2018 Summary of Benefits Eon Deluxe (HMO SNP) GEORGIA / SOUTH CAROLINA

Transcription

1 2018 Summary of Eon Deluxe (HMO SNP) GEORGIA / SOUTH CAROLINA For more information, call Y0122_0172 Accepted DSNP

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3 2018 Summary of Eon Deluxe (HMO SNP) This is a summary of drug and health services covered by Eon Health January 1, December 31, Eon Health has a contract with Medicare to offer HMO and PPO plans. Eon Health also has a contract with the Georgia Medicaid program and a contract with the South Carolina Medicaid program. Enrollment in Eon Health depends on contract renewal. The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the Evidence of Coverage. You can obtain a copy of our Evidence of Coverage by calling us at: Current Members: , Prospective Members: , TTY: 711 or visiting our website at For coverage and cost of Original Medicare look in your current Medicare and You Handbook. View it online at or get a copy by calling Medicare ( ). TTY users should call Eon Health 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 can see our Provider and Pharmacy Directory on our website at You can see our Formulary (List of Part D prescription drugs) on our website at

4 Introduction Eon Deluxe is a Medicare Advantage HMO Special Needs Plan (SNP) offered in Georgia and South Carolina. Georgia: To join Eon Deluxe, you must be entitled to Medicare Part A, enrolled in both Medicare Part B and Georgia Medicaid Program, and live in our service area. South Carolina: To join Eon Deluxe, you must be entitled to Medicare Part A, enrolled in both Medicare Part B and South Carolina Medicaid Program-Healthy Connections, and live in our service area. Eon Deluxe Service Areas: STATE GEORGIA SOUTH CAROLINA SERVICE AREA Baker, Baldwin, Banks, Barrow, Bibb, Bleckley, Bryan, Butts, Chatham, Cherokee, Clayton, Clinch, Crawford, Dawson, DeKalb, Dodge, Dooly, Fayette, Forsyth, Franklin, Greene, Hancock, Hart, Heard, Henry, Houston, Jasper, Jones, Lamar, Lumpkin, Macon, Madison, McIntosh, Meriwether, Monroe, Morgan, Newton, Oconee, Oglethorpe, Peach, Pickens, Pike, Pulaski, Putnam, Rabun, Rockdale, Schley, Screven, Stephens, Talbot, Taliaferro, Taylor, Twiggs, Walton, White, Wilcox, Wilkinson counties Beaufort, Chester, Colleton, Fairfield, Greenville, Hampton, Jasper, Lee, Saluda, Spartanburg, Union counties

5 Eon Deluxe (HMO SNP) SUMMARY OF BENEFITS Health Maintenance Organization (HMO) plans in most HMOs, you can only go to doctors, other health care providers, or hospitals in the plan s network. In an urgent or emergency situation you can access innetwork and out of network providers.

6 Eon Deluxe HMO SNP / Plan Highlights Monthly Premium: $0 Provider Copay: $0 PCP / $0 Specialist / $0 Hospital Generic Prescriptions: As low as $0 Dental Care: Preventative Comprehensive Dentures Vision Care: $225 towards glasses or contact lenses Hearing Care: Exams and up to $750 for hearing aids Over-The-Counter (OTC) items: $45 allowance per month Transportation: 30 one-way to plan-approved locations Meals: Up to 20 meals after inpatient hospital stay Fitness Program: SilverSneakers

7 Eon Deluxe (HMO SNP) SUMMARY OF BENEFITS Monthly Premium Deductible Maximum Out-of-Pocket Responsibility (does not include prescription drugs) Eon Deluxe / Health $0 per month Part C (Medical) $0 Part D (Pharmacy) $0 $3,400 annually $0 / day for days 1-5 Inpatient Hospital Coverage 1 $0 / day for days 6-90 Ambulatory Surgical Center: Outpatient Hospital Coverage 1 Outpatient Hospital: Doctor Visits (Primary and Specialist) Preventive Care Emergency Care Urgently Needed Care Diagnostic Services / Labs / Imaging 1 1 May require prior authorization Primary Care Physician visit: Specialist visit: Diagnostic radiology services (such as MRIs, CT scans): 0% coinsurance Diagnostic tests and procedures: Lab services: Outpatient x-rays: Therapeutic radiology services (such as radiation treatment for cancer): 0% coinsurance

8 Eon Deluxe (HMO SNP) SUMMARY OF BENEFITS Hearing Services 1 Dental Services 1 Vision Services Eon Deluxe / Health Exam to diagnose and treat hearing and balance issues: Routine hearing exam (for up to 1 every year): Hearing aid fitting/evaluation (for up to 1 every 3 years): Our plan pays up to $750 every three years for hearing aids. Benefit amount applies to both ears combined. Preventive dental services: Cleaning (for up to 1 every six months): Dental x-ray(s) (for up to 1 every six months): Oral exam (for up to 1 every six months): 1 dental bitewing x-ray per side every six months: 1 panoramic x-ray every five years: Comprehensive dental services: Coverage limit is $800 every year. Coverage is limited to fillings, simple extractions, dentures, and denture repair. Additional dental services, such as root canals, crowns, surgical extractions, denture relines and periodontal (gum) treatments, are not covered. 1 partial or 1 complete denture per arch every five years. Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): Routine eye exam (for up to 1 every year): Contact lenses: (for up to 1 every year): Eyeglasses (frames and lenses): (for up to 1 every year): Eyeglasses or contact lenses after cataract surgery: $225 every year for contact lenses and or eyeglasses (frames and lenses) 1 May require prior authorization

9 Eon Deluxe (HMO SNP) SUMMARY OF BENEFITS Eon Deluxe / Health Inpatient: $0 / Day for Days 1-5 $0 / Day for Days 6-90 Mental Health Services 1 Outpatient: Group therapy visit: Individual therapy visit: $0 / Day for Days 1-20 Skilled Nursing Facility (SNF) 1 $0 / Day for Days Physical Therapy Facility 1 Physical therapy visit: Ambulance 1 Transportation / 30 one-way trips Medicare Part B drugs 1 1 May require prior authorization

10 Eon Deluxe (HMO SNP) SUMMARY OF BENEFITS Initial Coverage Retail Coverage Gap Catastophic Coverage Eon Deluxe / Prescription Drug For generic drugs (including brand drugs treated as generic), either / $1.25 copay / $3.35 copay For all other drugs, either: / $3.70 copay / $8.35 copay For generic drugs (including brand drugs treated as generic), either / $1.25 copay / $3.35 copay For all other drugs, either: / $3.70 copay / $8.35 copay For generic (including brand drugs treated as generic): For all other drugs: 1 May require prior authorization

11 Eon Deluxe (HMO SNP) SUMMARY OF BENEFITS Chiropractic Care Foot Care (Podiatry Services) Diabetic Supplies and Services 1 Meals 1 Rehabilitation Services (Outpatient) 1 Medical Equipment and Supplies 1 Over-the-Counter (OTC) Items Wellness Programs (e.g. fitness) Eon Deluxe / Additional Health Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): Medicare Covered Visit Routine Visit Not Covered Foot exams and treatment if you have diabetes related nerve damage and/or meet certain conditions:. Routine foot care: Diabetes monitoring supplies: Therapeutic shoes or inserts: $0 coinsurance Up to 20 meals. Plan covers up to 28 days after inpatient hospital stay Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions for a period of up to 36 weeks): Occupational therapy visit: Speech and language therapy visit: Prosthetic devices: Related medical supplies: Members receive a $45 allowance every month Fitness program: SilverSneakers Basic membership to one Plan approved fitness facility per month Orientation to the fitness center and instructions about how to use equipment and services workout Pak per year 1 May require prior authorization

12 Eon Deluxe (HMO SNP) STATEMENT OF MEDICAID BENEFITS AND COST SHARING PROTECTIONS Eligibility Eon Deluxe (HMO SNP) The Eon Deluxe Plan is available to anyone with both Medicare Parts A and B and who receives Medical Assistance from the state Medicaid program to cover Medicare cost-sharing. Eon Deluxe (HMO SNP) members with Full benefit Medicaid status (Full Benefit Dual Eligible (FBDE), Qualified Medicare Beneficiary (QMB), Qualified Medicare Beneficiary Plus (QMB +), and Specified Low-Income Medicare Beneficiary Plus (SLMB +) are covered by the state Medicaid program for their Medicare cost sharing. Eon Deluxe (HMO SNP) plan with full Medicaid coverage are enrolled in the State Medicaid program that pays their Medicare cost sharing. These members are also eligible to receive additional Medicaid benefits describe below. Cost Sharing and Cost-sharing Protection for All Members In the Eon Deluxe plan, the state Medicaid program pays the cost sharing for Medicare-covered medical services you receive. You pay no cost sharing for the Medicare-covered benefits described in the Covered Medical and Hospital section of this Summary of. You will pay small copayments for prescriptions covered under the Medicare Part D prescription drug benefit. When you receive health services, the provider should only bill Eon Deluxe (HMO SNP) or the state Medicaid program for the cost of those services and cost-sharing amounts. The provider should not bill you for services or cost sharing. If you receive care from a non-contracted provider, the provider may not understand Eon Deluxe or these billing rules. If you receive a bill from a provider for Medicare-covered services, please notify Member Services so we can help you. Please see chapter 7 of your Eon Deluxe Evidence of Coverage for more information. The benefits described below are covered by Medicaid. The benefits described in the Covered Medical and Hospital section of the Summary of are covered by Medicare. For each benefit listed below, you can see what your state Medicaid covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility.

13 Georgia Medicaid Program Depending on your Medicaid category, you may have to make a small co-payment when you receive your medical care, but Medicaid will pay most or all of the bill. Ambulance Services Ambulatory Surgical Services Dental Services Georgia Medicaid For dual-eligible members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. For dual-eligible members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. Medicaid covers certain emergency dental care for adults. Preventive dental care, fillings and oral surgery for children Eon Deluxe Ambulatory surgical center: Preventive dental services: Cleaning (for up to 1 every six months) -Dental x-ray(s) (for up to 1 every six months) -Oral exam (for up to 1 every six months) -1 dental bitewing x-ray per side every six months -1 panoramic x-ray every five years: Comprehensive dental services coverage limit is $800 every year. Coverage is limited to fillings, simple extractions, dentures, and denture repair. Additional dental services, such as root canals, crowns, surgical extractions, denture relines and periodontal (gum) treatments, are not covered. 1 partial or 1 complete denture per arch every five years:

14 Georgia Medicaid Program Depending on your Medicaid category, you may have to make a small co-payment when you receive your medical care, but Medicaid will pay most or all of the bill. Diagnostic Tests, X-rays, Lab Services Doctor Office Visit Home Health Services (includes medically necessary intermittent skilled nursing care, home health aid services, and rehabilitation services, etc.) Hospice Services Georgia Medicaid For dual-eligible members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. *Not covered: portable X-ray services; services provided in facilities not meeting the definition of an independent laboratory or X-ray facility; services or procedures referred to another testing facility; services furnished by a State or public laboratory; services or procedures performed by a facility not certified to perform them. For dual-eligible members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. For dual-eligible members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. *Not covered: social services, chore services, meals on wheels, audiology services. For dual-eligible members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. *Available to Members certified as being terminally ill and having a medical prognosis of life expectancy of six (6) months or less. Eon Deluxe Diagnostic radiology services (such as MRIs, CT scans): 0% coinsurance Diagnostic tests and procedures: Lab services: Outpatient x-rays: Therapeutic radiology services (such as radiation treatment for cancer): 0% coinsurance Primary care physician visit: Specialist visit: You pay nothing for hospice care from a Medicare certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details

15 Georgia Medicaid Program Depending on your Medicaid category, you may have to make a small co-payment when you receive your medical care, but Medicaid will pay most or all of the bill. Inpatient Hospital Services (Includes Substance Abuse and Rehabilitation Services) Medical Equipment/ Supplies Mental Health Services Outpatient Hospital Services Podiatry Services (Foot Care) Georgia Medicaid For dual-eligible members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. For dual-eligible members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. For dual-eligible members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. For dual-eligible members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. For dual-eligible members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. *Not covered: services for flatfoot; subluxation; routine foot care, supportive devices; vitamin B-12 injections. Eon Deluxe $0 / Day for Days 1-5 $0 / Day for Days % Coinsurance Inpatient Mental Health Services: $0 / Day for Days 1-5 $0 / Day for Days 6-90 Outpatient Mental Health Services: Group therapy visit: Individual therapy visit: Outpatient hospital: Foot exams and treatment if you have diabetes related nerve damage and/or meet certain conditions: Routine foot care:

16 Georgia Medicaid Program Depending on your Medicaid category, you may have to make a small co-payment when you receive your medical care, but Medicaid will pay most or all of the bill. Georgia Medicaid Eon Deluxe For dual-eligible members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. Initial Coverage Retail: Mail Order: For generic drugs (including brand drugs treated as generic), either: / $1.25 copay/ $3.35 copay For all other drugs, either: / $3.70 copay / $8.35 copay Not Covered Prescription Drugs *Not covered: certain outpatient drugs pursuant to Section 1927(d) of the Social Security Act. Additionally, certain over the counter (OTC) drugs must be included, pursuant to the Georgia State Policies and Procedures Manual. Coverage Gap: Catastrophic Coverage: For generic drugs (including brand drugs treated as generic), either: / $1.25 copay / $3.35 copay For all other drugs, either: / $3.70 copay / $8.35 copay For generic drugs (including brand drugs treated as generic), either: / $1.25 copay/ $3.35 copay For all other drugs, either: / $3.70 copay/ $8.35 copay Skilled Nursing Facility (In a Medicarecertified Skilled Nursing Facility) Non-Emergency Transportation (NET) For dual-eligible members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. Medicaid covers NET emergency transportation as medically necessary. $0 / Day for Days 1-20 $0 / Day for Days / 30 one-way trips

17 Georgia Medicaid Program Depending on your Medicaid category, you may have to make a small co-payment when you receive your medical care, but Medicaid will pay most or all of the bill. Vision Services Georgia Medicaid Medically necessary diagnostic services may be covered. Services may only be covered if performed for medical reasons and not for refractive purposes for members twenty-one (21) years of age or older. Eon Deluxe Exam to diagnose and treat diseases and conditions of the eye: Glaucoma Screening: Routine eye exam (for up to 1 every year): Contact lenses: (for up to 1 every year): Eyeglasses (frames and lenses): (for up to 1 every year): Eyeglasses or contact lenses after cataract surgery: $225 every year for contact lenses and or eyeglasses (frames and lenses).

18 South Carolina Medicaid Program Statement of Understanding Within limits, Medicaid will pay for services that are medically necessary. For Medicaid payment purposes, the following definitions apply: Children - birth through 20 years of age Adults - 21 years of age and older Co-payments - The South Carolina Medicaid program requires many beneficiaries to pay a small part of their medical bill for some services called a co-payment. Certain groups do not pay co-payments for the medical services they receive: Children, Pregnant Women, People in a Nursing Home, People receiving Home and Community Based Waiver Services, and People receiving Family Planning.

19 South Carolina Medicaid Program Depending on your Medicaid category, you may have to make a small co-payment when you receive your medical care, but Medicaid will pay most or all of the bill. Ambulance Services Dental Services South Carolina Medicaid Medicaid covers ambulance services. Medicaid covers dental services. Eon Deluxe Preventive dental services: Cleaning (for up to 1 every six months) - Dental x-ray(s) (for up to 1 every six months) - Oral exam (for up to 1 every six months) - 1 dental bitewing x-ray per side every six months - 1 panoramic x-ray every five years: Comprehensive dental services: Coverage limit is $800 every year. Coverage is limited to fillings, simple extractions, dentures, and denture repair. Additional dental services, such as root canals, crowns, surgical extractions, denture relines and periodontal (gum) treatments, are not covered. 1 partial or 1 complete denture per arch every five years.

20 South Carolina Medicaid Program Depending on your Medicaid category, you may have to make a small co-payment when you receive your medical care, but Medicaid will pay most or all of the bill. Diagnostic Tests, X-rays, Lab Services South Carolina Medicaid Medicaid covers laboratory and x-ray services. Eon Deluxe Diagnostic radiology services (such as MRIs, CT scans): 0% coinsurance Diagnostic tests and procedures: Lab services: Outpatient x-rays: Therapeutic radiology services (such as radiation treatment for cancer): 0% coinsurance Doctor Office Visit Emergency Room Services Home Health Services Hospice Services Medicaid covers doctor visits. Copayment may apply. Medicaid covers emergency room services. Medicaid covers home health services. Medicaid covers hospice services. Primary care physician visit: Specialist visit: You pay nothing for hospice care from a Medicare certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details

21 South Carolina Medicaid Program Depending on your Medicaid category, you may have to make a small co-payment when you receive your medical care, but Medicaid will pay most or all of the bill. Inpatient Hospital Services Medical Equipment/ Supplies Mental Health Services Outpatient Hospital Services Outpatient Rehabilitation Services (Physical Therapy, Speech and Language Therapy) Outpatient Substance Abuse Services Podiatry Services (Foot Care) South Carolina Medicaid Medicaid covers inpatient hospital services. Medicaid covers medical equipment and supplies. Medicaid covers mental health services. Medicaid covers outpatient hospital services. Medicaid covers outpatient rehabilitation services. Medicaid covers outpatient substance abuse services. Medicaid covers podiatry services. Eon Deluxe $0 / Day for Days 1-5 $0 / Day for Days % Coinsurance Inpatient Mental Health Services: $0/Day for Days 1-5 $0/Day for Days 6-90 Outpatient Mental Health Services: Group therapy visit: Individual therapy visit: Outpatient hospital: Physical therapy visit: Speech and language therapy visit: Outpatient group therapy visit: Outpatient individual therapy visit: Foot exams and treatment if you have diabetes related nerve damage and/or meet certain conditions: Routine foot care:

22 South Carolina Medicaid Program Depending on your Medicaid category, you may have to make a small co-payment when you receive your medical care, but Medicaid will pay most or all of the bill. South Carolina Medicaid Eon Deluxe Initial Coverage Retail: For generic drugs (including brand drugs treated as generic), either: / $1.25 copay / $3.35 copay For all other drugs, either: / $3.70 copay / $8.35 copay Prescription Drugs Medicaid covers prescription drugs (not all drugs are covered). Mail Order: Coverage Gap: Not Covered For generic drugs (including brand drugs treated as generic), either: / $1.25 copay / $3.35 copay For all other drugs, either: / $3.70 copay / $8.35 copay Catastrophic Coverage: For generic drugs (including brand drugs treated as generic), either: For all other drugs: Skilled Nursing Facility Non-Emergency Transportation (NET) Medicaid covers nursing facility. Copayment may apply. Medicaid covers nonemergency transportation services to medical appointments. Copayment may apply. $0 / Day for Days 1-20 $0 / Day for Days / 30 one-way trips

23 South Carolina Medicaid Program Depending on your Medicaid category, you may have to make a small co-payment when you receive your medical care, but Medicaid will pay most or all of the bill. Vision Services South Carolina Medicaid Medicaid covers vision services. Eon Deluxe Exam to diagnose and treat diseases and conditions of the eye: Glaucoma Screening: Routine eye exam (for up to 1 every year): Contact lenses: (for up to 1 every year): Eyeglasses (frames and lenses): (for up to 1 every year): Eyeglasses or contact lenses after cataract surgery: $225 every year for contact lenses and or eyeglasses (frames and lenses).

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25 This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply., premiums and/ or copayments/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium The State pays the Part B premium for full dual members. Premium, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. Eon Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Current Members: TTY: 711 Prospective Members: TTY: 711 Hours of Operation: October 1 February 14: Seven days a week, 8:00am 8:00pm EST February 15 September 30: Monday through Friday, 8:00am 8:00pm EST (You may leave a voic Saturday, Sunday and Federal Holidays)