One Care and Senior Care Options Prior Authorization (PA) Requirements. Place of Service Code Type Code Range on Claim. Measure
|
|
- Denis Small
- 6 years ago
- Views:
Transcription
1 For Services That Require Prior Authorization, Please Refer To Claim Submission Billing Guidelines Below: Commonwealth Care Alliance (CCA) Covered Services One Care and Senior Care Options Prior Authorization (PA) Requirements Place of Service Code Type Code Range on Claim Modifier Unit of Measure Abortion* (One Care Only) Acupuncture 11,12, 21, 22, 50, 53, 62 Adult Day Health - Basic Adult Day Health Complex Adult Day Health Day Services CPT N/A N/A 11, 49, 99 HCPCS S5102 N/A Per Diem 11, 49, 99 HCPCS S5102 TG Per Diem 11, 49, 99 HCPCS S5102 UD Per Diem Adult Foster Care - Level I 12, 14, 33, 54 HCPCS S5140 N/A Per Diem Adult Foster Care - Level I Alternative Placement Please note: an authorization for S5140 must be on file in order to utilize modifiers TF, U6, U7. 12, 14, 33, 54 HCPCS S5140 TF U6 U7 Per Diem Per Diem Per Diem Adult Foster Care - Level II 12, 14, 33, 54 HCPCS S5140 TG Per Diem Adult Foster Care - Level II Alternative Placement. Please note, an authorization for S5140 TG must be on file in order to utilize modifiers U5, TGU6, TGU7. 12, 14, 33, 54 HCPCS S5140 TGU6 TGU7 U5 Per Diem Per Diem Per Diem Adult Foster Care Intake and Assessment Services Group Adult Foster Care (GAFC) (Supportive Housing) 12, 14, 33, 54 HCPCS T1028 N/A Per Admission 12, 14, 33, 54 HCPCS H0043 N/A Per Diem Ambulance: Emergency Transportation Rev 12/2017 Back to the top Page 15 of 83
2 Alzheimer s Assessment 04, 12, 13, 14, HCPCS S5110 N/A Per Session Alzheimer s Coaching 04, 12, 13, 14, HCPCS S5111 N/A Per 15 Minutes Ambulatory/Outpatient Surgery Please call CCA s Member Services for more information (866) Assisted Living (Basic) 13 HCPCS T2031 N/A Assisted Living Special Care/Memory Care Unit 13 HCPCS T2031 TG Per Diem Audiology Behavioral Health Care Services Please see: Behavioral Health Section Please see: Behavioral Health Section Cardiac Rehabilitation Services 11, 22, 31, 61, 62 CPT/ HCPC / N/A Per Session G0422, G0423 Care Transitions Across Settings Chemotherapy Chiropractic Care, after 20 sessions 11, 12, 22, 50, 53, 62 Chore Services - Heavy CPT N/A N/A 04, 12, 13, 14, HCPCS S5121 UB Per 15 minutes Chore Services - Light 04, 12, 13, 14, HCPCS S5120 N/A Per 15 minutes Companion Services 04, 12, 13, 14, HCPCS S5135 N/A Per 15 minutes Companion Services with Transportation 04, 12, 13, 14,, 99 HCPCS S5135 TG Per 15 Minutes Day Habilitation - Skills Training and Development Day Habilitation - Therapeutic Behavioral Services Day Habilitation - Community Based wraparound services 11, 18, 49, 99 HCPCS H2014 N/A Per 15 Minutes 11, 18, 49, 99 HCPCS T2020 N/A Per 15 Minutes 11, 18, 49, 99 HCPCS T2021 N/A Per 15 Minutes Dental: Emergency Oral Health Rev 12/2017 Back to the top Page of 83
3 Dental: Preventive Dental: Restorative fillings Dental: Crowns Dentures Oral Surgery Other Replacement dentures and crowns are limited to coverage once every five years unless authorized differently Commonwealth Care Alliance has selected Scion Dental as dental program administrator for its Senior Care Options and One Care plans. All claims and authorizations must be submitted to Scion. Additional requirements and limitations may apply. Please click here to access the Scion Dental Provider Manual for more information. Additional questions or inquiries should be directed to Scion Dental Provider Relations (855) Diabetic Self-Management Training, Services, and Supplies - for non-formulary Diabetic testing supplies If you have questions, please call member services. Diagnostic Services, including but not limited to endoscopy, colonoscopy, and sigmoidoscopy (or screening barium enema) Dialysis and Supplies Durable Medical Equipment and Medical Supplies Please Click here for DME PA list. 04, 11, 12, 13, 14, 33, 54, 55, 56, 65, Education and Wellness Programs Emergency Services Covered up to $1000 outside of the United States for SCO members only Enteral Therapy Environmental Aids and Assistive /Adaptive technology Please Click here for DME PA list. Rev 12/2017 Back to the top Page 17 of 83
4 Family Planning* (One Care Only) Family planning services are available through any MassHealth and/or Commonwealth Care Alliance family planning provider. Treatment for medical conditions of infertility*, treatment for AIDS and other HIV related conditions, and genetic testing needs to be received from CCA s providers. This service does not include artificial ways to become pregnant. Gender Reassignment Surgery and Related Services Please call CCA s Member Services for more information (866) Genetic Testing Please call CCA s Member Services for more information (866) Grocery Shopping and Delivery 12, 99 HCPCS S5121 N/A Per Order Gym Membership (SCO only) All - S9451 N/A Various (e.g. Per Month / Per Year / Per Weeks) Hearing Aids - Fitting and Refitting Hearing Aids - Major Repairs Hearing Aids, Replacement and Accessories Home Based Wandering Response System - Installation Home Based Wandering Response System Monthly Fee, unless cost exceeds $500 per line item., unless cost exceeds $500 per line item or identified on itemized DME PA list. Click here for DME PA list. 04, 12, 13, 14, HCPCS T2028 N/A Per Event 04, 12, 13, 14, HCPCS S51 U1 Per Month Home Delivered Meals 04, 12, 13, 14, HCPCS S5170 N/A Per Meal Home Health, including home health aides, therapies and skilled nursing, please see Home Health Services Please see Home Health Services section Rev 12/2017 Back to the top Page 18 of 83
5 Homemaker Service 04, 12, 13, 14, HCPCS S5130 N/A Per 15 Minutes Hospice - Medicare Hospice Commonwealth Care Alliance: The plan covers hospice (including room and board in a facility) under the MassHealth (Medicaid) benefit.. Medicare pays for Hospice Services if Member elects Medicare Hospice. Please call CCA s Member Services for more information (866) HCPCS T2044, T2045, T2046 N/A Per Diem Immunizations/Vaccines, including but not limited to: flu, Hepatitis B, and Pneumococcal vaccines Infusion therapy in an outpatient facility 11, 22, 24 CPT N/A N/A Inpatient Hospital Services, including all inpatient services at following settings: acute inpatient, chronic, rehabilitation, psych-detox, and substance abuse 21, 51, 61 REV N/A Days Interpreter Services Laboratory Services (excluding genetic testing) Laundry 04, 12, 13, 14, HCPCS S5175 N/A Per Order Massage Therapy 11, 12, 13,, 31, 32, 33, 99 CPT 97124, 97112, 97122, 97140, N/A Per 15 Minutes Medication Dispensing System 04, 12, 13, 14, HCPCS A9279 N/A Per Month Medication Dispensing System Installation 04, 12, 13, 14, HCPCS T5999 UB Per Installation Orthotics Please Click here for DME PA list. Rev 12/2017 Back to the top Page 19 of 83
6 Outpatient Blood Services Outpatient Hospital Services. Observation Level of Care Oxygen Please Click here for DME PA list. 12, 13, 14,, 33 Peer Support 11, 12, 99 HCPCS H0038 U1 Per 1 Hour Peer Support - Behavioral Health - Individual Peer Support, Community/Residential, including Individual Living Home Care Services 11, 12, 99 HCPCS H0038 HE Per 1 Hour Peer Support - Behavioral Health - Community/Residential, group of 2 Peer Support - Behavioral Health - Community/Residential, group of 5 or more Personal Care Homemaker through a Personal Care Agency (PCHM) 11, 12, 99 HCPCS H0038 UA Per Enrollee per 1 Hour 11, 12, 99 HCPCS H0038 UB Per Enrollee per 1 Hour 04, 12, 13, 14, HCPCS S Per 15 minutes Personal Care Attendant (PCA) Services 04, 12, 13, 14, HCPCS T Per 15 Minutes Personal Care Management Assessment- Initial Evaluation Personal Care Management Assessment Re-evaluation 04, 12, 13, 14,, 99 04, 12, 13, 14,, 99 Personal Care Management Skill Training 04, 11, 12, 13, 14, Personal Care Management 04, 11, 12, 13, 14, Intake, Orientation & Screening (PCM) Personal Emergency Response System (PERS) CPT U1 Per Session CPT TS U1 Per Session HCPCS T Per Month HCPCS T Per Month 04, 12, 13, 14, HCPCS S51 - Per Month PERS Auto Detect Fall 04, 12, 13, 14, HCPCS S51 SC Per Month PERS- Cellular 04, 12, 13, 14, HCPCS S51 SQ Per Month Rev 12/2017 Back to the top Page 20 of 83
7 Personal Emergency Response System (PERS) Installation and Testing Podiatry (excluding surgical procedures) Preventive Services and Screenings, including but not limited to: abdominal aortic aneurysm screening, annual wellness visits, alcohol misuse screening and counseling, bone mass measurement, breast cancer screening (mammograms), cardiovascular disease risk-reduction visit (therapy for cardiovascular disease), cardiovascular disease testing, cervical and vaginal cancer screening, colorectal cancer screening (fecal occult blood test sigmoidoscopy, colonoscopy or screening barium enema), smoking and tobacco use cessation (counseling to stop smoking or tobacco use), depression screening, diabetes screening, HIV screening, medical nutrition therapy services for people with diabetes or kidney disease, obesity screening and therapy to promote sustained weight loss, prostate cancer screening exams, screening for hepatitis C virus (HCV), screening for sexually transmitted infections (STI) and counseling, and any additional preventive services approved by Medicare and/or MassHealth during the contract year 04, 12, 13, 14, HCPCS S50 - Per Session, unless provided in a nursing home setting. Primary Care Provider Services Prosthetic Services and Devices Please Click here for DME PA list Pulmonary Rehabilitation 11, 22, 31, 61, 62 HCPCS G0424 N/A Per Hour Radiation Oncology Radiology and X-ray Services X-rays do not require a PA. Only specified radiology per itemized list requires PA Please click here for itemized list 11, 21, 22, 23, 50, N/A N/A Respiratory Equipment Please Click here for DME PA list Rev 12/2017 Back to the top Page 21 of 83
8 Respiratory Therapy Respite Care Skilled Nursing Facility Services, including services at the following levels: sub-acute, skilled, custodial, medical and nonmedical leave of absence, Please see Skilled Nursing Facility Services section Please see Skilled Nursing Facility Services section Supportive Day Program, SCO only (Social Day Care) 11, 49 HCPCS S5101 N/A ½ Day Supportive Home Care Aide 04, 12, 13, 14, HCPCS S5125 N/A Per 15 Minutes Specialty Physician Services, Including but not limited to the following list and second opinions upon the request of the Member: anesthesiology, audiology, cardiology, dermatology, gastroenterology, gynecology, internal medicine, nephrology, neurology, neurosurgery, obstetrics, oncology, ophthalmology, oral surgery, orthopedics, otolaryngology, podiatry, psychiatry, pulmonology, radiology, rheumatology, surgery, thoracic surgery, vascular surgery, and urology. Therapies: Home Occupational Physical Speech, Please see Home Health Services Section Please see Home Health Services Section Therapies: Outpatient Occupational Physical Speech Tobacco Cessation Rev 12/2017 Back to the top Page 22 of 83
9 Transplant Services Please call CCA s Member Services for more information (866) Transportation: Emergency Transportation: n-emergency; Taxi Transportation: n-emergency; Wheelchair Van Transportation: n-emergency; Patient Attendant/Escort Transportation: n-emergency; Stretcher Van, Emergency Transportation is not covered outside of the United States and its territories N/A CPT A0100 N/A One Way Trip N/A CPT A0130 N/A One Way Trip N/A CPT T2001 N/A One Way Trip N/A CPT T2005 N/A One Way Trip Transportation 1 way trip N/A CPT T2003 N/A One Way Trip Transportation: Mileage N/A CPT A0425 S0215 S0209 Vision Care Services: Eyeglasses and Contact Lenses SCO - Benefit limit $300 /year per frame. One Care - Benefit limit $125/year per frame N/A Mile Vision Care Services: Other: Comprehensive eye exams (including routine care) Vision training Outpatient physician services or diagnosis and treatment of disease and injuries of the eye. This includes treatment of agerelated macular degeneration. Glaucoma screenings. Rev 12/2017 Back to the top Page 23 of 83
10 Behavioral Health Services Commonwealth Care Alliance Covered Services Inpatient Mental Health Care (Inpatient Psychiatric) Inpatient Substance Abuse Behavioral Health Diversionary Services Acute Treatment Services for Substance Abuse Clinical Support Services for Substance Abuse (Residential Substance Abuse Programs) One Care and Senior Care Options Prior Authorization (PA) Requirements Emergency Admission: prior authorization is required, but notification is required before bed placement n-emergency admission: Prior authorization is not required, but notification is required before bed placement Place of Service Code Type Code Range on Claim Please see above page, Inpatient Hospital Services Please see above page, Inpatient Hospital Services Modifier Unit of Measure Community Support Program 15 HCPCS H2015 N/A Per 15 Minutes Community Crisis Stabilization tification is required within 24 hours Intensive Outpatient Program 11, 51, 52, 53, 56 REV 905 N/A Per Diem Observation/Holding Beds, tification is required within 24 hours Partial Hospitalization 21,22, 51,52 REV 912 N/A Per Session (Per Half Day) Program of Assertive Community Treatment (PACT) 15 HCPCS H0040 N/A Per Diem Psychiatric Day Treatment 11, 22, 52, 53, 57 HCPCS H2012 N/A Per Hour Rev 12/2017 Back to the top Page 24 of 83
11 Structured Outpatient Addiction Program Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; initial, including cortical mapping, motor threshold determination, delivery and management Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent delivery and management, per session Therapeutic repetitive transcranial magnetic stimulation (TMS) treatment; subsequent motor threshold 11, 19, 21, 22, 52, 53, 55, 57 11, 19, 21, 22, 51, 52, 56 11, 19, 21, 22, 51, 52, 56 11, 19, 21, 22, 51, 52, 56 HCPCS H0015 N/A Half Day HCPCS N/A Per Session HCPCS N/A Per Session HCPCS N/A Per Session Behavioral Health Emergency Services Emergency Screening Services/Short Term Crisis Counseling Medication Management Crisis Specialing Services for Community or Home Care Aide Behavioral Health Outpatient Services Behavioral (Mental) Health, including but not limited to treatment and therapy, consultations, medication visits, and ambulatory detoxification 11, 41, 51, 52, 54, 55, 56, 61 HCPCS T1004 HE Per 15 Minutes, unless provided in a day program Substance Abuse Services, including but not limited to acupuncture treatment and methadone maintenance Rev 12/2017 Back to the top Page 25 of 83
12 Behavioral Health Special Procedures Electro Convulsive Therapy 11, 19, 21, 22, 51, 52, 56 Neuropsychological Testing 11, 12, 21, 22, 31, 32, 33, 50, 51, 52, 53, 54, 55, 56, 57 CPT N/A Per Session CPT 96118, N/A Per Hour If a requested service or item is not listed above, please call Commonwealth Care Alliance at for clarification. All n-contracted providers and vendors require Prior Authorization The list has been updated on 01/01/18. Changes were made for clarification. Some of the requirements in member booklets may differ. The requirements provided herewith are provider requirements. Providers need to do diligence to ensure PA is obtained if required. Rev 12/2017 Back to the top Page 26 of 83
13 Home Health Services Commonwealth Care Alliance Covered Services One Care and Senior Care Options Prior Authorization (PA) Requirements Place of Service Home Health Aide 04, 12, 13, 14, Home Infusion Therapy 04, 12, 13,14,, 18 Code Type Code Range on Claim Modifier Unit of Measure HCPCS G0156 N/A 15 Minutes/ Service CPT 99601, N/A = Per Visit (Up to 2 Hours); = Each Additional Hour Independent Nursing/Private Duty Nursing/Continuous Nursing Services 12, 13, HCPCS T1000, T1002, T1003 N/A Per 15 Minutes Occupational Therapy 04, 12, 13, 14, Occupational Therapy Assistant 04, 12, 13, 14, Physical Therapy 04, 12, 13, 14, Physical Therapy Assistant 04, 12, 13, 14, Skilled Nursing 04, 12, 13, 14, HCPCS G0152 N/A Per Visit HCPCS G0158 N/A Per Visit HCPCS G0151 N/A Per Visit HCPCS G0157 N/A Per Visit HCPCS G0299 G0300 G0299 G0300 Social Work Visit 04, 12, 13, 14, HCPCS G0155 N/A Per Visit Speech Therapy 04,12, 13, 14, HCPCS G0153 N/A Per Visit - - UD UD Per Visit Remote Patient Monitoring Services: Tele-health originating site facility fee (Installation/removal of remote monitoring equipment) Remote Patient Monitoring Services: Nurse visit by RN & Nurse visit by LPN 12, 99 HCPCS Q3014 N/A Per event 12, 99 HCPCS T1030, T1031 GT Per Diem *Modifier Applicable Only to Specified Code Rev 12/2017 Back to the top Page 27 of 83
14 Skilled Nursing Facility Services (SNF) Commonwealth Care Alliance Covered Services One Care and Senior Care Options Prior Authorization (PA) Requirements Place of Service Code Type Code Range on Claim Modifier SNF Custodial 31, 32, 33 REV 120 N/A Days Unit of Measure SNF Custodial Medical LOA (20 Days Max) SNF Custodial n Medical LOA SNF Podiatry N/A Per Service CPT SNF Skill 31, 32, 33 REV 191 N/A Days SNF Sub-Acute 31, 32, 33 REV 192 N/A Days If a requested service or item is not listed above, please call Commonwealth Care Alliance at for clarification. All n-contracted providers and vendors require Prior Authorization The list has been updated on 1/1/2018. Changes were made for clarification. Some of the requirements in member booklets may differ. The requirements provided herewith are provider requirements. Providers need to do diligence to ensure PA is obtained if required. * Service Applicable Only to Program Specified Rev 12/2017 Back to the top Page 28 of 83
15 Radiology Services Commonwealth Care Alliance Covered Services Radiology: Cardiac MRI Radiology: CAT (CT) Scan Radiology: CTA (CT Angiography) Radiology: MPI (Myocardial Perfusion Imaging) Radiology: MRA (Magnetic Resonance Angiogram) Radiology: MRI (Magnetic Resonance Imaging) Radiology: MUGA (Multigated Acquisition Scan) Radiology: PET (Positron Emission Tomography) Bone Scan Radiology: PET (Positron Emission Tomography) CT Scan Radiology: PET (Positron Emission Tomography) Scan Stress Echocardiogram TEE (Transesophageal Echocardiogram) TTE (Transthoracic Echocardiogram) One Care and Senior Care Options Prior Authorization (PA) Requirements Durable Medical Equipment (DME) Click here for code specific list of Durable Medical Equipment (DME) and other services requiring Prior Authorization (PA) for Commonwealth Care Alliance One Care and SCO Program. Rev 12/2017 Back to the top Page 29 of 83
16 Provider Claim Submission Billing Guidelines E1399 Durable Medical Equipment Modifier Requirements for Items Billed as E1399 CCA recently updated modifier requirements for certain items billed as E1399. DME items billed as E1399 from the list below are required to have a modifier. Modifiers are used to increase accuracy in compensation, coding consistency, editing, and to capture payment data. The absence or presence of an inappropriate modifier may result in a claim denial. Prior Authorization Required DME Item Code Modifier Description Ramps Portable E1399 U1 Ramps Portable, Medicaid Level of Care 1, as defined by each State Ramps Modular E1399 U2 Ramps Modular, Medicaid Level of Care 2, as defined by each State Stair Lifts E1399 U3 Stair Lifts, Medicaid Level of Care 3, as defined by each State Porch Lifts E1399 U4 Porch Lifts, Medicaid Level of Care 4, as defined by each State Automatic Door Openers E1399 U5 Automatic Door Openers, Medicaid Level of Care 5, as defined by each State Home modifications not listed E1399 U6 Home modifications not listed, Medicaid Level of Care 6, as defined by each State *Beds other than standard or bariatric hospital beds E1399 U7 *Beds other than standard or bariatric hospital beds, Medicaid Level of Care 7, as defined by each State Mattresses other than standard hospital beds due to size or construction (sleep number, tempurpedic, regular inner spring for standard beds) E1399 U8 Mattresses other than standard hospital beds due to size or construction (sleep number, tempurpedic, regular inner spring for standard beds) - Medicaid Level of Care 8, as defined by each State *Exercise equipment > E1399 U9 *Exercise equipment, Medicaid Level of Care 9, as defined by each State Rev 12/2017 Back to the top Page 30 of 83
17 Shoes for non-diabetic or orthopedic needs E1399 UA Shoes for non-diabetic or orthopedic needs, Medicaid Level of Care 10, as defined by each State Air conditioners E1399 UB Air conditioners, Medicaid Level of Care 11, as defined by each State Reclining chairs with or without seat lift E1399 UC Reclining chairs with or without seat lift, Medicaid Level of Care 12, as defined by each State Bed positioning equipment E1399 UD Bed positioning equipment, Medicaid Level of Care 13, as defined by each State Custom fabricated equipment where cost is greater than allowable E1399 P6 Custom fabricated equipment where cost is greater than allowable Rehab shower commode chairs E1399 Q0 Rehab shower commode chairs, Investigational clinical service Safety equipment (bed alarms, floor mats, monitors) E1399 Q1 Safety equipment (bed alarms, floor mats, monitors) - Routine clinical service provided in a clinical research study A full list of Commonwealth Care Alliance s covered services and prior authorization requirements can be found in the Provider Manual on our website under the Providers tab. For additional questions or inquiries on CCA s requirements please ProviderRelations@commonwealthcare.org. Rev 12/2017 Back to the top Page 31 of 83
One Care and Senior Care Options Prior Authorization (PA) Requirements. Place of Service Code Type Code Range on Claim. Measure
For Services That Require Prior Authorization, Please Refer To Claim Submission Billing Guidelines Below: Commonwealth Care Alliance (CCA) Covered Services One Care and Senior Care Options Prior Authorization
More informationPROVIDER MANUAL 2018
PROVIDER MANUAL 2018 Table of Contents WELCOME LETTER... 7 SECTION 1: KEY CONTACT INFORMATION... 8 Key Contact Information... 8 Telephone & Prompts... 8 Fax... 8 Web/Email... 8 Claims... 8 Member Services...
More information2018 SUMMARY OF BENEFITS
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Senior Care Options (HMO SNP) H2226-001 Look inside to learn more about the plan and the health and drug services it covers. Call Customer
More informationSummary of Benefits Report SENIOR CARE PLUS: VALUE BASIC PLAN (HMO)-009 January 1, 2015 December 31, 2015 WASHOE COUNTY, NEVADA
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 (fee-for-service Medicare).
More informationINTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 SUMMARY OF BENEFITS
INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 SUMMARY OF BENEFITS January 1, 2015 - December 31, 2015 CARE1ST HEALTH PLAN California: Fresno, Merced, Stanislaus and San Joaquin Counties H5928_15_029_SB_CTCA_2
More informationMedicare Plus Blue SM Group PPO. Summary of Benefits. Michigan Public School Employees Retirement System
2018 Medicare Plus Blue SM Group Summary of Benefits January 1, 2018 December 31, 2018 Michigan Public School Employees Retirement System www.bcbsm.com/mpsers This information is a summary document and
More informationSelect Summary YOU HAVE CHOICES ABOUT HOW TO GET YOUR MEDICARE BENEFITS TIPS FOR COMPARING YOUR MEDICARE CHOICES
INTRODUCTION TO THE SUMMARY OF BENEFITS FOR January 1, 2015 - December 31, 2015 Central Alabama and Mobile Area SECTION I INTRODUCTION TO THE SUMMARY OF BENEFITS This booklet gives you a summary of what
More information2016 Summary of Benefits
2016 Summary of Benefits Health Net Jade (HMO SNP) Kern, Los Angeles and Orange counties, CA Benefits effective January 1, 2016 H0562 Health Net of California, Inc. H0562_2016_0175 CMS Accepted 09082015
More informationJanuary 1, 2015 December 31, Maintenance Organization (HMO) offered by HEALTHNOW NEW YORK INC. with a Medicare contract)
BLUECROSS BLUESHIELD SENIOR BLUE 601 (HMO), BLUECROSS BLUESHIELD SENIOR BLUE HMO SELECT (HMO) AND BLUECROSS BLUESHIELD SENIOR BLUE HMO 651 PARTD (HMO) (a Medicare Advantage Health Maintenance Organization
More informationSUMMARY OF BENEFITS. Cigna-HealthSpring. Advantage SMS (HMO) H January 1, December 31, Cigna H4407_16_32690 Accepted
SUMMARY OF BENEFITS January 1, 2016 - December 31, 2016 Cigna-HealthSpring Advantage SMS (HMO) H4407-011 2015 Cigna H4407_16_32690 Accepted SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS This booklet
More informationHMO Basic (HMO) / HMO 40 (HMO) / HMO 20 (HMO) Summary of Benefits
/ / Summary of Benefits January 1, 2015 December 31, 2015 Call toll-free 1-800-965-4022 8 a.m. to 8 p.m. daily October 1 to February 15 and 8 a.m. to 8 p.m. weekdays the rest of the year. TTY/TDD 711 HealthAllianceMedicare.org
More informationCovered Services List and Referrals and Prior Authorizations for MassHealth Members enrolled in Partners HealthCare Choice
Covered Services Covered Services List and s and Prior Authorizations for MassHealth Members enrolled in Partners HealthCare Choice This chart tells you two things: 1. the covered services and benefits
More information2017 Summary of Benefits
H5209 004_DSB9 23 16 File & Use 10/14/2016 DHS Approved 10 7 2016 This is a summary of drug and health services covered by Care Wisconsin Medicare Dual Advantage Plan (HMO SNP) January 1, 2017 to December
More informationBenefits are effective January 01, 2018 through December 31, 2018 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY
PLAN FEATURES Annual Deductible The maximum out-of-pocket limit applies to all covered Medicare Part A and B benefits including deductible. Hearing aid reimbursement does not apply to the out-of-pocket
More informationSummary Of Benefits. WASHINGTON Pierce and Snohomish
Summary Of Benefits WASHINGTON Pierce and Snohomish 2018 Molina Medicare Choice (HMO SNP) (800) 665-1029, TTY/TDD 711 7 days a week, 8 a.m. 8 p.m. local time H5823_18_1099_0007_WAChoSB Accepted 9/26/2017
More informationChapter 12 Benefits and Covered Services
12 Benefits and Covered Services Health Choice Generations covers the same benefits covered under Original Medicare. Sometimes Medicare adds coverage for a new service during the year. Health Choice Generations
More informationSignal Advantage HMO (HMO) Summary of Benefits
Signal Advantage HMO (HMO) Summary of Benefits January 1, 2016 December 31, 2016 The provider network may change at any time. You will receive notice when necessary. This information is available for free
More informationClassic Plan (HMO-POS) Value Plan (HMO) Rewards Plan (HMO)
January 1, 2016 December 31, 2016 Classic Plan Value Plan Rewards Plan SECTION I INTRODUCTION This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover
More informationY0021_H4754_MRK1427_CMS File and Use PacificSource Community Health Plans, Inc. is a health plan with a Medicare contract
Y0021_H4754_MRK1427_CMS File and Use 08262012 PacificSource Community Health Plans, Inc. is a health plan with a Medicare contract Section I - Introduction to Summary of s Thank you for your interest in.
More informationOur service area includes these counties in: Florida: Broward, Miami-Dade.
2018 SUMMARY OF BENEFITS Overview of your plan Preferred Medicare Assist (HMO SNP) H1045-012 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer Service
More informationSummary of Benefits 2018
SM Summary of Benefits 2018 bluecareplus.bcbst.com H3259_18_SB Accepted 08282017 This is a summary of drug and health services covered by BlueCare Plus (HMO SNP) SM health plan January 1, 2018 - December
More informationExplorer Plan (HMO-POS) SunSaver Plan (HMO-POS)
January 1, 2015 December 31, 2015 Explorer Plan SunSaver Plan SECTION I INTRODUCTION 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
More informationBenefits and Premiums are effective January 01, 2018 through December 31, 2018 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA HEALTH PLANS INC.
Benefits and Premiums are effective January 01, 2018 through December 31, 2018 PLAN FEATURES Network Providers Annual Maximum Out-of-Pocket Amount $2,500 The maximum out-of-pocket limit applies to all
More informationBenefits and Premiums are effective January 01, 2018 through December 31, 2018 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY
The maximum out-of-pocket limit applies to all covered Medicare Part A and B benefits including deductible. Primary Care Physician Selection Optional There is no requirement for member pre-certification.
More informationExplorer Plan (HMO-POS) SunSaver Plan (HMO-POS)
January 1, 2016 December 31, 2016 Explorer Plan SunSaver Plan SECTION I INTRODUCTION 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
More informationCorrection Notice. Health Partners Medicare Special Plan
Correction Notice Special Plan Following are corrections that apply to both the English and Spanish versions of the 2015 for Special (HMO SNP): Original Information Page 1, under the heading SECTIONS IN
More informationBenefits are effective January 01, 2017 through December 31, 2017
Benefits are effective January 01, 2017 through December 31, 2017 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY PLAN FEATURES Network & Out-of- Annual Deductible $0 This is the amount
More informationBenefits and Premiums are effective January 01, 2018 through December 31, 2018 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY
Benefits and Premiums are effective January 01, 2018 through December 31, 2018 PLAN FEATURES Network & Out-of- Annual Deductible This is the amount you have to pay out of pocket before the plan will pay
More informationOur service area includes Florida.
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Dual Complete RP ONE (Regional PPO SNP) R7444-013 Look inside to learn more about the health services and drug coverages the plan provides.
More informationBlue Cross Medicare Private Fee For Service. Summary of Benefits. January 1, 2018 December 31, 2018
Blue Cross Medicare Private Fee For Service Summary of Benefits January 1, 2018 December 31, 2018 This information is not a complete description of benefits. Contact the plan for more information. To get
More informationOur service area includes the 50 United States, the District of Columbia and all US territories.
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Group Medicare Advantage (PPO) Group Name (Plan Sponsor): NEW ENGLAND ANNUAL CONF OF THE METHODIST CHURCH Group Number: 13850 H2001-816 Look
More informationKY Medicaid Co-pays Except for the Pharmacy Non-Preferred co-pay, co-pays do not apply to the following:
This is a list of current covered services and co-pays. Except for the Pharmacy Non-Preferred co-pay, co-pays do not apply to the following: Non-KCHIP children Children under 19 in foster care Pregnant
More informationSummary of Benefits for Anthem MediBlue Dual Advantage (HMO SNP)
Summary of Benefits for Available in: Select Counties* in Maine *See Page 2 for a list of counties. Plan year: January 1, 2018 December 31, 2018 In this section, you ll learn about some of the benefits
More informationOur service area includes the following county in: Florida: Miami-Dade.
2018 SUMMARY OF BENEFITS Overview of your plan Medica HealthCare Plans MedicareMax (HMO) H5420-001 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer
More informationKY Medicaid Co-pays. Acute admissions medical Per admission diagnoses $0 Acute health care related to. Per admission substance abuse and/or for
This is a list of current covered services and co-pays. Except for the Pharmacy Non-Preferred co-pay, co-pays do not apply to the following: Non-KCHIP children Children under 19 in foster care Pregnant
More informationFLEX RETIREE MAP (Over 65 Flex Retirees) 2018 Benefits PROFESSIONAL SERVICES. Visit to a physician, physician assistant or nurse practitioner at a PPG
PROFESSIONAL SERVICES Visit to a physician, physician assistant or nurse practitioner at a PPG Periodic health evaluations/preventive services - Applies when the only service(s) provided is a Medicare
More informationGet More Than. Original Medicare. Summary of Benefits MA Special Needs Plan (HMO SNP) 014. H5826_MA_193_2016_v_01_SB014 Accepted.
Get More Than Original Medicare Offered by 2016 Summary of Benefits MA Special Needs Plan (HMO SNP) 014 H5826_MA_193_2016_v_01_SB014 Accepted Section I Introduction to the Summary of Benefits for Community
More informationOur service area includes these counties in: North Carolina: Durham, Wake.
2018 SUMMARY OF BENEFITS Overview of your plan AARP MedicareComplete (HMO) H5253-039 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer Service or go
More informationOur service area includes these counties in:
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Nursing Home Plan (HMO SNP) H5253-042 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer
More informationOur service area includes these counties in:
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Dual Complete (HMO SNP) H0432-009 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer
More informationVNSNY CHOICE. Monthly Premium, Deductible, and Limits on how much you pay for Covered Services
Medicare Advantage-Classic Program (HMO): The Medicare Classic service area includes the following counties in New York: Albany, Bronx, Kings (Brooklyn), Nassau, New York, Queens, Rensselaer, Richmond
More information2018 Summary of Benefits
2018 Summary of Benefits H5209-004_MDASB 9-13-17 Accepted 9/18/2018 DHS Approved 09/13/2017 This is a summary of drug and health services covered by Care Wisconsin Medicare Dual Advantage Plan (HMO SNP)
More informationOF BENEFITS. Cigna-HealthSpring TotalCare (HMO SNP) H Cigna H3949_15_19921 Accepted
agesummary OF BENEFITS Cover erage Cigna-HealthSpring TotalCare (HMO SNP) H3949-009 2014 Cigna H3949_15_19921 Accepted SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS You have choices about how to get
More informationOur service area includes the following county in: Delaware: New Castle.
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Dual Complete (HMO SNP) H3113-011 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer
More informationSummary of Benefits. New Mexico Bernalillo, Chaves, Dona Ana, Luna, McKinley, Otero, Sandoval, San Juan, Santa Fe, Sierra, Torrance and Valencia
Summary of Benefits New Mexico Bernalillo, Chaves, Dona Ana, Luna, McKinley, Otero, Sandoval, San Juan, Santa Fe, Sierra, Torrance and Valencia 2016 Molina Medicare Options Plus HMO SNP Member Services
More informationBasic Covered Benefits and Services
Basic Covered Benefits and A prior authorization is when UnitedHealthcare Community Plan gives the doctor permission to perform certain services. Bed Liners Coverage Covered for members age 4 and up; Prior
More information2018 SUMMARY OF BENEFITS
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Group Medicare Advantage (PPO) H2001-827 Group Name: North Carolina State Health Plan for Teachers and State Employees Group Numbers: 12309,
More informationOur service area includes these counties in: Texas: Aransas, Kleberg, Nueces, San Patricio.
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Dual Complete Focus (HMO SNP) H4527-004 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer
More informationSummary Of Benefits. IDAHO Ada, Bannock, Bingham, Bonner, Bonneville, Canyon, Kootenai, Nez Perce, and Twin Falls
Summary Of Benefits IDAHO Ada, Bannock, Bingham, Bonner, Bonneville, Canyon, Kootenai, Nez Perce, and Twin Falls 2018 Molina Medicare Options Plus (HMO SNP) (844) 239-4913, TTY/TDD 711 7 days a week, 8
More informationMedicare Basics. Part I of II
Part I of II August 2013 1 What are the Four Parts of Medicare? Part A Hospital Insurance Part B Medical Insurance Part C Medicare Advantage Plans, like HMOs and PPOs Includes Part A & B and usually Part
More informationExtra Value Summary YOU HAVE CHOICES ABOUT HOW TO GET YOUR MEDICARE BENEFITS TIPS FOR COMPARING YOUR MEDICARE CHOICES
INTRODUCTION TO THE SUMMARY OF BENEFITS FOR January 1, 2016 - December 31, 2016 Central Alabama and Mobile Area SECTION I INTRODUCTION TO THE SUMMARY OF BENEFITS This booklet gives you a summary of what
More informationOur service area includes these counties in:
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Dual Complete ONE (HMO SNP) H3113-012 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer
More informationServices Covered by Molina Healthcare
Services Covered by Molina Healthcare As a Molina Healthcare member, you will continue to receive all medically-necessary Medicaid-covered services at no cost to you. The following list of covered services
More informationOur service area includes these counties in: Arizona: Apache, Coconino, Maricopa, Mohave, Navajo, Pinal, Yavapai.
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Dual Complete ONE (HMO SNP) H0321-004 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer
More informationSummary Of Benefits. FLORIDA Broward, Hillsborough, Miami-Dade, Palm Beach, Pinellas, and Polk
Summary Of Benefits FLORIDA Broward, Hillsborough, Miami-Dade, Palm Beach, Pinellas, and Polk 2018 Molina Medicare Options Plus (HMO SNP) (866) 553-9494, TTY/TDD 711 7 days a week, 8 a.m. 8 p.m. local
More informationSummary Of Benefits. Molina Medicare Options Plus (HMO SNP) (866) , TTY/TDD days a week, 8 a.m. 8 p.m. local time
Summary Of Benefits OHIO Brown, Butler, Clark, Clermont, Clinton, Columbiana, Delaware, Fairfield, Fayette, Franklin, Greene, Hamilton, Highland, Hocking, Lake, Madison, Miami, Montgomery, Morrow, Perry,
More informationCovered Services List
CAREPLUS Covered Services List For CeltiCare Health with MassHealth CarePlus Coverage This is a list of all covered services and benefits for MassHealth CarePlus enrolled in CeltiCare Health. The list
More informationSummary Of Benefits. CALIFORNIA Imperial, Los Angeles, Riverside (partial), San Bernardino (partial), and San Diego
Summary Of Benefits CALIFORNIA Imperial, Los Angeles, Riverside (partial), San Bernardino (partial), and San Diego 2018 Molina Medicare Options Plus (HMO SNP) (800) 665-0898, TTY/TDD 711 7 days a week,
More informationVIVA MEDICARE Select (HMO)
INTRODUCTION TO THE SUMMARY OF BENEFITS FOR VIVA MEDICARE January 1, 2014 - December 31, 2014 Central Alabama and Mobile Area Thank you for your interest in. Our plan is offered by Viva Health, Inc., which
More information2017 Comparison of the State of Iowa Medicaid Enterprise Basic Benefits Based on Eligibility Determination
General Plan Provisions Benefits Available from Out-of-Network Providers 2017 Comparison of the State of Iowa Enterprise Cost Sharing: A variety of methods are used to share expenses between the state
More informationHealthPartners Freedom Plan (Cost) 2011 Medical Summary of Benefits Wisconsin
HealthPartners Freedom Plan 2011 Medical Summary of Benefits Wisconsin HealthPartners Wisconsin Freedom Plan I HealthPartners Wisconsin Freedom Plan II 420421 (10/10) H2462_SB WI_151 CMS Approved 10/5/10
More informationMedicaid Benefits at a Glance
Medicaid Benefits at a Glance Mountain Health Trust Benefits Children (0 up to 21 years) Ambulatory Surgical Center Services Any distinct entity that operates exclusively for the purpose of providing surgical
More informationCLASSIC BLUE SECURE/BLUE CROSS BLUE SHIELD COMPLEMENTARY Monroe County Benefit Summary/Comparison (Over 65 Retirees)
WHO IS COVERED Enrollment Requirement Members must be enrolled in both Medicare Parts A and B Members must be enrolled in both Medicare Parts A and B Type of Tier Single only Single only Dependent/Student
More informationIllustrative Benefits, Value Added Services and Premiums are effective January 1, 2016 through December 31, 2016
PLAN FEATURES Combined In and Out of Network Deductible (Plan Level/includes Network Deductible) Network & Out-of-Network Providers $0 Member Coinsurance N/A Applies to all expenses unless otherwise stated.
More informationServices That Require Prior Authorization
Services That Require Prior Authorization Some of the services listed in the Medical Benefits Chart are covered only if your doctor or other network provider gets approval in advance (sometimes called
More informationSUMMARY OF BENEFITS. Advantage (HMO) H
SUMMARY OF BENEFITS January 1, 2017 - December 31, 2017 Cigna-HealthSpring Advantage (HMO) H4513-009 Our service area includes the following counties in Texas: Angelina, Brazoria, Cameron, Chambers, Fort
More informationSummary Of Benefits. NEW MEXICO Bernalillo, Chaves, Dona Ana, Luna, McKinley, Otero, San Juan, Sandoval, Santa Fe, Sierra, Torrance, and Valencia
Summary Of Benefits NEW MEXICO Bernalillo, Chaves, Dona Ana, Luna, McKinley, Otero, San Juan, Sandoval, Santa Fe, Sierra, Torrance, and Valencia 2018 Molina Medicare Options Plus (HMO SNP) (866) 440-0127,
More informationINTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 SUMMARY OF BENEFITS
INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 SUMMARY OF BENEFITS January 1, 2015 - December 31, 2015 CARE1ST HEALTH PLAN California: Alameda,,,, San Francisco and Counties H5928_15_029_SB_TD_2 INTRODUCTION
More informationCOVERED SERVICES LIST FOR HNE BE HEALTHY MEMBERS WITH MASSHEALTH STANDARD OR COMMONHEALTH COVERAGE
COVERED SERVICES LIST FOR HNE BE HEALTHY MEMBERS WITH MASSHEALTH STANDARD OR COMMONHEALTH COVERAGE This is a list of all covered services and benefits for MassHealth Standard and CommonHealth members enrolled
More informationServices Covered by Molina Healthcare
Services Covered by Molina Healthcare Because you are covered by Medicaid, you pay nothing for covered services. As a Molina Healthcare member, you will continue to receive all medically necessary Medicaid-covered
More informationCigna Health and Life Insurance Company. Plan Benefits. Unlimited. Unlimited. Not applicable. Not applicable. Not applicable
SUMMARY OF BENEFITS Client Name: Washington County Public Schools Benefit Option Name: Medicare Supplement Effective: July 1, 2018 through June 30, 2019 1 Benefit Description Lifetime Maximum Applies to
More informationFIDA. Care Management for ALL
Care Management for ALL In 2011, Governor Andrew M. Cuomo established a Medicaid Redesign Team (MRT), which initiated significant reforms to the state s Medicaid program. This included a critical initiative
More informationYour Out-of-Pocket Type of Service
Calendar Year Deductible (CYD) 1 $0 single/ 3x family Out-of-Pocket Maximum - Deductibles, coinsurance and copays all accrue toward the outof-pocket maximum. With respect to family plans, an individual
More informationSummary of Benefits. Effective January 1, 2018 December 31, 2018 H2256_S_2018_4 Accepted
Tufts HEALth Plan Senior care Options (hmo snp) 2018 Summary of Benefits 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
More information2018 MA Plan 006. Alternative Medicine:Acupuncture and Naturopathy. $250 maximum combined total of acupuncture and naturopathy services
Abdominal Aortic Aneurysm Screening $0 copay For planned preventive services that become diagnostic during the Alternative Medicine:Acupuncture and Naturopathy AIR Ambulance (Non-emergency) $300.00 copay
More informationSummary of Benefits for Simply Level (HMO SNP)
Summary of Benefits for Available in: Hernando, Hillsborough, Pasco and Pinellas Counties Plan year: January 1, 2018 December 31, 2018 In this section, you ll learn about some of the benefits and services
More informationSchedule of Benefits
Schedule of Benefits ANTHEM Small Business Health Options Program (SHOP) This is a brief schedule of benefits. Refer to your Anthem Certificate of Coverage (Booklet) for complete details on benefits, conditions,
More informationCovered Benefits Rhody Health Partners ACA Adult Expansion
Covered s Rhody Health Partners ACA Adult Expansion Abortion Services Adult Day Services AIDS Medical and Non-Medical Case Management Alcohol and Substance Abuse Treatment Cosmetic Surgery Dental Care
More informationSummary of Benefits. for Blue Medicare Access Value SM (Regional PPO) Available in Ohio
Summary of Benefits for SM Available in Ohio Anthem Blue Cross and Blue Shield is a Health plan with a Medicare contract.anthem Insurance Companies, Inc. (AICI) is the legal entity that has contracted
More informationOur service area includes these counties in:
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Dual Complete (HMO SNP) H5253-041 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer
More informationHEALTH CARE BENEFITS YOU CAN COUNT ON. Retired Employees Health Program (REHP)
HEALTH CARE BENEFITS YOU CAN COUNT ON 2014 Retired Employees Health Program () PEBTF_2014 Thank you for your interest in Geisinger Gold Classic. Our plan is offered by Geisinger Health Plan/Geisinger Gold
More informationFACILITY BASED SERVICES
FACILITY BASED SERVICES Inpatient Hospital Care Elective Inpatient Admission or Elective Inpatient Surgery Inpatient Rehabilitation Care Skilled Nursing Facility Admission Non-Custodial Nursing Home Care
More informationKeystone First VIP Choice (HMO-SNP) 2018 Summary of Benefits
Keystone First VIP Choice (HMO-SNP) 2018 Summary of Benefits Y0093_SOB_2497 _ACCEPTED_09052017 January 1, 2018- December 31, 2018 Summary of Benefits This booklet gives you a summary of what we cover
More informationCovered Benefits Rhody Health Partners
Covered s Rhody Health Partners s Covered by UnitedHealthcare Community Plan As member of UnitedHealthcare Community Plan, you are covered for the following services. (Remember to always show your current
More informationMedi-Cal Program. Benefit. Benefits Chart
Chart Please note that the table below is only a summary. More details about benefits can be found in the section of the Medi-Cal Evidence of Coverage booklet. All health care is arranged through your
More informationMedicare & Medicare Supplemental Insurance (Medigap)
Elder Law Basics Medicare & Medicare Supplemental Insurance (Medigap) Steven A. Kass, Esq., CELA Law Office of Steven A. Kass, PC 105 Maxess Road, Suite N116 Melville, New York 11747 What is Medicare?
More informationOur service area includes these counties in:
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Dual Complete (HMO SNP) H5008-010 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer
More informationCovered (blood, blood components, human blood products, and their administration) Covered (Some restrictions)
Washington Apple Health Medical Benefits Allergy Services (Antigen/Allergy Serum/Allergy Shots) Ambulance Services (Air Transportation) by FFS* Ambulance Services (Emergency Transportation) Ambulatory
More informationSummary of Benefits Advantra Freedom PEBTF
Advantra Freedom is a Medicare Advantage Private Fee-For-Service (PFFS) Plan. This Summary of Benefits tells you some features of our Plan. It doesn't list every service that we cover or list every limitation
More informationCovered Benefits Matrix for Children
Medicaid Managed Care The matrix below lists the available for children (under age 21) enrolled in the West Virginia Mountain Health Trust and s. Ambulance Ambulatory surgical center services Some services
More informationSelect Summ ary. VIVA MEDICARE Plus Select (HMO) INTRODUCTION TO THE SUMMARY OF BENEFITS FOR. You have choices in your health care.
INTRODUCTION TO THE SUMMARY OF BENEFITS FOR VIVA MEDICARE Plus January 1, 2013 - December 31, 2013 Central Alabama and Mobile Area Thank you for your interest in. Our plan is offered by Viva Health, Inc./,
More informationBenefits and Premiums are effective January 01, 2019 through December 31, 2019 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY
Benefits and Premiums are effective January 01, 2019 through December 31, 2019 PLAN FEATURES Network & Out-of- Annual Deductible This is the amount you have to pay out of pocket before the plan will pay
More informationCUSTODIAL NURSING HOME CARE
CUSTODIAL NURSING HOME CARE Chiropratic Services Custodial Nursing Home Care DME Equipment and Supplies Incontinence Supplies: Diapers, briefs, wipes, gloves, pads Infusion (IV, Enteral) Services Outpatient
More informationCOVERED SERVICES FOR NHP MASSHEALTH MEMBERS
COVERED SERVICES FOR NHP MASSHEALTH MEMBERS Neighborhood Health Plan Covered Services for MassHealth Standard & CommonHealth, Family Assistance, and CarePlus Issued and effective October 1, 2015 nhp.org/member
More informationOur service area includes these counties in:
2018 SUMMARY OF BENEFITS Overview of your plan UnitedHealthcare Dual Complete (HMO SNP) H7464-001 Look inside to learn more about the health services and drug coverages the plan provides. Call Customer
More informationYour Out-of-Pocket Type of Service
Calendar Year Deductible (CYD) 1 $3,000 single/ 3x family Out-of-Pocket Maximum - Deductibles and copays all accrue towards the out-of-pocket $6,200 single/ 2x family maximum. With respect to family plans,
More informationFACILITY BASED SERVICES
CUSTODIAL NURSING HOME CARE Chiropratic Services Custodial Nursing Home Care DME Equipment and Supplies Incontinence Supplies: Diapers, briefs, wipes, gloves, pads Infusion (IV, Enteral) Services Outpatient
More informationFREEDOM BLUE PPO R CO 307 9/06. Freedom Blue PPO SM Summary of Benefits and Other Value Added Services
FREEDOM BLUE PPO R9943 2007 CO 307 9/06 Freedom Blue PPO SM Summary of Benefits and Other Value Added Services Introduction to Summary of Benefits for Freedom Blue January 1, 2007 - December 31, 2007 California
More informationUNM Medical Plan. summary of benefits. Effective: July 1, 2012
UNM Medical Plan summary of benefits Effective: July 1, 2012 Offered by The Regents of the University of New Mexico Administered by Lovelace Insurance Company administered by ANNUAL PLAN YEAR DEDUCTIBLE
More informationMyHPN Solutions HMO Gold 7
MyHPN Solutions HMO Gold 7 HIOS ID: 95865NV0030074 Attachment A Benefit Schedule Calendar Year Deductible (CYD): $3,000 of EME per Member and $6,000 of EME per family. The Calendar Year Out of Pocket Maximum
More information