Summary of Benefits. Allwell Dual Medicare (HMO SNP)

Transcription

1 2018 Summary of Benefits Allwell Dual Medicare (HMO SNP) Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Fayette, Greene, Indiana, Lawrence, Somerset, Washington and Westmoreland counties, Pennsylvania H Benefits effective January 1, 2018 H2915_18_3010SB Accepted

2 This booklet provides you with a summary of what we cover and your cost-sharing. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please call us at the number listed on the last page of this booklet, and ask for the Evidence of Coverage (EOC), or you may access the EOC on our website at You are eligible to enroll in Allwell Dual Medicare (HMO SNP) if: You are entitled to Medicare Part A and enrolled in Medicare Part B. Members must continue to pay their Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. You must be a United States citizen, or are lawfully present in the United States and permanently reside in the service area of the plan (in other words, your permanent residence is within one of the Allwell Dual Medicare (HMO SNP) service area counties). Our service area includes the following counties in Pennsylvania: Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Fayette, Greene, Indiana, Lawrence, Somerset, Washington and Westmoreland. You do not have end-stage renal disease (ESRD). (Exceptions may apply for individuals who develop ESRD while enrolled in a Allwell Dual Medicare (HMO SNP) commercial or group health plan, or a Medicaid plan.) For Allwell Dual Medicare (HMO SNP), you must also be enrolled in Pennsylvania Medicaid. Premiums, copays, coinsurance, and deductibles may vary based on your Medicaid eligibility category and/or the level of Extra Help you receive. Your Part B premium is paid by the State of Pennsylvania for full-dual enrollees. Please contact the plan for further details. The Allwell Dual Medicare (HMO SNP) plan gives you access to our network of highly skilled medical providers in your area. You can look forward to choosing a primary care provider (PCP) to work with you and coordinate your care. You can ask for a current provider directory or, for an up-to-date list of network providers, visit note that, except for emergency care, urgently needed care when you are out of the network, out-of-area dialysis services, and cases in which our plan authorizes use of out-of-network providers, if you obtain medical care from out-of-plan providers, neither Medicare nor Allwell Dual Medicare (HMO SNP) will be responsible for the costs.) This Allwell Dual Medicare (HMO SNP) plan also includes Part D coverage, which provides you with the ease of having both your medical and prescription drug needs coordinated through a single convenient source.

3 Summary of Benefits JANUARY 1, DECEMBER 31, 2018 Premiums and Benefits Monthly Plan Premium, including Part C and Part D premium Allwell Dual Medicare (HMO SNP) $0 You must continue to pay your Medicare Part B premium, if not otherwise paid for by Medicaid or another third party. Deductible $0-$405 deductible for Part D depending on the level of "Extra Help" you receive. Maximum Out-of-Pocket Responsibility (does not include monthly premium and prescription drugs) $3,400 annually This is the most you will pay in copays and coinsurance for medical services for the year. Not all covered services count towards the maximum out-of-pocket amount. For more information, please see the plan s Evidence of Coverage (EOC). You will still need to pay your monthly premiums and cost sharing for your Part D prescription drugs. Inpatient Hospital Coverage Days 1-90: $0 copay per day Lifetime reserve days: $0 copay per day Beyond lifetime reserve days: Member is responsible for all costs Prior authorization (approval in advance) may be required. Referral may be required. Outpatient Hospital (including services provided at hospital outpatient facilities and ambulatory surgical centers) Hospital Visit: $0 copay Ambulatory Surgical Center Visit: $0 copay Prior authorization (approval in advance) may be required. Referral may be required

4 Premiums and Benefits Doctor Visits Allwell Dual Medicare (HMO SNP) Primary Care: $0 copay per visit Specialist: $0 copay per visit Specialist services may require Prior Authorization (approval in advance). Preventive Care Emergency Care Urgently Needed Services Diagnostic Services/Labs/ Imaging A referral may be required for specialist visits. $0 copay for Medicare-covered zero cost-sharing preventive services For all preventive services that are covered at no cost under Original Medicare, we also cover the service at no cost to you. Cost-sharing may apply when other services are received in addition to the preventive service. Some services may require Prior Authorization (approval in advance). $0 copay $0 copay Lab services: $0 copay Diagnostic tests and procedures: $0 copay Outpatient x-ray services: $0 copay Diagnostic Radiological services: $0 copay Therapeutic radiological services (such as radiation treatment for cancer): $0 copay Some services may require Prior Authorization (approval in advance). Hearing Services Referral may be required. Hearing exam (Medicare-covered): $0 copay Medicare-covered services include an exam to diagnose and treat hearing and balance issues. Routine hearing exam: $0 copay per visit (up to 1 every year) Hearing aid: $0 copay (one hearing aid) every year. This plan pays up to $1,000 for one hearing aid (for either left or right ear) every year. Members are responsible for any remaining balance over the maximum coverage limit. Hearing aids are covered when determined to be medically necessary during the hearing exam.

5 Premiums and Benefits Dental Services Allwell Dual Medicare (HMO SNP) Dental services (Medicare-covered): $0 copay Medicare-covered services: Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth). Preventive dental services: Oral exam: $0 copay (up to 2 every year) Cleaning: $0 copay (up to 2 every year) Dental x-ray: $0 copay (1 every year) Flouride Treatment: $0 copay (up to 2 every year) Comprehensive dental services: Diagnostic services: $0 copay Restorative services: $0 copay Endodontics/Periodontics/ Extractions: $0 copay Prosthodontics/Other Oral/Maxillofacial surgery : $0 copay There is a maximum plan benefit coverage amount of $1,200 every calendar year, which applies to all comprehensive dental benefits. Members are responsible for any remaining balance over the $1,200 limit. Dental x-rays include bitewing series only. Vision Services Vision exam to diagnose and treat diseases and conditions of the eye (Medicare-covered): $0 copay Yearly Glaucoma screening (Medicare-covered): $0 copay Eyeglasses or contact lenses after cataract surgery (Medicarecovered): $0 copay Routine eye exam (non Medicare-covered): $0 copay per visit (up to 1 every calendar year) Routine (non Medicare-covered) eyewear: up to $300 allowance for contact lenses and/or eyeglasses (frames and lenses) every calendar year There is a maximum plan benefit coverage amount of $300 allowance for contact lenses and/or eyeglasses (frames and lenses) every calendar year). Members are responsible for any remaining balance over the $300 limit.

6 Premiums and Benefits Mental Health Services Allwell Dual Medicare (HMO SNP) Outpatient: $0 copay for each inidvidual or group therapy session Inpatient: Days 1-90: $0 copay per day Lifetime reserve days: $0 copay per day Beyond lifetime reserve days: Member is responsible for all costs Prior authorization (approval in advance) may be required. Skilled Nursing Facility Physical Therapy Referral may be required. Days 1 through 100: $0 copay per day Beyond day 100: Member is responsible for all costs Prior authorization (approval in advance) may be required Referral may be required. $0 copay Prior authorization (approval in advance) may be required. Referral may be required. Ambulance $0 copay Prior authorization (approval in advance) is required for nonemergency ambulance services. Transportation $0 copay Up to 48 one-way trips each calendar year. Prior Authorization (approval in advance) may be required. Medicare Part B Drugs Chemotherapy drugs: $0 copay Other Part B drugs: $0 copay Prior Authorization (approval in advance) may be required. Meal Benefits The plan covers home-delivered meals (up to 2 meals per day for 14 days) following discharge from an inpatient facility or skilled nursing facility provided the meals are medically necessary and ordered by a physician or non- physician practitioner. Prior authorization (approval in advance) may be required.

7 Premiums and Benefits Over-the-Counter (OTC) Items Allwell Dual Medicare (HMO SNP) $0 copay The plan covers up to $75 per month for items available via mail order. Any unused plan benefit amounts do not carry forward into the next month. Please visit the plan s website to see the list of covered over-thecounter items. Wellness Programs Fitness program: $0 copay The plan covers a basic fitness membership at participating fitness facilities. Members can also request an in-home fitness program. 24-hour nurse advice line: $0 copay You can call the nursing hotline 24 hours a day, 365 days a year with questions about your health. Personal Emergency Response System: $0 copay The plan covers Emergency Medical Response Device. A Personal Emergency Medical Response Device is an emergency pendant that gives members an easy way to call for help at any time of day or night.

8 Deductible Phase Initial Coverage Phase (After you pay your deductible, if applicable) Outpatient Prescription Drugs $0 to $405 Deductible. Cost-sharing is based on your level of Extra Help. Cost-Sharing may change depending on the pharmacy you choose (Such as Standard Retail, mail-order, Long Term Care or Home Infusion) and when you enter another of the four phases of the Part D benefit. Standard Retail Cost Sharing Mail Order 30-day supply 90-day supply 25% of the total cost 25% of the total cost Important Info: For more information about the costs for Long Term Supply, Home Infusion or additional pharmacy-specific cost-sharing and the phases of the benefit, please call us or access our Evidence of Coverage online. Premium, copays, coinsurance and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. If you qualify for Extra Help with your prescription drug costs, the Extra Help program will pay all or part of your monthly plan premium and your prescription drug deductibles and copays/coinsurance. If you are not eligible for Extra Help, refer to the Evidence of Coverage, Chapter 6, for outpatient prescription drug cost-sharing information. This is not a complete list of drugs covered by our plan. For a complete listing, please call (TTY: 711) or visit

9 Medicaid Benefits Information for People with Medicare and Medicaid How to Read the Medicaid Benefit Chart: The benefits described below are covered by Medicaid. For each benefit listed below, you can see what Pennsylvania Medical Assistance Program covers. If a benefit is used up or not covered by Medicare, then Medicaid may provide coverage. Because you get assistance from Medicaid, you pay nothing for your covered services as long as you follow the plans rules for getting your care. Pennsylvania s Current Medicaid State Plan Benefits and Home and Community Based Services Adult Benefit Package* Services Adult Benefit Package Category 1: Ambulatory Services Primary Care Provider Physician Services and Medical and Surgical Services provided by a Dentist Certified Registered Nurse Practitioner Federally Qualified Health Center/Rural Health Clinic except for Dental Care Services as described below Independent Clinic Outpatient Hospital Clinic Podiatrist Services Chiropractor Services Optometrist Services 2 visits (exams) per calendar year Hospice Care The only key limitation is related to respite care, which may not exceed a total of 5 days in a 60-day certification period. Radiology (For example: X-Rays, MRIs, and CTs) Dental Care Services Diagnostic, preventive, restorative, surgical dental procedures, prosthodontics and sedation. Key Limitations: Dentures 1 per lifetime Exams/prophylaxis 1 per 180 days Crowns, Periodontics and Endodontics only via approved benefit limit exception. Outpatient Hospital Short Procedure Unit (SPU)

10 Outpatient Ambulatory Surgical Center (ASC) Non-Emergency Medical Transport Only to and from Medicaid covered services. Family Planning Clinic, Services and Supplies Renal Dialysis Initial training for home dialysis is limited to 24 sessions per patient per calendar year. Backup visits to the facility limited to no more than 75 per calendar year. Category 2: Emergency Services Emergency Room Ambulance Category 3: Hospitalization Inpatient Acute Hospital Inpatient Rehab Hospital Inpatient Psychiatric Hospital Inpatient Drug & Alcohol Category 4: Maternity and Newborn Maternity ---Physician, Certified Nurse Midwives, Birth Centers Category 5: Mental Health and Substance Abuse (Behavioral Health) Outpatient Psychiatric Clinic Mobile Mental Health Treatment Outpatient Drug and Alcohol Treatment Methadone Maintenance Clozapine Psychiatric Partial Hospital Peer Support Crisis Targeted Case Management ---other than Behavioral Health Limited to individuals identified in the target group (). Targeted Case Management - Behavioral Health Only Limited to individuals with Serious Mental Illness (SMI) only (). Category 6: Prescription Drugs Prescription Drugs Nutritional Supplements Category 7: Rehabilitation and Habilitation Services and Devices Skilled Nursing Facility 365 days per calendar year Home Health Care includes nursing, aide Unlimited for first 28 days; limited to 15 days every and therapy services. month thereafter. Requires an institutional level of care (). ICF/IID and ICF/ORC Durable Medical Equipment

11 Prosthetics and Orthotics Orthopedic Shoes and Hearing Aids are not covered. Coverage for low vision aids is limited to 1 per 2 calendar years. Coverage for an eye ocular is limited to 1 per calendar year. Limited to individuals with aphakia 4 lenses Eyeglass Lenses per calendar year. Limited to individuals with aphakia 2 frames Eyeglass Frames per calendar year. Limited to individuals with aphakia 4 lenses Contact Lenses per calendar year. Medical Supplies Therapy (physical, occupational, Only when provided by a hospital, outpatient speech) ---Rehabilitative clinic, or home health provider. Therapy (physical, occupational, Only when provided by a hospital, outpatient speech) ---Habilitative clinic, or home health provider. Category 8: Laboratory Services Laboratory Category 9: Preventative / Wellness Services and Chronic Care Tobacco Cessation** 70 visits per calendar year All units of service, age, gender, diagnosis, and other procedure code related limits still apply as indicated on the Medical Assistance Fee Schedule. *Children s benefit plan will include all medically necessary services without limitation. **Tobacco cessation is one of the preventative services as recommended by the US Preventative Services Task Force. For a full listing of preventative services beyond tobacco cessation, please contact your MCO.

12 Home and Community-Based Services (HCBS) Services Limits Adult Daily Living Services Under Community Integration: Assistive Technology Behavior Therapy Benefits Counseling Career Assessment Cognitive Rehabilitation Therapy Community Integration Each distinct goal may not be more than twenty-six (26) weeks. No more than 32 units per week for one goal will be approved. If the participant has multiple goals, no more than 48 units per week will be approved. However, the Office of Long Term Living retains the discretion to authorize more than 48 units (12 hours) of Community Integration in one week for up to 21 hours per week and for periods longer than 26 weeks. Community Transition Services

13 Employment Skills Development Home Adaptations Home Delivered Meals Home Health Aide Home Health ---Nursing Home Health ---Occupational Therapy Home Health ---Physical Therapy Home Health ---Speech and Language Therapy Job Coaching Job Finding Non-Medical Transportation Nutritional Counseling Participant-Directed Community Supports Participant-Directed Goods and Services Personal Assistance Services Personal Emergency Response System (PERS) Pest Eradication Residential Habilitation Respite Service Coordination Specialized Medical Equipment and Supplies Structured Day Habilitation TeleCare Vehicle Modifications Community Transition Services are limited to an aggregate of $4,000 per participant, per lifetime, as pre- authorized by the State Medicaid Agency program office. Total combined hours for Employment Skills Development, or Job Coaching services are limited to 50 hours in a calendar week. A participant whose needs exceed 50 hours a week must obtain prior approval. Under Specialized Medical Equipment and Supplies non-covered items include: All prescription and over-the-counter medications, compounds and solutions (except wipes and barrier cream) Items covered under third party payer liability Items that do not provide direct medical or remedial benefit to the participant and/or are not directly related to a participant s disability Food, food supplements, food substitutes (including formulas), and thickening agents Eyeglasses, frames, and lenses Dentures Any item labeled as experimental that has been denied by Medicare and/or Medicaid Recreational or exercise equipment and adaptive devices for such

14 For all HCBS services that are also offered under the State Plan, the State Plan benefit must be exhausted before HCBS services can be accessed. Additionally, Medicare and other third party resources such as private insurance limitations must also have been exhausted. Lastly, some HCBS services may not be accessed at the same time.

15 For more information, please contact: Allwell Dual Medicare (HMO SNP) 300 Corporate Center Drive Camp Hill, PA Current members should call: (TTY: 711) Prospective members should call: (TTY: 711) From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. 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 This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits, premiums and/or copayments/ coinsurance may change on January 1 of each year. Premium, copayments, coinsurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. Coinsurance is the percentage you pay of the total cost of certain medical services. You pay a coinsurance at the time you get the medical service. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. This plan is available to anyone who has both Medical Assistance from the State and Medicare. This document is available in other formats such as Braille, large print or audio. Allwell is a Coordinated Care plan with a Medicare contract and a contract with the Pennsylvania Medicaid program. Enrollment in Allwell depends on contract renewal.

16 Allwell complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Allwell does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Allwell : Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Allwell Customer Contact Center at: (TTY: 711). From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. On weekends and holidays, an automated system will handle your call. If you believe that Allwell 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 by calling the number above and telling them you need help filing a grievance; Allwell Customer Contact Center 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

17 Español (Spanish) ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711) Allwell Medicare (HMO SNP). 中文 (Chinese) 注意 : 如果您說中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711) Allwell Medicare (HMO SNP). Tiếng Việt (Vietnamese) CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711) Allwell Medicare (HMO SNP). 한국어 (Korean) 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) Allwell Medicare (HMO SNP) 번으로전화해주십시오. જર ત (Gujarati) ચન : જ તમ જર ત બ લત હ, ત ન: ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલ ધ છ. ફ ન કર (TTY: 711) Allwell Medicare (HMO SNP). Русский (Russian) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (TTY: 711) Allwel Medicare (HMO SNP. العربية (Arabic) تنبيه: إذا كنت تتحدث العربية فإن خدمات المساعدة اللغوية المجانية متاحة لك. ي رجى االتصال بالرقم (TTY: 711) Allwell Medicare (HMO SNP). Français (French) ATTENTION : Si vous parlez français, des services d aide linguistique vous sont proposés gratuitement. Appelez le (TTY: 711) Allwell Medicare (HMO SNP). Deutsch (German) ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711) Allwell Medicare (HMO SNP). አማርኛ (Amharic) ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች በነጻ ሊያግዝዎት ተዘጋጀተዋል ወደ ሚከተለው ቁጥር ይደውሉ (TTY: 711) Allwell Medicare (HMO SNP). Kreyòl Ayisyen (French Creole) ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele Allwell Medicare (HMO SNP).

18 Português (Portuguese) ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: 711) Allwell Medicare (HMO SNP). ह द (Hindi) ध य न द : य द आप ह द ब लत ह त आपक लए म फ त म भ ष सह यत स व ए उपलब ध (TTY: 711) Allwell Medicare (HMO SNP). فارسی (Farsi) توجه: اگر زبان شما فارسی است خدمات امداد زبانی به طور رايگان در اختيار شما می باشد. لطفا با شماره.تماس بگيريد. SNP). (TTY: 711) Allwell Medicare (HMO 日本語 (Japanese) 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 711) Allwell Medicare (HMO SNP). まで お電話にてご連絡ください BKT013569EK00 (6/17)