract with the California Medi-Cal (Medicaid) program. Enrollment in Health Plan depends on contract renewal. Connections at Home is a Coordinated Care Plan. Connections at Home is available to anyone who has both Medical Assistance from the State and Medicare. The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of we cover, please request the Evidence of Coverage by calling our Member Service Department at the phone number listed in this document or online at Y _2017F File & Use Accepted DHCS Approved C-SMB009

2 SUMMARY OF BENEFITS JANUARY 1, 2018 DECEMBER 31, 2018 PREMIUM AND BENEFITS WHAT YOU SHOULD KNOW Los Angeles County Riverside County San Bernardino County Monthly Health Plan Premium Deductible This plan does not have a deductible. Maximum Out-of- Pocket Responsibility (this does not include prescription drugs) Inpatient Hospital Coverage $0 annually $0 annually $0 annually The most you pay for copays and coinsurance for Medicare-covered medical for the year. Our plan covers an unlimited number of days for an inpatient hospital stay. Prior authorization rules apply. Outpatient Hospital Coverage Ambulatory Surgical Center Outpatient Hospital Prior authorization is required for outpatient hospital.

3 PREMIUM AND BENEFITS WHAT YOU SHOULD KNOW Los Angeles County Riverside County San Bernardino County Doctor Visits Primary Care Prior authorization is required for specialist visits. Specialists Preventive Care Any additional preventive approved by Medicare during the contract year will be covered. Prior authorization rules apply. Emergency Care You are covered for worldwide emergency. Urgently Needed Services You are covered for worldwide urgent care. Diagnostic Services/ Labs/Imaging Lab Diagnostic tests and procedures Prior authorization is required for diagnostic, lab, and imaging. Outpatient X-rays Therapeutic radiology Diagnostic radiology (e.g., MRI, CT)

4 PREMIUM AND BENEFITS WHAT YOU SHOULD KNOW Los Angeles County Riverside County San Bernardino County Hearing Services Medicarecovered diagnostic hearing and balance exam Non-Medicarecovered (routine) hearing exam Non-Medicarecovered (routine) hearing aids Dental Services Medicarecovered dental Non-Medicarecovered (routine) cleaning for up to 1 visit per year You are covered for Flyte 770 or Flyte 990 hearing aids every year as medically necessary for up to 1 visit per year You are covered for Flyte 770 or Flyte 990 hearing aids every year as medically necessary for up to 1 visit per year You are covered for Flyte 770 or Flyte 990 hearing aids every year as medically necessary for up to 2 visits per year for up to 2 visits per year for up to 2 visits per year Prior authorization is required for Medicare-covered diagnostic hearing and balance exams. You must go to a -contracted provider to obtain a routine hearing exam and hearing aids. Prior authorization is required for Medicare-covered dental. Routine dental do not require a prior authorization. Non-Medicarecovered (routine) dental fillings Non-Medicarecovered (routine) denture You pay $0-$350 copay per denture You pay $0-$350 copay per denture You pay $0-$350 copay per denture You must go to a -contracted dentist to obtain routine dental.

5 PREMIUM AND BENEFITS WHAT YOU SHOULD KNOW Los Angeles County Riverside County San Bernardino County Vision Services Medicare-covered vision exam to diagnose/treat diseases of the eye Medicare-covered glasses after cataract surgery Prior authorization is required for Medicare-covered vision exam and glasses after cataract surgery. Routine vision do not require a prior authorization. Non-Medicarecovered (routine) vision exam Non-Medicarecovered (routine) glasses or contact lenses for up to 1 visit per year per pair every 2 years for up to 1 visit per year per pair every 2 years for up to 1 visit per year per pair every 2 years You must go to a -contracted vision provider to obtain routine vision. Non-Medicarecovered (routine) vision coverage limit You are covered for up to $300 for frames or contact lenses every 2 years You are covered for up to $300 for frames or contact lenses every 2 years You are covered for up to $300 for frames or contact lenses every 2 years Mental Health Services Inpatient visit Prior authorization is required for inpatient mental health hospitalization. Outpatient individual/group therapy visit Outpatient individual/ group therapy visit with a psychiatrist Prior authorization is required for outpatient mental health.

6 PREMIUM AND BENEFITS WHAT YOU SHOULD KNOW Los Angeles County Riverside County San Bernardino County Skilled Nursing Facility Prior authorization is required for skilled nursing facility. No prior hospitalization is required. Physical Therapy Prior authorization is required for physical therapy. Ambulance Transportation (Non-Medicarecovered - routine) for unlimited oneway trips per year 75-mile limit applies to each one-way trip for unlimited one-way trips per year 75-mile limit applies to each one-way trip for unlimited one-way trips per year 75-mile limit applies to each one-way trip Prior authorization is required for routine transportation. You must use a -contracted provider to obtain routine transportation. Medicare Part B Drugs for chemotherapy and other Part B drugs for chemotherapy and other Part B drugs for chemotherapy and other Part B drugs Prior authorization rules apply to select drugs.

7 OUTPATIENT PRESCRIPTION DRUGS Depending on your income and institutional status, you pay the following: Preferred Retail Pharmacy Standard Retail Pharmacy Mail-Order Pharmacy Initial Coverage Stage Tier 1 (Preferred Generic) One, two or three month supply or $1.25 or $3.35 copay Tier 2 (Generic) One, two or three month supply Tier 3 (Preferred Brand) One, two or three month supply Tier 4 (Non-Preferred Drug) One, two or three month supply You pay: For generic drugs (including brand drugs treated as generic), either: $0 or $1.25 or $3.35 copay For all other drugs, either: $0 or $3.70 or $8.35 copay Tier 5 (Specialty Tier) One month supply Catastrophic Coverage Stage You stay in the Initial Coverage Stage until your yearly out-of-pocket costs reach $5,000. After your yearly out-of-pocket costs reach $5,000, you will pay $0. Some of our network pharmacies have preferred cost-sharing. You may pay less for certain drugs if you use these pharmacies rather than pharmacies that offer standard cost-sharing. You may get your drugs at network retail pharmacies and mail-order pharmacy. If you reside in a long-term care facility, you pay the same as at a standard retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. Cost-Sharing may change depending on the pharmacy you choose (e.g., Preferred Retail, Standard Retail, Mail-Order, Long Term Care (LTC) or Home infusion, etc.) and when you enter another phase of the Part D benefit. For more information on the pharmacy-specific copays, please call Member Services Department at the phone number in this document or access your Evidence of Coverage online.

8 ADDITIONAL BENEFITS PREMIUM AND BENEFITS WHAT YOU SHOULD KNOW Los Angeles County Riverside County San Bernardino County Medical Equipment/ Supplies Durable Medical Equipment (e.g., wheelchairs, oxygen) Prosthetics (e.g., braces, artificial limbs) Prior authorization is required for covered durable medical equipment, prosthetic devices, and certain diabetic supplies. Diabetic supplies Wellness Programs Health club membership covers diabetic supplies such as glucose monitors, test strips, and control solution from a select manufacturer. Lancets are also covered and are available from all manufacturers.

9 Connections at Home has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these. ABOUT Who can join? Phone Number (Members) Phone Number (Non-Members) TTY You must: - have both Medicare Part A and Part B - have Full Medi-Cal (Medicaid) benefits - be 65 years of age or older - live in the plan service area (Los Angeles, Riverside, or San Bernardino Counties, California) - meet criteria for nursing facility level of care (NFLOC) as determined by staff, requiring an annual home visit - live in the community, such as in a house, apartment or assisted living facility - not be medically determined to have End-Stage Renal Disease (ESRD) - not be enrolled in any Medi-Cal (Medicaid) waiver program such as, but not limited to the In-Home Supportive Services (IHSS) program (Calling this number will direct you to a licensed insurance agent.) 711 Hours of Operation October 1 to February 14: 8:00 am to 8:00 pm, 7 days a week February 15 to September 30: 8:00 am to 8:00 pm, Monday through Friday (messages received on holidays and outside of our business hours will be returned within one business day) Website Provider & Pharmacy Directory link Formulary link Link to Evidence of Coverage To get more information 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

10 This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. Other providers are available in our network. You must continue to pay your Medicare Part B premium. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Premium, copays, coinsurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. You can get prescription drugs shipped to your home through our network mail-order delivery program. Typically, you should expect to receive your prescription drugs within 14 days from the time that the mailorder pharmacy receives the order. If you do not receive your prescription drug(s) within this time, please contact Health Plan s Member Services at , 8 a.m. to 8 p.m., 7 days a week from October 1 to February 14. From February 15 to September 30, hours are 8 a.m. to 8 p.m. Monday through Friday (messages received on holidays and outside of our business hours will be returned within one business day). TTY users call 711.

11 Additional Information about Your Medi-Cal (Medicaid) Benefits Connections at Home (HMO SNP) You may not qualify for all of the Medi-Cal (Medicaid) benefits listed. If you have any questions about your health care benefits, please contact at from 8 a.m. to 8 p.m., 7 days a week from October 1 to February 14. From February 15 to September 30, hours are 8 a.m. to 8 p.m. Monday through Friday (messages received on holidays and outside of our business hours will be returned within one business day). TTY users call 711. Members who qualify for both Medicare and Medi-Cal (Medicaid) health benefits have access to the Personal Assistance Line (PAL) Unit. The PAL Unit is a dedicated group of employees who are trained to understand the special needs of members who have both Medicare and Medi-Cal (Medicaid). They are called your PAL. Each Connections at Home member is partnered with a PAL to answer any questions about benefits, medications, specialty referrals, and other Medi-Cal (Medicaid) issues or questions. STATE OF CALIFORNIA MEDICAID (MEDI-CAL) PROGRAM COVERED BENEFITS FOR DUAL-ELIGIBLE (MEDICARE AND MEDICAID) BENEFICIARIES BENEFIT CATEGORY MEDI-CAL (MEDICAID) 1. Inpatient Hospital Services 2. Outpatient Hospital Services 3. Rural Health Clinic Services 4. Federally Qualified Health Center Services 5. Laboratory Services 6. X-Rays 7. Skilled Nursing Facility Care for Over 21 Years of Age Subacute Care 8. Pediatric Nursing Facility Care for Under 21 Years of Age Subacute Services (Early and periodic screening, diagnosis, and treatment supplemental )

12 BENEFIT CATEGORY MEDI-CAL (MEDICAID) 9. Family Planning Services and Supplies 10. Physician Services 11. Medical and Surgical Dental Services 12. Ophthalmologist Services 13. Podiatry Services* 14. Optometry Services 15. Chiropractic Services* 16. Psychology Services* 17. Nurse Anesthetist Services for Medicarecovered podiatry. per visit for routine podiatry. Limited to 6 visits per year. per visit for routine vision (refractions) limit 1 eye exam per year. for Medicarecovered chiropractic. You pay $5 for up to 12 visits per year for routine chiropractic. (Los Angeles County only) 18. Optician and Optical Fabricating Lab Services* for one pair of eyeglasses or contact lenses after cataract surgery. for non- Medicare-covered (routine) glasses, contact lenses, frames or lenses every 2 years. $300 plan coverage limit for frames or contact lenses every 2 years

13 BENEFIT CATEGORY MEDI-CAL (MEDICAID) 19. Medical Supplies (does not include incontinence creams and washes) 20. Incontinence Supplies 21. Durable Medical Equipment 22. Hearing Aids 23. Nutritional Products 24. Acupuncture Services 25. Licensed Midwife Services for briefs, pads, and diapers. for incontinence creams and washes. (must be medically necessary) for Flyte 770 or Flyte 990 hearing aids as medically necessary. for enteral nutrition products taken through a feeding tube or orally when your doctor indicates it is medically necessary. Criteria apply. for acupuncture per year. Limited to 24 visits per year. 26. Home Health Services Through a Home Health Agency (including home health nursing and aide, physical and occupational therapy, speech pathology and audiology, intermittent nursing, home health aid care, medical supplies, equipment and appliances) 27. Physical Therapy and Related Services 28. Rehabilitation Facilities

14 BENEFIT CATEGORY MEDI-CAL (MEDICAID) 29. Private Duty Nursing (Waiver only) 30. Clinic (Organized outpatient clinic, Indian Health Services, alternate birthing centers, ambulatory surgical centers) 31. Dental Services 32. Occupational Therapy for Medicare-covered dental benefits for the following routine dental : - Dental exams - Cleaning (limited up to 2 visits per year) - Dental X-rays (limited up to 1 series every 6 months) Please call Member Services or the PAL Unit for additional dental benefit information. 33. Speech Pathology/ Speech Therapy* 34. Audiology * for Medicarecovered hearing exams for a non- Medicare-covered (routine) hearing exam every year. Limited to 1 routine hearing exam per year.

15 BENEFIT CATEGORY MEDI-CAL (MEDICAID) 35. Pharmaceutical Services and Prescribed Drugs 36. Dentures Initial Coverage Depending on your income and institutional status, you pay the following until your yearly out-of-pocket costs reach $5,000: For generic drugs (including brand drugs treated as generic), either: $0 or $1.25 or $3.35 For all other drugs, either: $0 or $3.70 or $8.35 Catastrophic Coverage After your yearly out-of-pocket costs reach $5,000, you will pay $0. -$350 copay for covered dentures 37. Prosthetic Appliances (Orthotic Appliances) Prosthetic Eyes 38. Eyeglasses, Other Eye Appliances* 39. Comprehensive Perinatal Services Program (Preventive ) 40. Community-Based Adult Services (CBAS) (waiver only)** for one pair of eyeglasses or contact lenses after cataract surgery. for non- Medicare-covered (routine) glasses, contact lenses, frames or lenses every 2 years. $300 plan coverage limit for frames or contact lenses every 2 years 41. Chronic Dialysis Services

16 BENEFIT CATEGORY MEDI-CAL (MEDICAID) 42. Rehabilitation Services (Chronic dialysis, outpatient heroin detoxification, rehabilitative mental health, drug Medi-Cal, independent rehabilitation centers) 43. Institutes for Mental Diseases (for under 21 years of age and over 65 years of age, including inpatient psychiatric care). 44. Intermediate Care Facility 45. Nurse Midwife 46. Hospice 47. TB-Related Services You must get care from a Medicare-certified hospice agency. 48. Respiratory Care for Ventilator-Dependent Patients 49. Family Nurse Practitioner 50. Home and Community Care for Functionally Disabled Elderly (Waiver only) 51. Community-Supported Living Arrangements (Waiver only)

17 BENEFIT CATEGORY MEDI-CAL (MEDICAID) 52. Long Term Services and Support (LTSS) Health Plan provides the following under the Long Term Services and Supports (LTSS) program. You must be eligible to qualify for LTSS: Inpatient Custodial Level Care You are covered for up to five days for post-acute or respite support in a skilled nursing facility. You may use this service following a hospital discharge, ER visit, or for respite care. Non-Medicare-covered Durable Medical Equipment Members who qualify may be eligible to receive selected bathroom safety equipment to assist you in performing certain daily activities. Homemaker Services You are eligible to receive assistance with light cleaning, grocery shopping, laundry and meal preparation. Home Delivered Meals You are covered for home delivery of meals to meet nutritional needs. Personal Care Services You are covered for in-home assistance for tasks such as bathing, dressing, eating, getting in and out of bed, moving about/walking, and grooming. Transportation Escort Services As a Connections at Home member, you are eligible to receive an escort to assist you during transportation to and from medical appointments. In-Home Caregiver Relief Health Plan provides alternative caregiver in your home when your regular caregiver can t be there.

18 BENEFIT CATEGORY MEDI-CAL (MEDICAID) 52. Long Term Services and Support (LTSS) cont. 53. Rural Primary Care Hospital Nutitional Supplements (i.e., Ensure, Boost). Physician prescription is required. 54. Nonmedical Health Facilities 55. Emergency Hospital Services 56. Transportation (State provides emergency and non-emergency medical transportation. Meets federal requirement for insurance of transportation to medically necessary ) 57. Services for Pregnant Women that Treat a Condition that may impact the Woman and/ or the Fetus (Not specifically stated as a benefit but is a mandated provision under federal regulations) 58. Marriage and Family Counselor Services (Early and periodic screening, diagnosis, and treatment and waiver only) 59. Licensed Clinical Social Worker Services (Early and periodic screening, diagnosis, and treatment and waiver only) 60. Case Management (Early and periodic screening, diagnosis, and treatment and waiver only) 75-mile limit applies to each one-way trip

19 BENEFIT CATEGORY MEDI-CAL (MEDICAID) 61. Private Duty Nursing Agency Services (Early and periodic screening, diagnosis, and treatment and waiver only) 62. Individual Nurse Provider Services (Early and periodic screening, diagnosis, and treatment and waiver only) 63. Nonmedical Services (Waiver only) *Optional Benefit Exclusion: The benefits noted above with * are only available to this beneficiary population: 1) beneficiaries under 21 years of age for rendered pursuant to EPSDT program; 2) beneficiaries residing in a skilled nursing facility (Nursing Facilities Level A and Level B, including sub-acute care facilities; 3) beneficiaries who are pregnant (pregnancy-related benefits and ; other benefits and to treat conditions that, if left untreated, might cause difficulties for the pregnancy); 4) California Children s Services beneficiaries; and 5) beneficiaries enrolled in the Program of All-Inclusive Care for the Elderly. **Community-Based Adult Services (CBAS) has replaced Adult Day Health Care. Adult Day Health Care were eliminated on Mach 31, CBAS became effective April 1, Criteria apply.

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21 Health Plan complies with applicable federal civil rights laws and does not discriminate, exclude people, or treat them differently on the basis of, or because of, race, color, national origin, age, disability, or sex. Health Plan provides free aids and to people with disabilities to communicate effectively with us, such as qualified sign language interpreters, and written information in other formats (large print, audio, accessible electronic formats, other formats). Health Plan provides free language to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these, contact Member Services. If you believe that Health Plan has failed to provide these or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance in person, by phone, mail, or fax, at: Member Services Attention: Grievance and Appeals Department P.O. Box 22616, Long Beach, CA (TTY: 711) FAX: Or by filling out the File a Grievance form on our website at: If you need help filing a grievance, 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 (TTY: ) Complaint forms are available at Health Plan is an HMO plan with a Medicare contract. Enrollment in Health Plan depends on contract renewal.

22 Multi-language Interpreter Services English: ATTENTION: If you speak a language other than English, language assistance, free of charge, are available to you. Call (TTY: 711). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). Chinese Traditional: 注意 : 如果您使用中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711) Chinese Simplified: 注意 : 如果您使用中文, 您可以免费获得语言援助服务, 请致电 (TTY: 711) Vietnamese: CHÚ Ý: Nếu quý vị nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho quý vị. Xin vui lòng gọi số (TTY: 711). Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). Korean: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 번으로연락해주십시오. (TTY: 711). Armenian: ՈՒՇԱԴՐՈՒԹՅՈՒՆ Եթե խոսում եք հայերեն, ապա Ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարե'ք հեռախոսահամարով: Հեռատիպի համարն է 711: Persian: توجھ : اگر بھ زبان فارسی گفتگو می کنید تسھیلات زبانی بصورت رایگان برای شما فراھم می باشد. با شماره تماس بگیرید..(TTY: 711) Russian: ВНИМАНИЕ! Если вы говорите по-русски, вы можете бесплатно получить услуги перевод;а. Звоните по телефону (TTY: 711). Japanese: 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます お問合せ先 (TTY: 711). ملحوظة: إذا كنت تتحدث العربیة فا ن خدمات المساعدة اللغویة تتوافر لك Arabic: بالمجان. اتصل برقم (الھاتف النصي: 711). Punjabi: ਧਆਨ ਦਓ: ਜ ਤ ਸ ਪ ਜ ਬ ਬ ਲਦ ਹ, ਤ ਭ ਸ਼ ਵ ਚ ਸਹ ਇਤ ਸ ਵ ਤ ਹ ਡ ਲਈ ਮ ਫਤ ਉਪਲਬਧ ਹ ਤ ਕ ਲ ਕਰ (TTY: 711) Mon-Khmer, Cambodian: ស មយកច ត ទ ក ក ប ស ន អ កន យ ខ រ ស ជ ន យ ផ ក យម នគ ត ថ ច នស ប ប រ អ ក ស មទ រស ព លខ (TTY: 711) Hmong: LUS CEEV: Yog tias koj hais lus Hmoob (Ntawv Suav - Hmoob), muaj kev pab txhais lus pub dawb rau koj. Hu rau (TTY: 711). Hindi: ध य न द : य द आप ह द ब लत ह त आपक लए म फ त म भ ष सह यत स व ए उपलब ध ह क ल कर , (TTY: 711) Thai: โปรดทราบ: ถ าค ณพ ดภาษาไทย ค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: 711)

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