2018 Summary of Benefits

Transcription

1 2018 Summary of Benefits Medicare Advantage Plans Arkansas Arkansas, Ashley, Baxter, Bradley, Calhoun, Carroll, Chicot, Clark, Clay, Cleburne, Cleveland, Conway, Craighead, Crittenden, Cross, Dallas, Desha, Fulton, Garland, Grant, Greene, Hot Spring, Independence, Izard, Jackson, Lawrence, Lee, Lincoln, Lonoke, Marion, Mississippi, Monroe, Montgomery, Nevada, Newton, Ouachita, Perry, Phillips, Pike, Poinsett, Prairie, Pulaski, Randolph, Saline, Searcy, Sharp, St. Francis, Stone, Union, Van Buren, White, Woodruff, Yell H1416 Plan 043 1/1/ /31/18 WellCare Liberty (HMO SNP) H1416_WCM_03320E WellCare 2017 AR8IMRSOB03320E_0043

2 Summary of Benefits January 1, 2018 December 31, 2018 All WellCare Liberty (HMO SNP) members can be sure of one thing: the quality of their healthcare is our top priority. We cover everything that Original Medicare covers. On top of that, we add some other benefits to help you stay healthy. For instance, when you have urgent health care needs, you can talk to our nurses on call. If you become a member of our plan, the Nurse Advice Line is open 24 hours every day. We re here to help our members with every health question or concern they may have. This booklet gives you a brief overview of how we put members first. It highlights the services we cover and what you can expect to pay. Please keep in mind, however, that it doesn't list every service we cover or every limitation or exclusion. To get a complete list of services we cover, give us a call and ask for this plan s Evidence of Coverage. You can also find a copy on our website at You can compare the coverage and costs in this booklet with the coverage and costs offered by Original Medicare by looking in your current "Medicare & You" handbook. You can view it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users may call To joinwellcare Liberty (HMO SNP), 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 Arkansas: Arkansas, Ashley, Baxter, Bradley, Calhoun, Carroll, Chicot, Clark, Clay, Cleburne, Cleveland, Conway, Craighead, Crittenden, Cross, Dallas, Desha, Fulton, Garland, Grant, Greene, Hot Spring, Independence, Izard, Jackson, Lawrence, Lee, Lincoln, Lonoke, Marion, Mississippi, Monroe, Montgomery, Nevada, Newton, Ouachita, Perry, Phillips, Pike, Poinsett, Prairie, Pulaski, Randolph, Saline, Searcy, Sharp, St. Francis, Stone, Union, Van Buren, White, Woodruff, Yell Contact information and hours 1 If you are not a member of this plan, call toll-free (TTY 711). We d love to talk to you! 1 If you are a member of this plan, call toll-free (TTY 711). 1 From October 1 to February 14, we're here for you 7 days per week, 8 a.m. to 8 p.m. 1 From February 15 to September 30, you can call us Monday Friday, 8 a.m. to 8 p.m. 1 Our website: Which doctors, hospitals and pharmacies can I use? WellCare Liberty (HMO SNP) has a network of doctors, hospitals, and other providers. You can save money by using providers in the plan's network. If you use providers that are not in our network, the plan may not pay for these services. We also have a network of pharmacies and you must generally use these pharmacies to fill your prescriptions for covered Part D drugs. Summary of Benefits 1

3 You can see our plan's Provider/Pharmacy Directory and our complete plan formulary (list of Part D prescription drugs) at our website: Or, call us at the number above and we ll send you a copy. We re here for our members every step of the way. Summary of Benefits 2

4 Summary of Benefits January 1, 2018 December 31, 2018 For each benefit listed below, you can see what our plan covers in addition to what Arkansas Department of Human Services covers. Medicaid is a joint Federal and state government program that helps with medical costs for certain people with limited incomes and resources. Medicaid coverage varies depending on the state and the type of Medicaid you have. What you pay for covered services may depend on your level of Medicaid eligibility. Some people with Medicaid get help paying for their Medicare premiums and other costs. Other people may also get coverage for additional services and drugs that are covered under Medicaid but not by Medicare. No matter what your level of Medicaid eligibility is, WellCare Liberty (HMO SNP) will cover the benefits as described in the plan s column. If you have questions about your Medicaid eligibility and what benefits you are entitled to call: Below are the different levels of Medicaid eligibility. Full Benefit Dual Eligible (FBDE): Helps pay Medicare Part A and Part B premiums, and other cost-sharing (like deductibles, coinsurance, and co-payments). Eligible beneficiaries also receive full Medicaid benefits. Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums, and other cost-sharing (like deductibles, coinsurance, and co-payments). (Some people with QMB are also eligible for full Medicaid benefits (QMB+).) This booklet is also available in different formats, including Braille, large print and audio compact disc (CD). This document may be available in a non-english language. For additional information, call us at , (TTY 711). Summary of Benefits 3

5 Summary of Benefits January 1, 2018 December 31, 2018 NOTE: 1 SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION. 1 SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR. 1 SERVICES WITH A 3 MAY VARY DEPENDING ON YOUR LEVEL OF MEDICAID. WellCare Liberty (HMO SNP) Premiums and Benefits Monthly Plan Premium You pay $0.00 You must continue to pay your Medicare Part B premium. Deductible 3 This plan does not have a deductible Maximum Out-of-Pocket $6,700 annually Responsibility (does not include The most you pay for co-pays, prescription drugs) coinsurance and other costs for Medicare-covered Part A and B services for the year. If you reach this limit on out-of-pocket costs, you keep getting covered for hospital and medical services while we pay the full cost for the rest of the year. Summary of Benefits 4

6 WellCare Liberty (HMO SNP) Inpatient Hospital Coverage 1,2,3 You pay $0 co-pay per day for days 1-90 If you happen to have an inpatient hospital stay, talk to one of our care managers after you are discharged. Our care managers can help make sure you Covers overnight stays in the hospital, stay healthy and out of the hospital. but may require prior approval by Medicaid. Under age 21: No limit to the number of days covered for inpatient care. ARKids First-B does not cover mental health inpatient care. Over age 21: Limited number of days covered for inpatient care. A co-pay is required if you are 18 or older, or have ARKids First-B, but the amount depends on the first day's hospital bill. Outpatient Surgery 1,2,3 You pay $0 co-pay at an ambulatory surgical center 1 This includes the following: You pay $0 co-pay for outpatient hospital 4 Ambulatory surgical center services 4 Outpatient hospital Under age 21: Covers most outpatient hospital care but some charges may apply. No limit to the number of days covered for inpatient care. A co-pay is required by ARKids First-B. Summary of Benefits 5

7 WellCare Liberty (HMO SNP) Over age 21: Covers most outpatient hospital care but some charges may apply. Limits do apply to the number of days covered for inpatient care. Doctor Visits 1,2,3 1 This includes visits to your primary care physician and specialists You pay $0 co-pay for each primary care visit You pay $0 co-pay for each specialist visit Your primary care physician is the doctor who will handle most of your Under age 21: No limit to covered health care services. They will refer you service. to specialists when needed. Over age 21: Covers limited visits to your PCP. Referral is required for visit to specialist. Covers limited visits with a nurse practitioner. Referral may be required. A co-pay is required by ARKids First-B. Preventive Care You pay nothing for the following: 1 1 Abdominal aortic aneurysm screening These services are provided to help screen for and prevent or diagnose a health problem. 1 Alcohol misuse counseling 1 Bone mass measurement 1 Breast cancer screening (mammogram) Bone Mass Measurement (for people with Medicare who are at risk) Summary of Benefits 6

8 WellCare Liberty (HMO SNP) 1 Cardiovascular disease (behavioral therapy) 1 Cardiovascular screenings 1 Cervical and vaginal cancer screening 1 Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) 1 Depression screening 1 Diabetes screenings 1 HIV screening 1 Medical nutrition therapy services 1 Obesity screening and counseling Colorectal Screening Exams (for people with Medicare age 50 and older) Immunizations (Flu vaccine, Hepatitis B vaccine - for people with Medicare who are at risk, Pneumonia vaccine) Mammograms (Annual Screening) (for women with Medicare age 40 and older) 1 Prostate cancer screenings (PSA) 1 Sexually transmitted infections Pap Smears and Pelvic Exams screening and counseling (for women with Medicare) 1 Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) 1 Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots 1 "Welcome to Medicare" preventive Prostate Cancer Screening Exams (for men with Medicare age 50 and older) Health/Wellness Education Written health education materials, including newsletters visit (one-time) Nutritional Training 1 Yearly "Wellness" visit Additional Smoking Cessation Other Wellness Benefits Any additional preventive services approved by Medicare during the contract year will be covered. Welcome to Medicare; and Annual Wellness Visit Summary of Benefits 7

9 WellCare Liberty (HMO SNP) Stay healthy by getting your annual Under age 21: Covers shots to prevent wellness visit. A wellness visit is a good diseases and regular check-ups under step to take for your health. During that well-child services. No co-pay required. visit, you can work with your PCP to get Over age 21: Covers limited number of all your preventive screenings and care. doctor's visits per year. Pelvic exams, pap tests and mammography are covered for women of all ages. No referral needed at a doctor's office. Emergency Care 3 You pay $0 co-pay 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 Covered if you have a good reason to believe that your life or health or your child s life or health is in serious danger. No referral necessary. A co-pay is required by ARKids First-B. Urgently Needed Services 3 You pay $0 co-pay per visit If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for urgently needed services Summary of Benefits 8

10 WellCare Liberty (HMO SNP) Diagnostic Services/Labs/ Imaging 1,2,3 You pay $0 co-pay for diagnostic radiology services 1 This includes the following: You pay $0 co-pay for lab services 4 Diagnostic radiology service (e.g., MRI, CT scan) 4 Lab services 4 Diagnostic tests and procedures 4 Outpatient X-rays 4 Therapeutic radiology services (e.g., radiation treatment for cancer) You pay $0 co-pay for diagnostics tests and procedures Covers lab tests and x-rays if medically You pay $0 co-pay for X-rays necessary. A referral from your PCP is required. You pay $0 co-pay for therapeutic radiology services A co-pay is required by ARKids First-B. Over age 21: Covers limited number of some tests and x-rays. Co-pays may be required. Hearing Services 1,2,3 1 This includes information on coverage of hearing exams and aids You pay $0 co-pay for a hearing exam to diagnose and treat hearing and balance issues You pay $0 for Routine hearing exam (1 per year) Hearing aid covered with an Annual allowance of $500 towards the purchase of a hearing aid. Under age 21: Covers hearing tests and hearing aids if enrolled in the Child Health Services (EPSDT) Program. Must be prescribed by a doctor. If the child needs a hearing aid, three follow-up You pay $0 for hearing aid fitting/ evaluations (for up to 1 every year) visits to the hearing aid dealer are covered to make sure it works properly. Hearing aids are not covered by ARKids First-B. Only the examination used to test the condition of the middle ear, called Summary of Benefits 9

11 WellCare Liberty (HMO SNP) tympanometry, is covered for ARKids First-B Over age 21: Not covered You pay nothing for the following preventive dental services: Dental Services 1,2,3 1 Cleaning (for up to 2 every year) 1 Dental x-ray(s) (for up to 1 every 12 to 36 months) 1 Oral exam (for up to 1 every six months) 1 Fluoride treatment (for up to 1 every year) Under age 21: Covers dental care. Orthodontic care (braces) if needed for medical reasons. Prior approval required. Orthodontic care not covered for orthodontic care by ARKids First-B. Our plan pays up to $250 per calendar Over age 21: Covers up to $500 a year quarter with a maximum of $1000 every for most dental care, from July 1 to June year for most dental services. Unused 30. Includes one office visit, one cleaning, amounts carry over to the next calendar one set of x-rays and one fluoride quarter, but not the next calendar year. treatment. If your dentist says you need Additional comprehensive dental services it. you will pay nothing for one of the following: one Endodontic procedure per Medicaid will pay for simple tooth year, one Periodontics procedure every 6 pulling, surgical tooth pulling (if to 36 months or one Extraction per year. approved by Medicaid first), fillings, and Also included is one Prosthodontic one set per lifetime of dentures (if procedure every 12 to 60 months, one approved by Medicaid first). Oral Maxillofacial procedure every 60 Summary of Benefits 10

12 WellCare Liberty (HMO SNP) months or other services every 6 to 24 months. The dental benefits on this plan include coverage for a deep cleaning, filling, dentures or a bridge or a crown and a root canal. Summary of Benefits 11 Dental Lab fees and tooth-pulling do not count toward the $500 limit. However, you can only get one set of dentures or partial dentures in your lifetime. It s up to you to make sure Medicaid will pay for other dental care if you need it. ConnectCare services include dental coordinated care. Dental care coordinators are available from 8 a.m. to 4:30 p.m. Monday through Friday to help with: Dental information Finding a Medicaid dentist in your area Scheduling dental appointments Scheduling needed transportation (Medicaid and ARKids First-A only). ARKids First-B beneficiaries cannot use the Non-Emergency Transportation (NET) Program. Reminding you of your dental appointment Rescheduling missed dental appointments To find out more, call (TDD: ).

13 WellCare Liberty (HMO SNP) Vision Services 1,2,3 1 This includes information on coverage of vision exams and eyewear You pay $0 co-pay for Medicare-covered diabetes retinopathy screening and $0 co-pay for all other Medicare-covered eye exams You pay nothing for Medicare-covered Glaucoma screenings. These screenings are important for early detection and prevention of Glaucoma. You pay $0 co-pay for routine vision exam (1 per year) Our plan pays up to $300 every year for up to 2 pairs of contact lenses, eyeglasses (frames and lenses), eyeglass frames or eyeglass lenses. If you choose to get 2 pairs of eyewear, they must both be obtained in the same visit. You pay nothing for eyeglasses or contact lenses after cataract surgery. Under age 21: Covers limited eye exams by an optometrist and eyeglasses. No co-pay required. Over age 21: Covers limited eye exams by an optometrist and eyeglasses. Co-pay is required. Mental Health Services 1,2,3 You pay $0 co-pay for inpatient mental health services 1 This includes the following: You pay $0 co-pay per outpatient therapy 4 Inpatient visits visit 4 Outpatient group or Covers licensed mental health individual therapy visits practitioner services in an Immediate Care Facility for mentally retarded. Summary of Benefits 12

14 WellCare Liberty (HMO SNP) Referral from a doctor and prior authorization required. You pay nothing per day for days 1 through 100 Skilled Nursing Facility (SNF) 1,2,3 Our plan covers up to 100 days in a SNF Covered for members over age 21 Physical therapy and speech language You pay $0 co-pay for physical and therapy visit 1,2,3 speech language therapy Under age 21: Covers physical, occupational or speech therapy. Prescription and referral from your doctor required. Not covered by ARKids First-B. Ambulance 1,3 You pay $0 co-pay Ambulance service is emergency transportation that can be by emergency automobile, helicopter, or airplane. Summary of Benefits 13

15 Transportation 1 WellCare Liberty (HMO SNP) You pay nothing for 24 One-way trips every year. These are shared trips to plan Summary of Benefits 14 Medicaid and ARKids First will pay for ambulance service only in certain cases, and only when you need it to stay alive or to prevent serious damage to your health. Under those circumstances, Medicaid and ARKids First will pay for ambulance service: From the place of an emergency to a hospital emergency room if the patient is admitted. From a hospital to another hospital. From the patient s home to a hospital for admission. From a hospital to the person s home after the person is discharged from the hospital. From a nursing home to a hospital for admission. From a nursing home (after being discharged) to the person s home. From one nursing home to another nursing home, when the original nursing home has been decertified and the transportation

16 Medicare Part B Drugs 1,3 1 This includes the following: 4 Chemotherapy drugs 4 Part B drugs WellCare Liberty (HMO SNP) approved locations. Call Customer Service 72 hours in advance to reserve a ride for your appointment. Non-emergency transportation services The first step to staying healthy is covers trips to and from doctor getting to your doctor. That's why we appointments and other covered provide rides to plan approved health Medicaid services if you have no other care providers. We want to make sure type of transportation. No limits on you get the care you need, when you number of trips or miles. NET will only need it. take you to and from Medicaid-covered services. Not covered by ARKids First-B. You pay $0 co-pay for chemotherapy drugs You pay $0 co-pay for other Part B drugs Not Applicable Summary of Benefits 15

17 WellCare Liberty (HMO SNP) Part D Info Part D Cost Shares State Medicaid Benefits Initial Coverage You pay the following until your total yearly drug costs reach $3,750. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail service pharmacies. Initial Coverage (After you pay your deductible, if applicable) Retail 30-Day Supply Preferred Mail Order 90-Day Supply Tier 1: Preferred Generic Drugs Generics: You pay $0 or $1.25 or $3.35 You pay $0 Tier 2: Generic Drugs Tier 3: Preferred Brand Drugs Tier 4: Non-Preferred Drugs Generics: You pay $0 or $1.25 or $3.35 Brands: You pay $0 or $3.70 or $8.35 Tier 5: Specialty Drugs Generics: You pay $0 or $1.25 or $3.35 Brands: You pay $0 or $3.70 or $8.35 Not Covered If you reside in a long term care (LTC) facility, you pay the same as a retail pharmacy. When you move from one phase of the Part D benefit to another, your cost-sharing may change as well. For more information on the additional pharmacy specific cost-sharing and the phase of the benefit, please call us or access our Evidence of Coverage online. Summary of Benefits 16

18 Coverage Gap Catastrophic Coverage WellCare Liberty (HMO SNP) Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,750. This stage does not apply to you. After your yearly out-of-pocket drug costs (not including what the plan has paid, but including drugs you purchased through your retail pharmacy and through mail Service order) reach $5,000, you pay nothing. Summary of Benefits 17

19 WellCare Liberty (HMO SNP) Benefits Continued Prescription Drug Please see the Part D information above Covers most generic prescription drugs. Prior approval may be required for some drugs. Brand name drugs not covered. Under age 21: No limit to the number of prescriptions per month. Over age 21: Covers a limited number of prescriptions per month. *A co-pay is required by members 18 and older. *A co-pay is required by ARKids First-B. Rehabilitation Services 1,2,3 You pay $0 co-pay for cardiac rehab services 1 This includes the following: 4 Cardiac (heart) rehab services 4 Occupational therapy visit You pay $0 co-pay for occupational therapy Under age 21: Covers physical, occupational or speech therapy. Prescription and referral from your doctor Summary of Benefits 18

20 WellCare Liberty (HMO SNP) required. Not covered by ARKids First-B. Foot Care (podiatry You pay $0 co-pay for Medicare covered services) 1,2,3 podiatry You pay $0 co-pay for 6 visits every year 1 This includes information on coverage of foot exams, treatment and care Referral required from your PCP. Over age 21: Covers surgery and limited visits to the doctor's office. A co-pay is required by ARKids First-B. Medical Equipment/Supplies 1,3 You pay $0 co-pay for durable medical equipment 1 This includes the following: You pay $0 co-pay for prosthetics 4 Durable medical equipment (e.g., wheelchairs, oxygen) You pay $0 co-pay for diabetic supplies Under age 21: Limited coverage. Co-pay 4 Prosthetics (e.g., braces, You pay $0 co-pay for diabetic is required. artificial limbs) therapeutic shoes and inserts 4 Diabetes supplies Over age 21: Limited kinds of equipment 4 Diabetic therapeutic shoes and covered. Prescription from your PCP inserts required. Summary of Benefits 19

21 WellCare Liberty (HMO SNP) Wellness Programs 1 1 This includes the following: You pay nothing for fitness. This is a basic fitness membership at no cost to you. 4 Fitness You pay nothing for a Personal Emergency Response System. 4 Personal Emergency Response System (PERS) 4 Additional routine annual physical 4 Nurse Advice Line 24 hours You pay nothing for an additional routine annual physical. You pay nothing for our Nurse Advice Line. These programs are ways to stay healthy. Whether it s an extra checkup during the year or you just have a simple health question, we are here as your partner in health. Chiropractic Care 2,3 You pay $0 co-pay for medical chiropractic services 1 This includes the following: Routine chiropractic services: Not 4 Medical chiropractic services covered 4 Routine chiropractic services ARKids First cover chiropractic care. You will need a referral from your PCP. Referral from your PCP is required. A co-pay is required by ARKids First-B. Over age 21: Limited number of visits. Summary of Benefits 20

22 WellCare Liberty (HMO SNP) Over-the-Counter items Our plan will pay up to $100 every quarter for the purchase of covered over-the-counter items. Please visit our website to see our list of covered over-the-counter items. Home Health 1,2 You pay nothing Some services provided in your home are covered, only when approved by your doctor as medically necessary. Prior approval may be required. Limits may apply. A co-pay is required by ARKids First-B. Renal Dialysis 1,2,3 You pay nothing Hospice 1,2 You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost of drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. Covered in the patient's home or in a Summary of Benefits 21

23 WellCare Liberty (HMO SNP) hospital or nursing home. Not covered by ARKids First-B. Federal Qualified Health Center You pay nothing for Medicare covered Services 3 services One of these health centers may be your PCP instead of choosing a doctor. Otherwise a referral from your PCP will be required. A co-pay is required by ARKids First-B. Private Duty Nursing Services 3 Not Covered Family Planning 3 You pay nothing for Medicare covered services You pay nothing for Medicare covered services Rural Health Clinic Services 3 One of these health centers may be your PCP instead of choosing a doctor. Otherwise a referral from your PCP will Summary of Benefits 22

24 WellCare Liberty (HMO SNP) be required. A co-pay is required by ARKids First-B. Offered by the plan if you meet qualifications Targeted Case Management 3 Assists with helping patients find and get the medical services they need. A doctor must prescribe targeted case management. You may be able to get this service if you: Have ARKids First-A or regular Medicaid. Are younger than 21 and were referred as a result of a well-child check-up. Have a developmental disability. Are age 60 or older. Are pregnant. Not covered by ARKids First-B. Transplants 3 You pay nothing for Medicare covered services Summary of Benefits 23

25 Long-term Care 3 DomiciliaryCare [room and board for out of town care] 3 Child Health Management Services (CHMS) 3 WellCare Liberty (HMO SNP) You pay nothing for Medicare covered services You pay nothing for Medicare covered services Not covered Summary of Benefits 24 Over age 65, or over age 21 and disabled: Living Choices Assisted Living covers apartment-style housing for those who need extra care and supervision. Based on medical necessity and other requirements. Covers room and board when you live too far away to drive back and forth every day. No limit to the number of days you can stay while being treated. Also covers a ride from home to the place you will stay, and to the clinic/medical center for treatment. Not covered by ARKids First-B. Under age 21: Covered services may include medical, psychological, speech and language pathology, occupational therapy, physical therapy, behavioral

26 Ambulatory Surgical Center 3 Autism Waiver 3 WellCare Liberty (HMO SNP) You pay nothing for Medicare covered services Not covered Summary of Benefits 25 therapy and audiology. Not covered by ARKids First-B. Over age 21: No coverage. Covers surgeries that do not require an overnight hospital stay. Medicaid and ARKids First pays for covered surgeries in these centers. A referral from your PCP is usually required. A co-pay is required by ARKids First-B. The purpose of the autism waiver is to provide one-on-one, intensive early intervention treatment for beneficiaries ages 18 months through 6 years with a diagnosis of autism. Participants must meet both medical and financial criteria. Medical criteria include meeting the ICF/IID level of care and having a diagnosis of autism. The community-based services offered through the autism waiver are as follows: Individual assessment/treatment development

27 Community Health Centers 3 DDS Alternative Community Services (ACS) 3 WellCare Liberty (HMO SNP) You pay nothing for Medicare covered services Not covered Summary of Benefits 26 Provision of therapeutic aides and behavioral reinforcers Plan implementation and monitoring of intervention effectiveness Lead therapy intervention Line therapy intervention Consultative clinical and therapeutic services The waiver program is operated by the Partners for Inclusive Communities (also known as Partners) under the administrative authority of the Division of Medical Services. You may choose one of these health centers as your PCP instead of choosing a doctor. Otherwise, you will need a referral from your PCP if you need to go to an FQHC. A co-pay is required by ARKids First-B. Alternative Community Services (ACS), are for people who have a developmental disability and need special care, no matter

28 Developmental Day Treatment Clinic Services (DDTCS) 3 Nurse Practitioners 3 WellCare Liberty (HMO SNP) Not covered You pay nothing for Medicare covered services Summary of Benefits 27 how old they are. The person must have cerebral palsy, epilepsy or autism, or have been declared intellectually disabled before they are 22 years old. The care is provided in the person s home, in a foster home, or an apartment in a group home. A referral from a doctor may be required. To find out more or apply, call for children. For adults call or DDTCS services are provided by a licensed clinic to adults and children with developmental and intellectual disabilities, such as autism or severe learning disabilities. The services may include identifying the developmental or intellectual disability and assessing how severe it is. For more information, call Developmental Day Treatment Clinic Services at A co-pay is required by ARKids First-B.

29 Nurse-Midwife (Certified) 3 Inpatient Psychiatric Services for Under Age 21 3 Rehabilitative Services for Persons with Mental Illness (RSPMI) 3 WellCare Liberty (HMO SNP) You pay nothing for Medicare covered services You pay nothing for Medicare covered services You pay nothing for Medicare covered services Summary of Benefits 28 A co-pay is required by ARKids First-B. Referral from a doctor and prior authorization required. Medicaid must approve these services in advance, except in an emergency. The patient will also require a certificate of need in order for Medicaid to pay. The doctor who refers the patient should provide this document. A co-pay is required by ARKids First-B. The amount of the co-pay depends on the first day s hospital bill. Medicaid will pay for rehab for members with mental illnesses in some cases. Services must be provided by a certified RSPMI provider. Medicaid must approve these services before they are provided, or Medicaid will not pay. The RSPMI provider should handle getting Medicaid s approval.

30 Rehabilitative Services for Youth and Children (RSYC) 3 Meals 1,3 1 Post-Acute Meals 1 Chronic Meals WellCare Liberty (HMO SNP) You pay nothing for Medicare covered services Not Covered Summary of Benefits 29 A referral from a PCP may be required for children under age 21. If the person needs more than eight hours of care within a 24-hour period, the doctor or other provider will need to apply for an extension of benefits for the patient. If you have A co-pay is required by ARKids First-B. Medicaid will pay for rehab services for children under age 21 who are in the Child Health Services EPSDT Program and in the custody or care of the Arkansas Division of Youth Services (DYS). These services are for children who have been abused or neglected, to help them deal with any psychological or emotional problems they may have. Not covered for ARKids First-B.

31 Multi-Language Insert Multi-language Interpreter Services ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 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: 711) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم (رقم هاتف الصم والبكم: 711). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711). ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (TTY: 711). UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: 711). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). 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 (TTY: 711) まで お電話にてご連絡ください ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). توجه: اگر به زبان فارسی گفتگو می کنید تسهیالت زبانی بصورت رایگان برای شما فراهم می باشد. با 711) (TTY: تماس بگیرید. Y0070_WCM_00961Z CMS ACCEPTED WellCare 2017 NA7WCMINS02310E_0000

32 Discrimination is Against the Law WellCare Health Plans, Inc., complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. WellCare Health Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. WellCare Health Plans, Inc.: 1 Provides free aids and services to people with disabilities to communicate effectively with us, such as: 4 Qualified sign language interpreters 4 Written information in other formats (large print, audio, accessible electronic formats, other formats) 1 Provides free language services to people whose primary language is not English, such as: 4 Qualified interpreters 4 Information written in other languages If you need these services, contact WellCare Customer Service for help or you can ask Customer Service to put you in touch with a Civil Rights Coordinator who works for WellCare. If you believe that WellCare Health Plans, Inc., 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: WellCare Health Plans, Inc., Grievance Department, P.O. Box 31384, Tampa, FL ; Telephone ; TTY number ; Fax: ; OperationalGrievance@wellcare.com. You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, a WellCare Civil Rights Coordinator 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, DC 20201, , (TDD). Complaint forms are available at * This Nondiscrimination Notice also applies to Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc., and Easy Choice Health Plan, a WellCare company. NA035233_WCM_INS_ENG

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36 WellCare (HMO SNP) is a Medicare Advantage organization with a Medicare contract and a contract with the Arkansas Medicaid program. Enrollment in WellCare (HMO SNP) depends on contract renewal. We Cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You must continue to pay your Medicare Part B premium. If you meet certain eligibility requirements for both Medicare and Medicaid, your Part B premiums may be covered in full. WellCare uses a formulary. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments and restrictions may apply. Benefits, premiums and/or co- payments/coinsurance may change on January 1 of each year. You have the choice to sign up for automated mail service delivery. You can get prescription drugs shipped to your home through our network mail service delivery program. You should expect to receive your prescription drugs within calendar days from the time that the mail service pharmacy receives the order. If you do not receive your prescription drugs within this time, please contact us at (TTY ), 24 hours a day, seven days a week, or visit mailrx.wellcare.com Some plans are available to those who have medical assistance from both the state and Medicare. Premiums, co-pays, coinsurance and deductibles may vary based on the level of Extra Help you receive.