OF BENEFITS. Cigna-HealthSpring TotalCare (HMO SNP) H Cigna H3949_15_19921 Accepted

Transcription

1 agesummary OF BENEFITS Cover erage Cigna-HealthSpring TotalCare (HMO SNP) H Cigna H3949_15_19921 Accepted

2 SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (feefor-service Medicare). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Cigna-HealthSpring TotalCare (HMO SNP)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what Cigna- HealthSpring TotalCare (HMO SNP) covers and what you pay. If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on 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 Sections in this booklet Things to Know About Cigna-HealthSpring TotalCare (HMO SNP) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits This document is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call us at Este documento puede estar disponible en un idioma distinto al inglés. Para obtener información adicional, llámenos al

3 THINGS TO KNOW ABOUT CIGNA-HEALTHSPRING TOTALCARE (HMO SNP) Hours of Operation You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Local time. Cigna-HealthSpring TotalCare (HMO SNP) Phone Numbers and Website If you are a member of this plan, call toll-free If you are not a member of this plan, call toll-free Our website: Who can join? To join Cigna-HealthSpring TotalCare (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and Delaware Medicaid or Pennsylvania Medicaid, and live in our service area. Our service area includes the following counties in Pennsylvania: Bucks, Chester, Cumberland, Delaware, Lancaster, Montgomery, Philadelphia, and York. Which doctors, hospitals, and pharmacies can I use? Cigna-HealthSpring TotalCare (HMO SNP) 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 services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan s provider and pharmacy directory at our website ( Or, call us and we will send you a copy of the provider and pharmacy directories. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers - and more. Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. Coverage

4 We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs 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. How will I determine my drug costs? The amount you pay for drugs depends on the drug you are taking and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage. If you have any questions about this plan's benefits or costs, please contact Cigna-HealthSpring for details. SECTION II - SUMMARY OF BENEFITS Benefit Cigna-HealthSpring TotalCare (HMO SNP) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the monthly premium? How much is the deductible? $25.40 per month. In addition, you must keep paying your Medicare Part B premium. This plan has deductibles for some hospital and medical services. $0 or $147 per year for in-network services, depending on your level of Medicaid eligibility. This plan does not have a deductible for Part D prescription drugs. Cigna-HealthSpring is contracted with Medicare for PDP plans, HMO and PPO plans in select states, and with select State Medicaid programs. Enrollment in Cigna-HealthSpring depends on contract renewal.

5 Benefit Cigna-HealthSpring TotalCare (HMO SNP) Is there any limit on how much I will pay for my covered services? Is there a limit on how much the plan will pay? Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. In this plan, you may pay nothing for Medicare-covered services, depending on your level of Delaware Medicaid or Pennsylvania Medicaid eligibility. Refer to the Medicare & You handbook for Medicare-covered services. For Delaware Medicaid or Pennsylvania Medicaid-covered services, refer to the Medicaid Coverage section in this document. Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and costsharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain in-network Contact us for the services that apply. Coverage Covered Medical and Hospital Benefits Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Outpatient Care and Services Acupuncture and Other Alternative Therapies Ambulance 1 Chiropractic Care 2 Dental Services 1 Diabetes Supplies and Services 1 Not covered 0% or 20% of the cost Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): 0% or 20% of the cost Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): 0% or 20% of the cost Preventive dental services: Cleaning (for up to 1 every six months): You pay nothing Dental X-ray(s) (for up to 1 every year): You pay nothing Oral exam (for up to 1 every six months): You pay nothing Diabetes monitoring supplies: 0% or 0-20% of the cost, depending on the supply Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: 0% or 20% of the cost

6 Benefit Diagnostic Tests, Lab and Radiology Services, and X-rays 1 Doctor s Office Visits 2 Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Emergency Care Foot Care (podiatry services) 1 Hearing Services Home Health Care 1 Mental Health Care 1 Outpatient Rehabilitation 1 Outpatient Substance Abuse 1 Cigna-HealthSpring TotalCare (HMO SNP) Diagnostic radiology services (such as MRIs, CT scans): 0% or 20% of the cost Diagnostic tests and procedures: 0% or 0-20% of the cost, depending on the service Lab services: You pay nothing Outpatient X-rays: 0% or 20% of the cost Therapeutic radiology services (such as radiation treatment for cancer): 0% or 20% of the cost Primary care physician visit: 0% or 10% of the cost Specialist visit: $0 or $50 copay 0% or 20% of the cost $0 or $65 copay If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. See the Inpatient Hospital Care section of this booklet for other costs. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $0 or $50 copay Exam to diagnose and treat hearing and balance issues: 0% or 20% of the cost You pay nothing Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. $0 or $210 copay per day for days 1 through 7 You pay nothing per day for days 8 through 90 Outpatient group therapy visit: 0% or 20% of the cost Outpatient individual therapy visit: 0% or 20% of the cost Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): 0% or 20% of the cost Occupational therapy visit: 0% or 20% of the cost Physical therapy and speech and language therapy visit: 0% or 20% of the cost Group therapy visit: 0% or 20% of the cost Individual therapy visit: 0% or 20% of the cost

7 Benefit Cigna-HealthSpring TotalCare (HMO SNP) Outpatient Surgery 1 Over-the-Counter Items Prosthetic Devices (braces, artificial limbs, etc.) 1 Renal Dialysis 1,2 Transportation 1 Urgent Care Vision Services 1 Ambulatory surgical center: 0% or 20% of the cost Outpatient hospital: 0% or 20% of the cost Not Covered Prosthetic devices: 0% or 20% of the cost Related medical supplies: 0% or 20% of the cost 0% or 20% of the cost You pay nothing 0% or 20% of the cost If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for urgent care. See the Inpatient Hospital Care section of this booklet for other costs. Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): 0% or 0-20% of the cost, depending on the service Routine eye exam (for up to 1 every year): You pay nothing Contact lenses: You pay nothing Eyeglasses (frames and lenses) (for up to 1 every two years): You pay nothing Eyeglasses or contact lenses after cataract surgery: You pay nothing Our plan pays up to $100 every two years for contact lenses and eyeglasses (frames and lenses). Coverage

8 Benefit Preventive Care Hospice Cigna-HealthSpring TotalCare (HMO SNP) You pay nothing Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Any additional preventive services approved by Medicare during the contract year will be covered. Annual physical exam: You pay nothing You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. Inpatient Care Inpatient Hospital Care 1 Inpatient Mental Health Care Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. $0 or $270 copay per day for days 1 through 7 You pay nothing per day for days 8 through 90 For inpatient mental health care, see the Mental Health Care section of this booklet.

9 Benefit Skilled Nursing Facility (SNF) 1 Cigna-HealthSpring TotalCare (HMO SNP) Our plan covers up to 100 days in a SNF. You pay nothing per day for days 1 through 20 $0 or $156 copay per day for days 21 through 100 Prescription Drug Benefits How much do I pay? Initial Coverage Catastrophic Coverage For Part B drugs such as chemotherapy drugs 1 : 0% or 20% of the cost Other Part B drugs 1 : 0% or 20% of the cost Our plan does not have a deductible for Part D prescription drugs. Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: $0 copay; or $1.20 copay; or $2.65 copay For all other drugs, either: $0 copay; or $3.60 copay; or $6.60 copay You may get your drugs at network retail pharmacies. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an innetwork pharmacy. After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay nothing for all drugs. Coverage This plan is available to anyone who has both Medical Assistance from the State and Medicare. For full dual-eligible members the state will continue to pay your Medicare Part B premium. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

10 SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H3949, PLAN 009 This section demonstrates the Medicaid benefit package for full benefit dual-eligible recipients in the state of Pennsylvania. The services offered in your Medicaid benefit package are based on your Medicaid eligibility level (Categorically Needy or Medically Needy). Medicare coverage must be used first and the Medicaid Program may cover payment of Medicare Part A and B deductible and coinsurance for all Medicare covered services. The services listed below are available only to those SNP members eligible under Medicaid for medical services. If you are eligible for both Medicare and Medicaid, you will not be held liable for Medicare Part A and B cost sharing when the state is responsible for paying these amounts. For more information about your Medicaid benefits and copayments, please contact the State Medicaid Office. 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 Pennsylvania Medicaid covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. If you have any questions about Medicaid benefits, please contact the State Medicaid office. Benefit Category Pennsylvania Medicaid Cigna-HealthSpring TotalCare (HMO SNP) Doctors or Medical Personnel Certified Nurse Practitioner** Chiropractors** Nurse Midwife Referral from your Primary Care Physician, (PCP) may be required. 0% or 10% of the cost for each Medicare-covered primary care doctor visit. $50 copay for each Medicare-covered specialist visit. Referral from your Primary Care Physician, (PCP) may be required. chiropractic visit Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor. Referral from your Primary Care Physician, (PCP) may be required. 0% or 10% of the cost for each Medicare-covered primary care doctor visit. $50 copay for each Medicare-covered specialist visit.

11 Benefit Category Pennsylvania Medicaid Cigna-HealthSpring TotalCare (HMO SNP) Dentist For Categorically Needy beneficiaries, medically necessary dental services are covered. These services may include diagnostic (X-rays and exams), preventive (prophylaxis), restorations (amalgam and composite), extractions, other types of oral surgery, complete and partial dentures, root canals and crowns. For Medically Needy beneficiaries, Dental Services are only covered in an inpatient or Ambulatory surgical center (ASC) and Short Procedure Unit (SPU) setting. $0 copay for the following preventive dental benefits: up to 1 oral exam(s) every six months up to 1 cleaning(s) every six months up to 1 dental X-ray every year 0% or 20% of the cost for Medicare-covered dental benefits Coverage Optometrist** Referral from your Primary Care Physician, (PCP) may be required. 0% or 0% to 20% of the cost for Medicare-covered exams to diagnose and treat diseases and conditions of the eye, including an annual glaucoma screening for people at risk $0 copay for up to 1 supplemental routine eye exam every year $0 copay for one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery up to 1 pair of eyeglasses (lenses and frames) every two years contact lenses $100 plan coverage limit for supplemental eyewear every two years Referral from your Primary Care Physician, (PCP) may be required. 0% or 10% of the cost for each Medicare-covered primary care doctor visit. $50 copay for each Medicare-covered specialist visit. Physician**

12 Benefit Category Pennsylvania Medicaid Cigna-HealthSpring TotalCare (HMO SNP) Podiatrist** Inpatient Services Acute Care Hospital Drug and Alcohol Facility Private Intermediate Care Facility for the Mentally Retarded Private Intermediate Care Facility for other Related Conditions Referral from your Primary Care Physician may be required. $50 copay for each Medicare-covered podiatry visit Medicare-covered podiatry visits are for medically necessary foot care. Plan covers 90 days each benefit period. For Medicare-covered hospital stays, $0 or Days 1-7: $270 copay per day Days 8-90: $0 copay per day Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. 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 conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. For Medicare-covered hospital stays, $0 or Days 1-7: $210 copay per day Days 8-90: $0 copay per day Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. This benefit is not covered. This benefit is not covered.

13 Benefit Category Pennsylvania Medicaid Cigna-HealthSpring TotalCare (HMO SNP) Psychiatric Facility Limited up to 30 days per fiscal year. If you need additional services beyond the limit, you or your provider may apply for an exception through the Department. 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 conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. Coverage For Medicare-covered hospital stays, $0 or Days 1-7: $210 copay per day Days 8-90: $0 copay per day Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. Rehabilitation Hospital Facility One admission per fiscal year. If you need additional services beyond the limit, you or your provider may apply for an exception through the Department. Plan covers up to 100 days each benefit period No prior hospital stay is required. For Medicare-covered SNF stays, $0 or Days 1-20: $0 copay per day Days : $156 copay per day Other Settings Birthing Centers This benefit is not covered. Nursing Facilities Plan covers up to 100 days each benefit period No prior hospital stay is required. For Medicare-covered SNF stays, $0 or Days 1-20: $0 copay per day Days : $156 copay per day Outpatient Services Ambulatory Surgical Center (ASC) and Short Procedure Unit (SPU) (same day surgery) ambulatory surgical center visit

14 Benefit Category Pennsylvania Medicaid Cigna-HealthSpring TotalCare (HMO SNP) Federally Qualified Health Center ** Hospital Clinic** and Emergency Room Services Drug and Alcohol Clinic Services (Includes methadone maintenance) Independent Medical Surgical Clinic** Renal Dialysis Center Rural Health Clinic** Referral from your Primary Care Physician, (PCP) may be required. 0% or 10% of the cost for each Medicare-covered primary care doctor visit. $50 copay for each Medicare-covered specialist visit. $0 or $65 copay for Medicare-covered emergency room visits 0% or 20% of the cost for Medicare-covered individual substance abuse outpatient treatment visits 0% or 20% of the cost for Medicare-covered group substance abuse outpatient treatment visits ambulatory surgical center visit outpatient hospital facility visit Referral from your Primary Care Physician, (PCP) may be required. 0% or 20% of the cost for Medicare-covered renal dialysis $0 copay for Medicare-covered kidney disease education services Referral from your Primary Care Physician, (PCP) may be required. 0% or 10% of the cost for each Medicare-covered primary care doctor visit. $50 copay for each Medicare-covered specialist visit.

15 Benefit Category Pennsylvania Medicaid Cigna-HealthSpring TotalCare (HMO SNP) Psychiatric Clinic Limited up to 5 hours or 10 one-half hour sessions of psychotherapy per recipient in a 30 consecutive day period. If you need additional services beyond the limit, you or your provider may apply for an exception through the Department. Psychiatric Partial Hospitalization Facility Limited up to 180 three-hour sessions, 540 total hours per fiscal year. If you need additional services beyond the limit, you or your provider may apply for an exception through the Department. individual therapy visit group therapy visit individual therapy visit with a psychiatrist group therapy visit with a psychiatrist 0% or 20% of the cost for Medicare-covered partial hospitalization program services 0% or 20% of the cost for Medicare-covered partial hospitalization program services Coverage Other Services Ambulance Family Planning Services Home Health (visiting nurse) Hospice 0% or 20% of the cost for Medicare-covered ambulance This benefit is not covered. $0 copay for Medicare-covered home health visits You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice.

16 Benefit Category Pennsylvania Medicaid Cigna-HealthSpring TotalCare (HMO SNP) Medical Supplies and Equipment Pharmacy Laboratory Portable X-ray Transportation Services For Medically Needy beneficiaries, medical supplies and equipment are only covered when prescribed for the purpose of family planning or in conjunction with Home Health Agency Services. For Medically Needy beneficiaries in Long-Term Care limited to legend Barbiturates, Benzodiazepines, and certain over-the-counter drugs and vitamins. A legend drug is any drug that requires a prescription. For Categorically Needy beneficiaries limited to legend Barbiturates, Benzodiazepines, and certain over-the-counter drugs and vitamins. 0% or 20% of the cost for Medicare-covered durable medical equipment Drugs covered under Medicare Part B $0 yearly deductible for Medicare Part B drugs. 0% or 20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs. You pay a $0 annual deductible. Initial Coverage Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: A $0 copay; or A $1.20 copay; or A $2.65 copay For all other drugs, either: A $0 copay; or A $3.60 copay; or A $6.60 copay. $0 copay for Medicare-covered: lab services 0% or 20% of the cost for Medicare-covered X-rays $0 copay for up to 24 one-way trip(s) to planapproved location every year

17 Benefit Category Pennsylvania Medicaid Cigna-HealthSpring TotalCare (HMO SNP) Psychiatric Rehabilitation Peer Specialist Services individual therapy visit group therapy visit individual therapy visit with a psychiatrist group therapy visit with a psychiatrist 0% or 20% of the cost for Medicare-covered partial hospitalization program services This benefit is not covered. ** Certain evaluation, management and consultation procedures are limited to a combined maximum of 18 clinic, office and home visits per fiscal year (July 1 through June 30) by physicians, podiatrists, optometrists, certified registered nurse practitioners (CRNP), chiropractors, outpatient hospital clinics, independent medical clinics, rural health clinics and federally qualified health centers (FQHC). Talk with your provider if you have any questions about these procedures. If you need more than 18 visits, you or your provider may ask for an exception through the Department of Public Welfare. Coverage

18 All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Cigna HealthCare of South Carolina, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of Arizona, Inc., HealthSpring Life & Health Insurance Company, Inc., HealthSpring of Tennessee, Inc., HealthSpring of Alabama, Inc., HealthSpring of Florida, Inc., Bravo Health Mid-Atlantic, Inc., and Bravo Health Pennsylvania, Inc. The Cigna name, logos, and other Cigna marks are owned by Cigna Intellectual Property, Inc.