2019 Health Net Seniority Plus Amber I (HMO SNP) H0562: 055 Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco

Transcription

1 2019 Health Net Seniority Plus Amber I (HMO SNP) H0562: 055 Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco and Tulare Counties, CA H0562_19_7837SB_055_M_Accepted

2 This booklet provides you with a summary of what we cover and your cost-sharing responsibilities. 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, and ask for the "Evidence of Coverage" (EOC), or you may access the EOC on our website at, ca.healthnetadvantage.com. You are eligible to enroll in Health Net Seniority Plus Amber I (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 the Health Net Seniority Plus Amber I (HMO SNP) service area county). Our service area includes the following counties in California: Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco and Tulare. You do not have end-stage renal disease (ESRD). (Exceptions may apply for individuals who develop ESRD while enrolled in a Health Net commercial or group health plan, or a Medicaid plan.) For Health Net Seniority Plus Amber I (HMO SNP), you must also be enrolled in the California Medicaid plan. Premiums, copays,, 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 California for full-dual enrollees. Please contact the plan for further details. The Health Net Seniority Plus Amber I (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-todate list of network providers, visit ca.healthnetadvantage.com. (Please 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 Health Net Seniority Plus Amber I (HMO SNP) will be responsible for the costs.) This Health Net Seniority Plus Amber I (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. 2

3 Summary of Benefits JANUARY 1, 2019 DECEMBER 31, 2019 Benefits Health Net Seniority Plus Amber I (HMO SNP) H0562: 055 Premiums / Copays / Coinsurance Plus Amber I, Medicare and full Medicaid/ Medi- Cal eligibility, you pay Plus Amber I and Medicare only, you pay Premiums, copays,, and deductibles may vary based on your Medicaid eligibility category and/or the level of Extra Help you receive. Monthly Plan Premium $0 Deductible (You must continue to pay your Medicare Part B premium, if not otherwise paid for by Medicaid or another third party.) $0 deductible for covered medical services $0 - $85 deductible for Part D prescription drugs (applies to drugs on Tiers 2, 3, 4 and 5) $34.80 (You must continue to pay your Medicare Part B premium, if not otherwise paid for by Medicaid or another third party.) $0 deductible for covered medical services $320 deductible for Part D prescription drugs (applies to drugs on Tiers 2, 3, 4 and 5) Maximum Out-of-Pocket Responsibility (does not include prescription drugs) Inpatient Hospital Coverage* Outpatient Hospital* Doctor Visits* $6,700 annually This is the most you will pay in copays and for medical services for the year. $6,700 annually This is the most you will pay in copays and for medical services for the year. $0 copay per stay $0 copay per stay Outpatient Hospital (includes ambulatory surgical center and observation services): $0 copay per visit Primary Care: Specialist: Outpatient Hospital services: $0 copay per visit Observation Services: $30 copay per visit Ambulatory Surgical Center: $0 copay per visit Primary Care: Specialist: Preventive Care* (e.g. flu vaccine, diabetic screening) $0 copay for Medicare-covered preventive services Other preventive services are available. $0 copay for Medicare-covered preventive services Other preventive services are available. 3

4 Benefits Health Net Seniority Plus Amber I (HMO SNP) H0562: 055 Premiums / Copays / Coinsurance Plus Amber I, Medicare and full Medicaid/ Medi- Cal eligibility, you pay Plus Amber I and Medicare only, you pay Emergency Care $30 copay per visit Urgently Needed Services Diagnostic Services/Labs/ Imaging* Hearing Services* Dental Services* Vision Services Lab services: $0 copay Diagnostic tests and procedures: $0 copay Outpatient X-ray services: $0 copay Diagnostic Radiological services: $0 copay Hearing exam (Medicarecovered): $0 copay Routine hearing exam: $0 copay (1 every calendar year) Hearing aid: $0 copay (2 hearing aids every year) Dental services (Medicarecovered): Preventive Dental Services: $0 copay (including oral exams, cleanings, fluoride treatment, and X-rays) Comprehensive dental services: Additional comprehensive dental benefits are available. Vision exam (Medicare-covered): Routine eye exam: $0 copay per visit (up to 1 every calendar year) Routine eyewear: up to $400 allowance every 2 calendar years You do not have to pay the copay if admitted to the hospital immediately. Lab services: $0 copay Diagnostic tests and procedures: $0 copay Outpatient X-ray services: $0 copay Diagnostic Radiological services: $0 copay Hearing exam (Medicarecovered): $0 copay Routine hearing exam: $0 copay (1 every calendar year) Hearing aid: $0 copay (2 hearing aids every year) Dental services (Medicarecovered): Preventive Dental Services: $0 copay (including oral exams, cleanings, fluoride treatment, and X-rays) Comprehensive dental services: Additional comprehensive dental benefits are available Vision exam (Medicare-covered): Routine eye exam: $0 copay per visit (up to 1 every calendar year) Routine eyewear: up to $400 allowance 2 calendar years Mental Health Services* Individual and group therapy: $0 copay per visit Individual and group therapy: $10 copay per visit 4

5 Benefits Health Net Seniority Plus Amber I (HMO SNP) H0562: 055 Premiums / Copays / Coinsurance Plus Amber I, Medicare and full Medicaid/ Medi- Cal eligibility, you pay Plus Amber I and Medicare only, you pay Skilled Nursing Facility * $0 copay per stay $0 copay per day, days 1 through 20 $50 copay per day, days 21 through 100 Physical Therapy* Ambulance* $0 copay (per one-way trip) Ground ambulance services:$50 copay per one-way trip Air ambulance services:5% per one-way trip Transportation* $0 copay for each one-way trip, up to 24 one-way trips per year Medicare Part B Drugs* Chemotherapy drugs: 0% Other Part B drugs: 0% $0 copay for each one-way trip, up to 24 one-way trips per year Chemotherapy drugs: 20% Other Part B drugs: 20% 5

6 Deductible Phase Initial Coverage Phase (after you pay your Part D deductible, if applicable) Part D Prescription Drugs $0 - $320 deductible (Deductible does not apply to Tiers 1 and 6.) Standard Retail Rx 30-day supply Tier 1: Preferred Generic $0 copay $0 copay Mail-Order Rx 90-day supply Tier 2: Generic $20 copay $60 copay Tier 3: Preferred Brand $47 copay $141 copay Tier 4: Non-Preferred Drug $100 copay $300 copay Tier 5: Specialty 26% Not available Tier 6: Select Care Drugs $0 copay $0 copay Important Info: Cost-sharing may change depending on the level of help you receive, 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. 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 EOC online. Low income subsidy (LIS) is extra help you receive from Medicare. To find out if you qualify, visit Medicare.gov or call Member Services at (TTY: 711). 6

7 Additional Covered Benefits Benefits Health Net Seniority Plus Amber I (HMO SNP) 055 Premiums / Copays / Coinsurance Chiropractic Care* Plus Amber I, Medicare and full Medicaid/ Medi- Cal eligibility, you pay Chiropractic services (Medicarecovered): Plus Amber I and Medicare only, you pay Chiropractic services (Medicarecovered): Medical Equipment/ Supplies* Foot Care * (Podiatry Services) Durable Medical Equipment (e.g., wheelchairs, oxygen): 0% Prosthetics (e.g., braces, artificial limbs): 0% Diabetic supplies: 0% Foot exams and treatment (Medicare-covered): 0% per visit Routine foot care: $0 copay per visit (12 visits per year.) Durable Medical Equipment (e.g., wheelchairs, oxygen): 15% Prosthetics (e.g., braces, artificial limbs): 15% Diabetic supplies: $0 copay Foot exams and treatment (Medicare-covered): Routine foot care: $0 copay per visit (12 visits per year) Wellness Programs Fitness program: $0 copay 24-hour nurse advice line: $0 copay Fitness program: $0 copay 24-hour nurse advice line: $0 copay For a detailed list of wellness program benefits offered, please refer to the EOC. For a detailed list of wellness program benefits offered, please refer to the EOC. 7

8 Section 1557 Non-Discrimination Language Notice of Non-Discrimination Health Net complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Net does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Health Net: 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 Health Net s Customer Contact Center at California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO); Oregon: (HMO and PPO) (TTY: 711). From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 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 believe that Health Net 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; Health Net s 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 Health Net is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Health Net depends on contract renewal. 8

9 Section 1557 Non-Discrimination Language Multi-Language Interpreter Services ARABIC California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO); Oregon: (HMO and PPO) ARMENIAN California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO) (TTY: 711). CHINESE California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO); Oregon: (HMO and PPO) (TTY: 711) CUSHITE (TTY: 711). Oregon: (HMO and PPO) FRENCH (TTY: 711). Oregon: (HMO and PPO) GERMAN Oregon: (HMO and PPO) (TTY: 711). HINDI California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO) (TTY: 711). HMONG California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO) (TTY: 711). JAPANESE KOREAN California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO); Oregon: (HMO and PPO) (TTY: 711) 9

10 MON-KHMER CAMBODIAN California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO); Oregon: (HMO and PPO) (TTY: 711) PERSIAN PUNJABI California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO) (TTY: 711) ROMANIAN Oregon: (HMO and PPO) (TTY: 711). RUSSIAN California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO); Oregon: (HMO and PPO) (TTY: 711). SPANISH California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO); Oregon: (HMO and PPO) (TTY: 711). TAGALOG THAI California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO) (TTY: 711). California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO); Oregon: (HMO and PPO) (TTY: 711). UKRAINIAN Oregon: (HMO and PPO) (TTY: 711). VIETNAMESE 10

11 Comprehensive Written Statement for Prospective Enrollees The benefits described in the Premium and Benefit section of the Summary of Benefits are covered by our Medicare Advantage plan. For each benefit listed, you can see what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. Coverage of the benefits described in this Summary of Benefits depends upon your level of Medicaid eligibility. No matter what your level of Medicaid eligibility is, Health Net Seniority Plus Amber I (HMO SNP) will cover the benefits described in the Premium and Benefit section of the Summary of Benefits. If you have questions about your Medicaid eligibility and what benefits you are entitled to, call California Health Advocates toll-free at Our source of information for Medicaid benefits is cahealthadvocates.org. All Medicaid covered services are subject to change at any time. For the most current California Medicaid coverage information, please visit cahealthadvocates.org or call Member Services for assistance. A detailed explanation of California Medicaid benefits can be found in the California Summary of Services online at cahealthadvocates.org. 11

12 For more information, please contact: Health Net Seniority Plus Amber I (HMO SNP) PO Box Van Nuys, CA ca.healthnetadvantage.com Current members should call: (TTY: 711) Prospective members should call: (TTY: 711) From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 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 plan is available to anyone who has both Medical Assistance from the State and Medicare. This information is not a complete description of benefits. Call (TTY: 711) for more information. Coinsurance is the percentage you pay of the total cost of certain medical services. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. This document is available in other formats such as Braille, large print or audio. Health Net is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Health Net depends on contract renewal. SBS020820EK00_A (07/18) 12