2019 SUMMARY OF. - december 31, 2019

Transcription

1 ALOHACARE ADVANTAGE PLUS 2019 SUMMARY OF BENEFITS january 1, december 31, 2019 This booklet gives you a summary of what 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. H5969_SB109901_M ACCEPTED

2 Summary of Benefits AlohaCare Advantage Plus H5969, Plan 002 This is a summary of drug and health services covered by AlohaCare Advantage Plus (HMO-SNP). January 1, 2019 December 31, 2019 AlohaCare Advantage Plus is an HMO SNP plan with a Medicare contract and a contract with the Hawaii Medicaid Program. Enrollment in AlohaCare Advantage Plus depends on contract renewal. This plan is available to anyone who has both Medical Assistance from the State and Medicare. To join AlohaCare Advantage Plus, you must be entitled to Medicare Part A, be enrolled in Medicare Part B and QUEST Integration Program (Medicaid), and live in our service area. Our service area includes the following counties in Hawaii: Hawaii, Honolulu, Kalawao, Kauai, and Maui. You must continue to pay your Medicare Part B premium. Premiums, copayments, coinsurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. 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. This information is not a complete description of benefits. Call member services for more information at , toll free or TTY/TDD at To get a complete list of services we cover, please request the Evidence of Coverage. You can view the Evidence of Coverage at our website ( Or, call us and we will send you a copy of the Evidence of Coverage. Services with an * may require a prior authorization. H5969_SB109901_M Page 1

3 Monthly Premium, Deductible, and Maximum Out-of-Pocket Monthly Plan Premium You pay $0. You must continue to pay your Medicare Part B Premium Deductible You pay nothing. This plan does not have a deductible. Maximum Out-of-Pocket Responsibility (does not include prescription drugs) $6,700 annually The most you pay for copays, coinsurance and other costs for medical services for the year. Services that are covered for you Inpatient Hospital Coverage* Outpatient Hospital Coverage What you must pay when you get these services You pay nothing. You pay nothing. What you should know Plan covers 90 days each benefit period. Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor s order. The day before you are discharged is your last inpatient day. We cover medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. Doctor Office Visits You pay nothing. Primary Specialists Preventive Care You pay nothing. Any additional preventive services approved by Medicare during the contract year will be covered. Emergency Care Page 2 World-wide benefit You pay nothing. You pay $0 copay and any amounts over $1000 A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse. An annual maximum benefit limit of $1000 is covered for emergency or urgent care services you receive

4 Services that are covered for you Urgently Needed Services World-wide benefit Diagnostic Tests, Lab and Radiology Services, and x-rays* (Costs for these services may vary based on place of service) What you must pay when you get these services You pay nothing. You pay $0 copay and any amounts over $1000 You pay nothing. What you should know outside of the U.S. You will have to pay the facility or provider for Receipts must be in English with billed charges in U.S. dollars. AlohaCare Advantage Plus will reimburse you up to your benefit limit. Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services may be furnished by network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible. An annual maximum benefit limit of $1000 is covered for emergency or urgent care services you receive outside of the U.S. You will have to pay the facility or provider for Receipts must be in English with billed charges in U.S. dollars. AlohaCare Advantage Plus will reimburse you up to your benefit limit. Diagnostic radiology services (such as MRIs, CT scans) Diagnostic tests and procedures Lab Service Outpatient x-rays Therapeutic radiology services (such as radiation treatment for cancer) Hearing Services* Exam to diagnose and treat hearing and balance issues. Dental Services $0 copay. $0 copay for preventive dental benefits. $2000 plan coverage limit for preventive and comprehensive dental services each year Preventive dental benefits: - Cleaning (for up to 2 every year); - Dental x-ray(s) (for up to 2 every year; Page 3

5 Services that are covered for you What you must pay when you get these services $0 copay for comprehensive dental benefits. What you should know - Oral exam (for up to 2 every year); - Fluoride treatment (for up to 2 every year) Comprehensive dental services: - Endodontics (root canals) - Extractions (removal of teeth) - Prosthodontics (dentures) - Periodontics (deep cleaning and periodontal maintenance) - Restorative (fillings and crowns) - Other (oral/maxillofacial surgery) Vision Services You pay nothing. Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening). Eyeglasses or contact lenses after cataract surgery. Mental Health Care* Outpatient group therapy visit. Outpatient Individual therapy visit. You pay nothing. You pay nothing. You pay nothing. Inpatient Visit: Plan covers up to 190 day lifetime limit for inpatient services in a psychiatric hospital. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. The 190-day limit does not apply to mental health services provided in a psychiatric unit of a general hospital. Outpatient Visit: Covered services include mental health services provided by a state-licensed psychiatrist or doctor, clinical psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or other Medicare-qualified mental health care professional as allowed under applicable state laws. Skilled Nursing Facility You pay nothing. Our plan covers up to 100 days in a (SNF) * SNF. Page 4

6 Services that are covered for you Physical Therapy* (Outpatient Rehabilitation Services) What you must pay when you get these services You pay nothing. What you should know Outpatient Rehabilitation Services includes physical therapy, occupational therapy, and speech and language therapy. Ambulance* You pay nothing. Covered ambulance services include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide care only if they are furnished to a member whose medical condition is such that other means of transportation could endanger the person s health or if authorized by the plan. Non-emergency transportation by ambulance is appropriate if it is documented that the member s condition is such that other means of transportation could endanger the person s health and that transportation by ambulance is medically required. Transportation Not Covered. Medicare Part B Drugs* You pay nothing. For Part B drugs such as chemotherapy drugs* Other Part B drugs* Foot Care (podiatry services)* You pay nothing. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: Routine foot care (for up to 8 visit(s) every year) Over-the-Counter Items You pay nothing. The plan provides $75 credit every three months. Delivery services may be available when medically necessary and prior authorized. Please visit our website to see our list of covered over-the-counter items. Page 5

7 Prescription Drug Benefits Stage 1 Yearly Deductible Stage Because there is no deductible for the plan, this payment stage does not apply to you. If you receive Extra Help to pay your prescription drugs, this payment stage does not apply to you. Stage 2 Initial Coverage Stage You begin in this stage when you fill your first prescription of the year. During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost. You stay in this stage until your year-to-date out-of-pocket costs (your payments) reach $5,100. Stage 3 Coverage Gap Stage Because there is no coverage gap for the plan, this payment stage does not apply to you. Stage 4 Catastrophic Coverage Stage During this stage, the plan will pay all of the costs of your drugs for the rest of the calendar year (through December 31, 2019) Cost Sharing Generic Drugs Standard retail cost-sharing (innetwork) (up to a 30-day supply) $0 copay or $1.25 copay or $3.40 copay Mail-order costsharing (up to a 90-day supply) $0 copay or $3.75 copay or $10.20 copay Long-term care (LTC) costsharing (up to a 31-day supply) $0 copay or $1.25 copay or $3.40 copay Out-of-network cost-sharing (Coverage is limited to certain situations) (up to a 30-day supply) $0 copay or $1.25 copay or $3.40 copay Cost-Sharing Brand Drugs $0 copay or $3.80 copay or $8.50 copay $0 copay or $11.40 copay or $25.50 copay $0 copay or $3.80 copay or $8.50 copay $0 copay or $3.80 copay or $8.50 copay Cost-Sharing may change depending on the pharmacy you choose and when you enter another phase of the Part D benefit. For more information on the additional pharmacy specific cost-sharing and the phases of the benefit, please call us to access our Evidence of Coverage online. Page 6

8 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 AlohaCare Advantage Plus has a network of doctors, hospitals, pharmacies, and other providers. If you use providers that are not in our network, the plan may not pay for these You can see our plan s Provider & Pharmacy directory at our website ( Or, call us and we will send you a copy of the Provider & Pharmacy directory. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, Or, call us and we will send you a copy of the formulary. AlohaCare Advantage Plus Phone Numbers and Website Toll-free TTY/TDD users should call at Website: AlohaCare.org AlohaCare Advantage Plus Hours of Operation From October 1 to March 31, you can call us 8:00 a.m. to 8:00 p.m. 7 days a week. From April 1 to September 30, you can call us 8:00 a.m. to 8:00 p.m. Monday through Friday. Page 7

9 Summary of Medicaid-Covered Benefits AlohaCare Advantage Plus, H5969, Plan 002 The following section will describe benefits that you are entitled to as a recipient of Medicaid benefits, in the State of Hawaii. Medicare members, who also qualify for Medicaid, are eligible for additional benefits, including assistance with paying for their Medicare premiums, deductibles and cost sharing, such as copays and coinsurance. The Medicaid benefits available to you are managed under the QUEST Integration Program. This document does not describe all of the details of your Medicaid benefits. Please contact your QUEST Integration plan for a complete listing. As a QUEST Integration beneficiary, you can access these benefits through one of five health plans handbooks; AlohaCare, HMSA, Kaiser Foundation Health Plan, Ohana Health Plan, or United Healthcare Community Plan. You can also get more information from Med-QUEST: Med-QUEST Enrollment Services Section Oahu: Neighbor Islands: The benefits described below are covered by Medicaid. The benefits described in the Covered Medical and Hospital Benefits section of the Summary of Benefits are covered by Medicare. For each benefit listed below, you can see what QUEST Integration covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. Benefit Category Medicaid AlohaCare Advantage Plus IMPORTANT INFORMATION Premium and Other Important Information There are no co-pays and no coinsurance for this plan $0 monthly plan premium. $6,700 out-of-pocket limit for Medicare-covered Once you have paid $6,700 outof-pocket for covered Part A and Part B services, you will pay nothing for your covered Part A and Part B services for the rest of the calendar year. Doctor and Hospital Choice Page 8

10 (For more information, see Emergency Care and Urgently Needed Care.) You must go to network doctors, specialists, and hospitals. SUMMARY OF BENEFITS INPATIENT CARE Inpatient Hospital Care (Includes Substance Abuse and Rehabilitation Services and Cognitive Rehabilitation) Inpatient Mental Health Care No limit on number of days of service. Includes the cost of room and board for Inpatient stays for: Nursing care Medical supplies Equipment Drugs Diagnostic services Post stabilization services Physical and occupational therapy Audiology Speech-language pathology services Substance abuse treatment Cognitive Rehabilitation services include education and training to help with daily activities after a brain injury. No limit on number of days of service. Members covered under the QI (CCS) behavioral health program with a diagnosis of Serious and persistent Mental Illness (SPMI) will have all their behavioral health services covered by the CCS program. $0 copay. Plan covers 90 days each benefit period. You will not be charged additional cost sharing for professional Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. $0 copay. You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain Page 9

11 Covered services include all medically necessary behavioral health These services include: Ambulatory services, including 24-hours-a-day, 7-days-a-week crisis services 24-hour-a-day care for acute psychiatric illnesses, including: Room and board Nursing care Medical supplies and equipment Diagnostic services Physician services Other practitioner services, as needed Other medically necessary services Medically necessary alcohol and chemical dependency service, include inpatient substance abuse conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. Skilled Nursing Facility (SNF) (In a Medicare-certified skilled nursing facility) Page 10 No limit on number of days of service. Covered for members who need 24-hour-a-day help with activities of daily living (ADLs) and instrumental activities of daily living (IADLs.) These members need regular, long-term care from licensed nurses and paramedical personnel. The care that is provided in a nursing facility includes: Independent and group activities Meals and snacks Housekeeping and laundry services Nursing and social work $0 copay for SNF Plan covers up to 100 days each benefit period. No prior hospital stay is required. You will not be charged additional cost sharing for professional

12 services Nutritional monitoring and counseling Pharmaceutical services and rehabilitative services Home Health Care (Includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.) Some home health services included are: Skilled nursing Home health aides Medical supplies Physical and occupational Therapy Audiology and speechlanguage pathology $0 copay for Medicare-covered home health visits. Hospice Provides care to terminally ill patients who have 6 months or less to live. When you enroll in a Medicarecertified hospice program, your hospice services and your Part A and Part B services related to your terminal prognosis are paid for by Original Medicare, not AlohaCare Advantage Plus. Doctor Office Visits Cornea Transplants and Bone Graft Services OUTPATIENT CARE Services include: Initial and interval histories Comprehensive physical examinations (including developmental services) Immunizations Diagnostic and screening laboratory X-ray services (including screening for tuberculosis) $0 copay for each Medicarecovered primary care doctor visit. $0 copay for each Medicarecovered specialist visit. Page 11

13 Cornea transplants (keratoplasty) and Bone graft. Chiropractic Services Not a covered benefit. 20% coinsurance for each Medicare-covered chiropractic service Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). Podiatry Services Medically necessary foot care. $0 copay for Medicare-covered podiatry visits. You pay nothing for up to 8 supplemental routine podiatry visit(s) every year. Medicare-covered podiatry visits are for medically necessary foot care. Outpatient Mental Health Care Page 12 Covered services include all medically necessary behavioral health These services include: Ambulatory services, including 24-hours-a-day, 7-days-a-week crisis services Acute day hospital/partial hospitalization, including: Medication management psychiatrist* $0 copay for: - each Medicare-covered individual therapy visit. - each Medicare-covered group therapy visit. $0 copay for Medicare-covered partial hospitalization program

14 Prescribed drugs Medical supplies Diagnostic tests Therapeutic services, including individual, and group therapy and aftercare Other medically necessary services Outpatient Substance Abuse Care Covered services include all medically necessary behavioral health These services include: Methadone treatment services, which include the provision of methadone or a suitable alternative (e.g. LAAM), as well as outpatient counseling services Medically necessary alcohol and chemical dependency service, outpatient substance abuse Prescribed drugs including medication management and patient counseling Diagnostic/laboratory services, including: - Psychological testing - Screening for drug and alcohol problems - Other medically necessary diagnostic services Psychiatric or psychological evaluation Physician services Rehabilitation services Occupational therapy $0 copay for: - each Medicare-covered individual substance abuse outpatient treatment visit. - each Medicare-covered group substance abuse outpatient treatment visit. Page 13

15 Other medically necessary therapeutic services Outpatient Hospital Services- Outpatient Services and Ambulatory Surgical Center $0 co-pay per visit for Medicaidcovered Services at a hospital or care center where a member stays less than one day include: Diagnostic services Medical supplies, equipment and drugs Sleep laboratory services including diagnosis and treatment of sleep disorders. DME such as CPAP and BiPAP. Surgeries performed in a free-standing or hospital ambulatory surgical center Therapeutic services Urgent care services This service includes 24-hour-aday, 7-days-per-week care for: Emergency services Ambulatory center services Urgent care services Medical supplies Equipment and drugs Diagnostic services Therapeutic services (including chemotherapy and radiation therapy) $0 copay for each Medicarecovered ambulatory surgical center visit. $0 copay for each Medicarecovered outpatient hospital facility visit. Habilitative Services services Medically necessary services and devices to develop, improve or maintain skills such as: $0 co-pay for Medicare-covered services Page 14

16 Audiology services Occupational therapy Physical therapy Speech therapy Vision services Ambulance Services (medically necessary ambulance services) $0 co-pay per trip for Medicaidcovered $0 copay for Medicare-covered ambulance benefits. Emergency Care and Post Stabilization services (You may go to any emergency room if you reasonably believe you need emergency care.) $0 co-pay per visit for Medicaidcovered Medical emergency care and care after an emergency to keep the member stable may include: Emergency eye and hearing exams Emergency room services Pathology/lab services, diagnostic tests, radiology services, medical supplies and drugs within the ER visit Physician services provided during the ER visit Surgery and anesthesiology services provided during the ER visit Covered for medically necessary No prior authorization is required. $0 copay for Medicare-covered emergency room visits. If you are admitted to the hospital within 3-day(s) for the same condition, you pay $0 for the emergency room visit. World Wide Benefit for Emergency Care and Urgent Care Outside the U.S., there is a plan annual maximum covered benefit limit of $1,000. You pay $0 copay for services up to the $1,000 benefit maximum. Amounts that you pay above the $1,000 are excluded from your annual maximum out-of-pocket costs, and are not covered by the plan. You will have to pay the facility or provider directly for To file a claim, bring your itemized list and receipts of services received to AlohaCare Advantage Plus. Receipts must be in English with billed charges in U.S. dollars. AlohaCare Advantage Plus will reimburse you up to your benefit limit. Urgently Needed Care $0 copay for Medicare-covered Page 15

17 Covered as medically necessary. No prior authorization is required. urgently-needed-care visits. World Wide Benefit for Emergency Care and Urgent Care Outside the U.S., there is a plan annual maximum covered benefit limit of $1,000. You pay $0 copay for services up to the $1,000 benefit maximum. Amounts that you pay above the $1,000 are excluded from your annual maximum out-of-pocket costs, and are not covered by the plan. You will have to pay the facility or provider directly for To file a claim, bring your itemized list and receipts of services received to AlohaCare Advantage Plus. Receipts must be in English with billed charges in U.S. dollars. AlohaCare Advantage Plus will reimburse you up to your benefit limit. Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy, Audiology and Cognitive Rehabilitation) Covered services include: Physical and occupational therapy Audiology and speechlanguage pathology Cognitive Rehabilitation services include education and training to help with daily activities after a brain injury. $0 copay for Medicare-covered Occupational Therapy visits. $0 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits. Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered. Durable Medical Equipment (Includes wheelchairs, oxygen, etc.) Page 16 Covered services include but are not limited to the following: $0 copay for Medicare-covered durable medical equipment.

18 Oxygen tanks and concentrators Ventilators Wheelchairs Crutches and canes Eyeglasses Orthotic devices Prosthetic devices Hearing aids Pacemakers Medical supplies such as surgical dressings and ostomy supplies Prosthetic Devices (Includes braces, artificial limbs and eyes, etc.) Diabetes Programs and Supplies Covered as medically necessary. Covered services include: Coverage for glucose monitors Test strips Lancets Screening tests Diabetes selfmanagement Training $0 co-pay for Medicare-covered: prosthetic devices medical supplies related to prosthetics, splints, and other devices $0 copay for Medicare-covered: - Diabetes monitoring supplies. - Therapeutic shoes or inserts. - Diabetes self-management training Diagnostic Tests, X- Rays, Lab Services, and Radiology Services $0 co-pay per visit for Medicaidcovered Covered services include: Diagnostic Therapeutic radiology and imaging Screening and diagnostic laboratory tests $0 copay for Medicare-covered: lab services diagnostic procedures and tests X-rays Page 17

19 Laboratory and diagnostic exclusions: Experimental Investigational or generally unproven Chromosomal evaluations IgG4 testing diagnostic radiology services (not including X- rays) therapeutic radiology services Cardiac Pulmonary Rehabilitation Services Family Planning Pregnancy Related Services- including Cesarean and Vaginal Delivery Page 18 Covered as medically necessary. Covered services: Education and counseling Family planning drugs and supplies Pregnancy testing Diagnosis and treatment for sexually transmitted diseases Infertility assessment Covered services: Diagnostic test Prenatal care Prenatal vitamins Prenatal laboratory screening tests $0 copay for: - Medicare-covered Cardiac Rehabilitation Services - Medicare-covered Intensive Cardiac Rehabilitation Services - Medicare-covered Pulmonary Rehabilitation Services $0 co-pay for Medicare-covered services $0 co-pay for Medicare-covered services

20 Radiology Treatment of missed, threatened and incomplete abortions Delivery of infant Postpartum care Lactation counseling Breast pump (rental or purchase) Inpatient hospital services, including physician services and other practitioner 4-day stay after cesarean delivery 2-day stay after vaginal delivery Outpatient hospital services that are related to pregnancy Sterilizations and Hysterectomies Preventive Services services Covered Sterilization Services for all members who are 21 years of age at the time of consent. Covered Hysterectomy Services for all members who are 21 years of age at the time of consent PREVENTIVE SERVICES Health Education and Counseling Substance use (including Alcohol) Diet and exercise Injury prevention Sexual behavior $0 co-pay for Medicare-covered services $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. Plan covers a physical exam annually. Page 19

21 Smoking Cessation counseling and medication Bone Mass Measurement (for people with Medicare who are at risk) You pay nothing. Colorectal Screening Exams (for people with Medicare age 50 and older) Annually One sigmoidoscopy or annual fecal occult blood test Every 10 years after initial screening Initial screening completed at age 50 You pay nothing. Immunizations (Flu vaccine; Pneumonia vaccine; Hepatitis B vaccine - for people with Medicare who are at risk) $0 co-pay for Medicare-covered Tetanus-diphtheria (td) booster, Rubella, Hepatitis B in high risk - household and contacts with HBsAg positive person You pay nothing. Mammograms (Annual Screening) (for women with Medicare age 40 and older) Pap Smears and Pelvic Exams (for women with Medicare) Page 20 Mammography and clinical breast exam every year. A woman of any age with a history of breast cancer, or whose mother or sister has a history of breast cancer, is eligible for a screening mammography when authorized by a physician. Annually One Pap Test and pelvic exam You pay nothing. You pay nothing.

22 Prostate Cancer Screening Exams You pay nothing. (for men with Medicare age 50 and older) Kidney Disease and Conditions - $0 co-pay per visit for Medicaidcovered Dialysis Services and Epogen Injections. Acute hospital admissions solely to provide chronic dialysis are not covered. $0 copay for Medicare-covered renal dialysis. $0 copay for Medicare-covered kidney disease education PRESCRIPTION DRUG BENEFITS Outpatient Prescription Drugs Covers drugs listed on the Drugs covered under Medicare Part B Plan s Preferred Drug List (PDL). This list will also have drugs that may have limits such as prior authorization, quantity limits, step therapy, age limits, or gender limits. Alternate Drugs may be covered with prior authorization. OTC drugs may be covered by the Plan when physician prescribed and medically necessary at $0 co-pay. Drugs covered under Medicare Part B $0 yearly deductible for Medicare Part B drugs. $0 copay for Part B chemotherapy drugs and other Part-B drugs. Drugs covered under Medicare Part D This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at on the web. For generic drugs (including brand drugs treated as generic), either: - A $0 copay; or - A $1.25 copay; or - A $3.40 copay Page 21

23 For all other drugs, either: - A $0 copay; or - A $3.80 copay; or - A $8.50 copay. OUTPATIENT MEDICAL SERVICES AND SUPPLIES Cost-Sharing may change depending on the pharmacy you choose and when you enter another phase of the Part D benefit. This list will also have drugs that may have limits such as prior authorization, quantity limits, step therapy, age limits, or gender limits. Alternate Drugs may be covered with prior authorization. For more information on the additional pharmacy specific cost-sharing and the phases of the benefit, please call us and request the Evidence of Coverage. You can view the Evidence of Coverage at our website ( care/memberdocuments). Or, call us and we will send you a copy of the Evidence of Coverage. Dental Services $0 co-pay for medically related Medicaid-covered For adults, emergency-only dental services are also covered under the QUEST Integration dental plan. Dental services are coordinated through Community Case Management Corporation (CCMC). CCMC will help members: $0 copay for Medicare-covered dental benefits. $0 copay for the following preventive dental benefits: - up to 2 oral exam(s) every year - up to 2 cleaning(s) every year - up to 2 dental x-ray(s) every year Page 22

24 Find a dentist Make an appointment - up to 2 fluoride treatments every year Coordinate transportation and translation $0 copay for the following comprehensive dental benefits: Call from Oahu or toll-free Endodontics (root canals) -Extractions (removal of teeth) -Prosthodontics (dentures) - Periodontics (deep cleaning and periodontal maintenance) - Restorative (fillings and crowns) -Other (oral/maxillofacial surgery) $ plan coverage limit for preventive and comprehensive dental services each year. No additional comprehensive dental benefits covered beyond $ max coverage. Hearing Services Hearing/Audiology Services - $0 co-pay per visit for Medicaidcovered Hearing Evaluation - one per 12 month period (Hearing Aid Suppliers will not be paid for a hearing evaluation) Hearing Services - Ear Plugs (Custom-made earplugs can be prescribed only by ENT specialists for individuals with recurrent middle ear infections) $0 copay for: Medicare-covered diagnostic hearing exams. In general, supplemental routine hearing exams and hearing aids not covered. Hearing Aids one per 24 month period Page 23

25 - $0 per item prescribed by an ENT specialist Vision Services Over-the-Counter Items Hearing aid check, examination and fitting, monaural or binaural one per 36 month period The Plan provides eye and vision exam and services: once every 24 month period More visits may be allowed, depending on the symptoms or medical condition. Covered services include: Vision examinations Prescription lenses Cataract removal Prosthetic eyes Ophthalmologic exam with refraction Visual aids (eyeglasses) Contact lenses and miscellaneous vision supplies (if medically necessary). This includes the costs for the lens, frames, or other parts of the glasses. Fittings and adjustments are also covered. Not Covered. $0 copay for exams to diagnose and treat diseases and conditions of the eye. $0 copay for one Medicarecovered glaucoma screening each year for persons at high risk $0 copay for one pair of eyeglasses (lenses and frames) or contact lenses after cataract surgery. The plan provides $75 credit every three months. Delivery services may be available when medically necessary and prior authorized. Please visit our website to see our list of covered over-thecounter items. Transportation (Routine) Page 24

26 The Plan provides both emergency and non-emergency ground and air services to and from medically necessary medical appointments for members who: - Have no means of transportation - Reside in areas not served by public transportation - Cannot access public transportation due to their medical condition Acupuncture and Other Alternative Therapies Methadone Maintenance Treatment Program (MMTP) Not covered Medication management, prescribed drugs, medical supplies, diagnostic tests, therapeutic services, (individual, family, group and after care), and other medically necessary Includes the provision of methadone or suitable alternatives, as well as outpatient counseling $0 copay for up to 15 visit(s) for acupuncture and other alternative therapies every year. $1000 plan coverage limit for acupuncture and other alternative therapies every year. Long-Term Care Services (Institutional) (Nursing Facility services) $0 copay for Medicaid-covered Cost sharing amounts from members who have cost-sharing requirements may apply. Page 25

27 At-Risk Services At-risk services are certain Home and Community-based Services (HCBS) which are listed below and that are provided to you if an assessment of your health by your QUEST Integration Service Coordinator indicates that you are at-risk for worsening and going into a nursing home or other type of care outside of your home. Adult Day Care Services include: Observation and supervision by center staff Coordination of behavioral, medical and social plans and implementation of the instructions as listed in the participant s care plan Therapeutic, social, educational, recreational activities Adult day care staff may not perform healthcare related services such as medication administration Adult Day Health Adult day health services are organized day programs for therapeutic, social and health services for individuals that require nursing oversight or care. Services include: Emergency care Dietetic services Occupational therapy Physical therapy Physician services Pharmaceutical services Psychiatric or psychological services Page 26

28 Recreational and social activities Social services Speech-language pathology Transportation services Home-Delivered Meals Includes nutritious meals delivered to a location where an individual resides (excluding residential or institutional settings). The meals will not replace or substitute for a full day s nutrition (i.e., no more than 2 meals per day). Personal Assistance Services Level 1 Services may include: Routine housekeeping Meal preparation Laundry Shopping Errands Personal Assistance Services Level 2 Covered for those that require assistance with their activities of daily living (ADL). This level of service is to be provided by a Home Health Aide (HHA), Personal Care Aide (PCA), Certified Nurse Aide (CNA) or Nurse Aide (NA) with applicable skills. Page 27

29 Some activities include: Personal hygiene and grooming, including bathing, skin care, oral hygiene, hair care and dressing Help with bowel and bladder care Help with mobility Help with transfers Help with medications Help with routine or maintenance health care services by a personal care provider Help with feeding, nutrition, meal preparation and other dietary activities Help with exercise, positioning and range of motion Taking and recording vital signs, including blood pressure Personal Emergency Response Services (PERS) PERS services are limited to those individuals: Who live alone Who are alone for significant parts of the day Who have no regular caregiver for extended periods Who would otherwise need extensive routine supervision PERS services will only be offered to a member living in a non-licensed setting. Page 28

30 Skilled Nursing Services Covered for those who need ongoing nursing care. The service is provided by licensed nurses within the scope of state law. Home and Community-Based Services You must meet certain level of care requirements and have an assessment performed by your QUEST Integration Service Coordinator. Your Service Coordinator will determine what services you need based on your assessment. Please contact your for details on this benefit. Adult Day Care Services include: Observation and supervision by center staff Coordination of behavioral, medical and social plans and implementation of the instructions as listed in the participant s care plan Therapeutic, social, educational, recreational activities Adult day care staff may not perform healthcare related services such as medication administration Adult Day Health Adult day health services are organized day programs for therapeutic, social and health services for individuals that requires nursing oversight or care). This also includes: Emergency care Dietetic services Page 29

31 Occupational therapy Physical therapy Physician services Pharmaceutical services Psychiatric or psychological services Recreational and social activities Social services Speech-language pathology Transportation services Assisted Living Services Assisted living services include: Personal care Supportive care services (homemaker, chore, attendant services and meal preparation) The QUEST Integration health plan is not responsible for payment for room and board. Community Care Management Agency (CCMA) Community Care Foster Family Home (CCFFH) Services Page 30 Covered for members living in Community Care Foster Family Homes and other community settings, as required. Covered services include: Personal care Supportive services Homemaker services Attendant care Companion services Local transportation

32 Day programming Medication oversight (to the extent permitted under state law) All services must be provided in a certified private home by a principal care provider who lives in the home. The QUEST Integration health plan is not responsible for payment for room and board. Counseling and Training Counseling and training activities include the following: Member care training for members, family and caregivers regarding the nature of the disease and the disease process Methods of transmission and infection control measures Biological, psychological care and special treatment needs/regimens Use of equipment specified in the care and service plan Skills updates, as necessary, to safely maintain the individual at home Crisis intervention Supportive counseling Family therapy Suicide risk assessments and intervention Death and dying counseling Substance abuse counseling Nutritional assessment and counseling Some services may be covered by Medicare such as: Psychological services including family therapy (under Outpatient Mental Health Care) Substance abuse service (under Outpatient Substance Abuse care) Equipment (under Durable Medical Equipment (DME)) Nutritional assessment (under Medical Nutrition Therapy) For counseling and training services that are not covered by Medicare, please contact your for details on how to receive Page 31

33 Counseling and training services may be provided to: Members Families/caregivers on behalf of the member Professional and paraprofessional caregivers on behalf of the member Environmental Accessibility Adaptations Covered services to safely maintain the individual at home include: The installation of ramps and grab-bars Widening of doorways Modification of bathroom facilities Installation of specialized electric and plumbing systems (must be necessary to accommodate the medical equipment and supplies that are necessary for the welfare of the individual) Home-Delivered Meals All services shall comply with state or local building codes. Includes nutritious meals delivered to a location where an individual resides (excluding residential or institutional settings). The meals will not replace or substitute for a full day s nutrition (i.e., no more than 2 meals per day). Page 32

34 Home Maintenance Home maintenance services are those services not included as a part of personal assistance and include: Heavy-duty cleaning to bring a home up to acceptable standards of cleanliness at the start of service to a member Minor repairs to essential appliances, limited to stoves, refrigerators and water heaters Fumigation or extermination services This benefit is provided to individuals who cannot perform these services without assistance and are determined, through assessment, to require the service to prevent institutionalization. Moving Assistance This benefit is provided in the rare instances when it is determined through an assessment that an individual needs to move to a new home. This benefit is not utilized when the individual has family members, a landlord, and other community members who can provide this service. Situations for which this benefit may be used include: Unsafe home due to deterioration The individual is wheelchair bound, living in a building with no Page 33

35 elevator, multistory building with no elevator or where the client lives above the first floor Member is evicted from his or her current home Member can no longer afford the home due to a rent increase Moving expenses include packing and moving of belongings. Non-Medical Transportation Personal Assistance Services Level 1 Personal Assistance Services Level 2 Page 34 This service helps members travel as specified by the member care plan. It helps members get to community services, activities and resources. Whenever possible, those who can offer this service without cost will be used. They include family, neighbors, friends or community agencies. Exclusion: Members living in a residential care setting or a CCFFH are not eligible for this service. Services may include: Routine housekeeping Meal preparation Laundry Shopping Errands Covered for those that require assistance with their activities of

36 daily living (ADL). This level of service is to be provided by a Home Health Aide (HHA), Personal Care Aide (PCA), Certified Nurse Aide (CNA) or Nurse Aide (NA) with applicable skills. Some activities include: Personal hygiene and grooming, including bathing, skin care, oral hygiene, hair care and dressing Help with bowel and bladder care Help with mobility Help with transfers Help with medications Help with routine or maintenance health care services by a personal care provider Help with feeding, nutrition, meal preparation and other dietary activities Help with exercise, positioning and range of motion Taking and recording vital signs, including blood pressure Measuring and recording intake and output, when ordered. Collecting and testing specimens as directed. Personal Emergency Response Services (PERS) PERS services are limited to those individuals: Who live alone Who are alone for Page 35

37 significant parts of the day Who have no regular caregiver for extended periods Who would otherwise need extensive routine supervision PERS services will only be offered to a member living in a non-licensed setting Acute Waitlisted ICF/SNF Skilled or Private-Duty Nursing Sub-acute Facility Services Licensed Residential Care Page 36 Services when a member is in a hospital waiting to be moved to a skilled nursing facility. Covered for those who need ongoing nursing care. The service is provided by licensed nurses within the scope of state law. Level of care that does not require hospital acute care, but requires more intensive skilled nursing care than is provided in a skilled nursing facility. Residential care is provided in a licensed private home by a principle care provider who lives in the home. He or she gives the following services to members: Personal care services Homemaker, chore, attendant care and companion services

38 Medication oversight (to the extent allowed by law) Transportation to medical appointments The QUEST Integration health plan is not responsible for payment for room and board. Respite Care Respite care is short-term caregiving support and relief provided to caregivers of members who are unable to care for themselves. It may be provided hourly, daily and overnight. Respite care may be provided in the following locations: Member s home or place of residence Foster home or expanded-care adult residential care home Medicaid-certified nursing facility Licensed respite day care facility Other community care residential facility approved by the Plan Respite care services are authorized by the member s PCP as part of the member s care plan. Page 37

39 Specialized Medical Equipment Warranty and Supplies Refers to the purchase, rental, lease, costs, installation, repairs and removal of devices, controls or appliances specified in the care plan. This also includes: Items necessary for life support Supplies and equipment needed for the proper functioning of such items Durable and non-durable medical equipment not available under the Medicaid state plan Examples include: Shower seat Portable humidifiers Electric bills specific to electrical life support devices (ventilator, oxygen concentrator) Medical supplies Page 38

40

41 AlohaCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. AlohaCare does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. AlohaCare provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters 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 AlohaCare s Compliance Officer. If you believe that AlohaCare 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: You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, AlohaCare s Grievance and Appeals Department 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 hhs.gov/ocr/portal/lobby.jsf, 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 AlohaCare Attn: Grievance and Appeals Department 1357 Kapiolani Blvd., Ste Honolulu, HI Phone: Toll-free: TTY/TDD: Fax: Compliance@alohacare.org