Y0114_17_27850_U_085 CMS Accepted 10/01/ MUSENMUB_085 H3240_ _NJ HMO SNP Amerivantage Dual Coordination (HMO SNP) 1

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1 Summary of Benefits for Amerivantage Dual Available in: Select Counties* in New Jersey *See Page 2 for a list of counties. Plan year: January 1, 2017 December 31, 2017 In this section, you ll learn about some of the services we cover and other important details to help you choose the right Medicare Advantage plan for you. While the benefit information provided does not list every service that we cover or list every limitation or exclusion, you can get a complete list of those services. Just give us a call and ask for the Evidence of Coverage. Have questions? Here s how to reach us and our hours of operation: If you are not a member of this plan, please call toll free (TTY: 711), and follow the instructions to be connected to a representative. If you are a member of this plan, call our toll free Customer Service number at (TTY: 711). 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14, and Monday to Friday (except holidays) from February 15 through September 30. You can learn more about us on our website at This plan is available to anyone who has both full Medicaid eligibility and Medicare. Y0114_17_27850_U_085 CMS Accepted 10/01/ MUSENMUB_085 H3240_ _NJ HMO SNP Amerivantage Dual 1

2 What you should know about our plan Amerivantage Dual is a Medicare Advantage Dual Eligible Special Needs Plan (D SNP), which includes hospital, medical and prescription drug benefits in one plan. To join this plan, you must be entitled to Medicare Part A, enrolled in Medicare Part B, eligible for full Medicaid benefits, and live in our service area. To join this plan, you must be entitled to Medicare Part A, enrolled in Medicare Part B, eligible for full Medicaid benefits, and live in our service area. Our service area includes: NJ: Atlantic, Cumberland, Gloucester, Mercer, Morris With this plan, you must use a provider in the plan s network. If you use providers that are not in our network, the plan may not pay for these services. You can find a doctor in the network online visit and choose Find a Doctor. (Be sure to check that the doctor displays as In Network for these plans.) Or you can call Customer Service and request a copy of the provider directory. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers Part A (hospital services) and Part B (medical services), plus more. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. Medicare Part D drugs and Part B drugs (such as chemotherapy and some drugs administered by your provider). To see if your drugs are covered, you can view the plan s Formulary (list of covered Part D prescription drugs) and any restrictions on our website at Or you can call us for a copy of the 2 Formulary. The plan also has a contract with the NJ FamilyCare (Medicaid) program to provide your Medicaid benefits. We are pleased to be providing your Medicare and Medicaid health care coverage, including your prescription drug coverage as well as long term care and home and community based services. Amerivantage Dual

3 How can I learn more about Medicare or compare my choices with other plans? Refer to your current Medicare & You handbook. You can view it online at or call Medicare for a copy at MEDICARE ( ), 24 hours a day, 7 days a week. TTY users can call If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or you can go online to and use the Medicare Plan Finder. Now that you are familiar with how Medicare works and some of the benefits included in our plan, it s time to consider the type of plan you may need. On the following pages, you can review our plan s covered benefits. Be in the know Before you continue, here are a few important things to know as you review our available plan options: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Amerivantage Dual 3

4 Statement of Benefits and Cost-Sharing Protections Eligibility The Amerivantage Dual plan is available to anyone with both Medicare Parts A and B and who is eligible for full Medicaid benefits. Cost sharing and cost sharing protections for all members In an Amerivantage Dual plan, youpay nothing for any benefits or services covered by the plan. When you receive health services, the provider should only bill Amerivantage Dual. The provider cannot bill you for services or cost sharing. If you receive care from a non contracted provider, the provider may not understand Amerivantage Dual or these billing rules. If you receive a bill from a provider, please notify Customer Services so we can help you. Please see Chapter 7 of your Amerivantage Dual Evidence of Coverage for more information. 4 Amerivantage Dual

5 Can I use any pharmacy to fill my covered prescriptions? You must generally use a pharmacy in our network. If you use a pharmacy that is not in our network, your drugs may not be covered. For a complete listing of network pharmacies, refer to our plan s Pharmacy Directory on our website at (under Useful Tools, select Find a Pharmacy). Or you can give us a call, and we will send you a copy. Amerivantage Dual 5

6 How much is my premium? $0 per month. $0 per month. Part B premium is covered by NJ FamilyCare (Medicaid). How much is my You have no medical You have no medical deductible? Is there a limit on how much I will pay for my covered medical services? (does not include Part D drugs) Inpatient Hospital 2 deductible. Because you receive NJ FamilyCare (Medicaid), this stage does not apply to you. Covered. deductible. Because you receive NJ FamilyCare (Medicaid), this stage does not apply to you. Refer to the "Medicare & You" handbook for Medicare covered services. Doctor s Office Visits 1,2 Covers semi private room accommodations; physicians and surgeons services; anesthesia; lab, x ray, and other diagnostic services; drugs and medication; therapeutic services; and other services and supplies that are usually provided by the hospital. Primary care physician visit: This plan covers stays in critical access hospitals; inpatient rehabilitation facilities; inpatient mental health care; semi private room accommodations; physicians and surgeons services; anesthesia; lab, x ray, and other diagnostic services; drugs and medication; therapeutic services; general nursing; and other services and supplies that are usually provided by the hospital. Primary care physician visit: 6 Amerivantage Dual

7 Benefit Doctor s Office NJ FamilyCare (Medicaid) Covered. Amerivantage Dual Visits 1,2 continued Specialist visit: Specialist visit: Covered. Preventive Care Preventive care screenings: Preventive care screenings: Screenings and Covered. Annual Physical Annual physical exam: Annual physical exam: Exams Covered. Preventive care screenings Covered. See specific screenings in the Additional Services section later in this document. Abdominal aortic aneurysm screening Alcohol misuse counseling Annual Wellness visit Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screening Cervical and vaginal cancer screening Colorectal cancer screenings (colonoscopy, fecal occult blood test, flexible sigmoidoscopy) Depression screening Diabetes screenings and monitoring HIV screening Lung cancer screenings Amerivantage Dual 7

8 Preventive care screenings continued Emergency Care Covered. Medical nutrition therapy services Obesity screenings and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screenings and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco related disease) Vaccines, including flu shots, hepatitis B shots, pneumococcal shots Welcome to Medicare preventive visit (onetime) Any additional preventive services approved by Medicare during the contract year will be covered. Worldwide ER Not covered. This plan also offers limited coverage for urgent and emergency care outside of 8 Amerivantage Dual

9 Worldwide ER continued the United States. This plan may provide coverage up to a $25,000 limit. Plan not liable for cost above this amount. Urgently Needed Covered. Services Diagnostic Tests, Lab and Radiology Services, and X rays 1,2 Hearing Services 1,2 Diagnostic Radiology Services (such as MRIs, CT scans): Covered. Diagnostic Tests and Procedures: Covered. Lab Services: Covered. Outpatient X rays: Covered. Therapeutic Radiology Services (such as radiation treatment for cancer): Covered. Covered. Diagnostic Radiology Services (such as MRIs, CT scans): Diagnostic Tests and Procedures: Lab Services: Outpatient X rays: Therapeutic Radiology Services (such as radiation treatment for cancer): Covers routine hearing exams, diagnostic hearing exams and balance exams, otologic and hearing aid examinations prior to prescribing hearing aids, exams for the purpose of fitting hearing aids, and Covers routine hearing exams, diagnostic hearing exams and balance exams, otologic and hearing aid examinations prior to prescribing hearing aids, exams for the purpose of fitting hearing aids, and Amerivantage Dual 9

10 Hearing Services 1,2 continued follow up exams and adjustments, and repairs after warranty expiration. follow up exams and adjustments, and repairs after warranty expiration. Dental Services Covered. Vision Services Covered care includes (but is not limited to): Diagnostics (X rays and exams twice per year) Preventive(cleanings and fluoride treatments) Restorative (crowns, silver or tooth colored fillings) Endodontics (root canals) Periodontal (gum treatments/therapies) Prosthetics (dentures and fixed bridges) Oral and maxillofacial surgical (extractions) Adjunctive services (treatment for dental trauma) Covered. Covers medically necessary eye care services for detection and treatment of disease or injury to the eye, including a Covered care includes (but is not limited to): Diagnostics (X rays and exams twice per year) Preventive(cleanings and fluoride treatments) Restorative (crowns, silver or tooth colored fillings) Endodontics (root canals) Periodontal (gum treatments/therapies) Prosthetics (dentures and fixed bridges) Oral and maxillofacial surgical (extractions) Adjunctive services (treatment for dental trauma) Covers medically necessary eye care services for detection and treatment of disease or injury to the eye, 10 Amerivantage Dual

11 Vision Services continued comprehensive eye exam once per year. including a comprehensive eye exam once per year. Mental Health Care 1, 2 Covers optometrist services and optical appliances, including artificial eyes, low vision devices, vision training devices, and intraocular lenses. Replacement lenses and frames (or contact lenses) are covered once every 24 months for beneficiaries age 19 through 59, and once per year for those 18 years of age or younger and those 60 years of age or older. Eyeglasses or contact lenses after cataract surgery are covered. Inpatient visit: Covered. For Medicaid beneficiaries, all Inpatient Mental Health services are covered by Medicaid Fee for Service. Services in a general hospital, psychiatric unit of an acute care hospital, Covers optometrist services and optical appliances, including artificial eyes, low vision devices, vision training devices, and intraocular lenses. Replacement lenses and frames (or contact lenses) are covered once every 24 months for beneficiaries age 19 through 59, and once per year for those 18 years of age or younger and those 60 years of age or older. Eyeglasses or contact lenses after cataract surgery are covered. Inpatient visit: Inpatient mental health services are covered by the plan (except where noted) for all SNP members for up to 190 days. Inpatient mental health services beyond 190 days are Amerivantage Dual 11

12 Mental Health Care 1, 2 continued covered directly by Medicaid Fee for Service. Short Term Care Facility (STCF), or critical access hospital are covered. Inpatient psychiatric services in a general hospital are covered for patients of any age. Psychiatric Acute Partial Hospital: Covered by Medicaid Feefor Service. Admission is only through a psychiatric emergency screening center or post psychiatric inpatient discharge. Limited to 6 months. Institutional: Covers inpatient psychiatric hospital services in a State, private, or county hospital, and nursing facility services for individuals under age 21 or age 65 or older in an institution for mental diseases. Covers services in a general hospital, psychiatric unit of an acute care hospital, Short Term Care Facility (STCF), or critical access hospital. Inpatient psychiatric services in State, private, or county hospitals are covered for those under age 21 or age 65 and older. Inpatient psychiatric services in a general hospital are covered for patients of any age. Psychiatric Acute Partial Hospital: Covered by the plan. Admission is only through a psychiatric emergency screening center or post psychiatric inpatient discharge. Limited to 6 months. 12 General Hospital: Institutional: Inpatient psychiatric Covers inpatient psychiatric services in a general hospital services in a State, Amerivantage Dual

13 Mental Health Care 1, 2 continued hospital covered for patients of any age. Substance Abuse (Inpatient): Detoxification in a medical acute care inpatient setting is covered. Substance Abuse (Residential): Covers a minimum of 30 days per year in a facility licensed to provide residential alcohol and substance abuse services. Services provided in a State or County operated psychiatric facility are generally not covered. Services provided in an inpatient psychiatric institution (other than an acute care hospital) to individuals under 65 years of age and over 21 years of age are not covered. private, or county hospital, and nursing facility services for individuals under age 21 or age 65 or older in an institution for mental diseases. General Hospital: Inpatient psychiatric services in a general hospital are covered for patients of any age. Substance Abuse (Inpatient): Detoxification in a medical acute care inpatient setting is covered. Substance Abuse (Residential): Covered by Medicaid Feefor Service. Covers a minimum of 30 days per year in a facility licensed to provide residential alcohol and substance abuse services. Services provided in a State or County operated psychiatric facility are generally not covered. Amerivantage Dual 13

14 Mental Health Care 1, 2 continued Services provided in an inpatient psychiatric institution (other than an acute care hospital) to individuals under 65 years of age and over 21 years of Outpatient individual and group therapy visit: Covered. age are not covered. Outpatient individual and group therapy visit: For Medicaid beneficiaries, Medicaid Fee for Service covers outpatient psychiatric services in general hospitals and private psychiatric hospitals for patients of all ages. Methadone cost, administration, and maintenance are covered by Medicaid Fee For Service, except for MLTSS members, for whom the services are covered by the plan. Private Psychiatric Hospital: Outpatient psychiatric services in The plan covers mental health and substance abuse services in hospitalbased and communitybased settings, and covers screening, referrals, prescription drugs, and the treatment of conditions. Private Psychiatric Hospital: The plan covers outpatient psychiatric services in private psychiatric hospitals for members of all ages. General Hospital Outpatient: The plan covers outpatient psychiatric services provided in a general 14 Amerivantage Dual

15 Mental Health Care 1, 2 continued hospital outpatient setting for members of all ages. private psychiatric hospitals are covered by Medicaid Fee for Service for patients of all ages, except for MLTSS members and clients of the Division of Developmental Disabilities (DDD), for whom the services are covered by the plan. General Hospital Outpatient: Outpatient psychiatric services provided in a general hospital outpatient setting are covered by Medicaid Fee for Service for patients of all ages, except for MLTSS members and clients of the Division of Developmental Disabilities (DDD), for whom the services are covered by the plan. Methadone cost, administration, and maintenance are covered by Medicaid Fee For Service, except for MLTSS members, for whom the services are covered by the plan. Skilled Nursing Covered. Facility (SNF) 1 Nursing Facility Care is covered by the plan for all members. Coverage includes skilled nursing and rehabilitative services, and Amerivantage Dual 15

16 Skilled Nursing Facility (SNF) 1 continued other medically necessary services and supplies. Long term (custodial) care Outpatient Rehabilitation 1,2 Cardiac (heart) rehab services: Covered. Pulmonary (lung) rehab services: Covered. Occupational therapy visit: Covered. Physical therapy and speech/language therapy visit: is also covered. Cardiac (heart) rehab services: Pulmonary (lung) rehab services: Occupational therapy visit: Physical therapy and speech/language therapy visit: Ambulance 1 Covered. Transportation 1,2 Covered. Emergency/Emergent Transportation: Covers medically necessary ground ambulance transportation to a hospital or skilled nursing facility for medically necessary services. May cover emergency ambulance transportation in an airplane or helicopter if ground transportation cannot provide the Emergency/Emergent Transportation: Covers medically necessary ground ambulance transportation to a hospital or skilled nursing facility for medically necessary services. May cover emergency ambulance transportation in an airplane or helicopter if ground transportation cannot provide the 16 Amerivantage Dual

17 Transportation 1,2 continued immediate and rapid transportation that is necessary. immediate and rapid transportation that is necessary. Foot Care (podiatry services) 1,2 Non Emergency/Urgent Transportation: Medicaid Fee for Service covers all non emergency transportation, such as mobile assistance vehicles (MAVs), and nonemergency basic life support (BLS) ambulance (stretcher). Livery transportation services, such as bus and train fare or passes, car service and reimbursement for mileage, are also covered. Covered. Foot exams and treatment are covered if you have diabetes related nerve damage and/or meet certain conditions. Medically necessary podiatric services, as well as therapeutic shoes or inserts for those with severe diabetic foot disease, and exams to fit Non Emergency/Urgent Transportation: Medicaid Fee for Service covers all non emergency transportation, such as mobile assistance vehicles (MAVs), and nonemergency basic life support (BLS) ambulance (stretcher). Livery transportation services, such as bus and train fare or passes, car service and reimbursement for mileage, are also covered. Foot exams and treatment are covered if you have diabetes related nerve damage and/or meet certain conditions. Medically necessary podiatric services, as well as therapeutic shoes or inserts for those with severe diabetic foot disease, and exams to fit Amerivantage Dual 17

18 Foot Care (podiatry services) 1,2 continued those shoes or inserts, are covered. those shoes or inserts, are covered. Medical Equipment/Supplies 1 Wellness Programs Durable Medical Equipment: Covered. Includes wheelchairs, oxygen, etc. Medical supplies and prosthetic devices: Covered. Includes braces, artificial limbs, etc. Diabetic supplies and services: Covered. Healthways SilverSneakers * Fitness program: Not covered. Durable Medical Equipment: Includes wheelchairs, oxygen, etc. Medical supplies and prosthetic devices: Includes braces, artificial limbs, etc. Diabetic supplies and services: Healthways SilverSneakers * Fitness program: When you become our member, you can sign up for SilverSneakers. Additional details can be found at Or you can call SilverSneakers Customer Service at (TTY: 711), 18 Amerivantage Dual

19 Wellness Programs continued Monday through Friday, 8 a.m. to 8 p.m. ET. * The SilverSneakers Fitness Program is provided by Healthways, Inc., an independent company. Healthways and SilverSneakers are registered marks of Healthways, Inc. and/or its subsidiaries Healthways, Inc. All rights reserved. Medicare Part B Covered. Drugs 1 Amerivantage Dual 19

20 Prescription Drug Benefits What is my coverage? Amerivantage Dual Stage 1: Deductible Because you receive "Extra Help" to pay your prescription drugs, this payment stage does not apply to you. Stage 2: Initial Coverage Because you receive "Extra Help," this stage does not apply to you. You may get your drugs at network retail pharmacies and mail order pharmacies. You may get drugs from an out of network pharmacy. 20 Amerivantage Dual

21 Amerivantage Dual Stage 2: Initial Coverage Preferred Retail, Standard Retail and Standard Mail Order Cost Sharing Tier 1: Preferred Generic, Tier 2: Generic, Tier 3: Preferred Brand, Tier 4: Non-Preferred Drug, Tier 5: Specialty, Tier 6: Select Care Drugs One month supply: $0.00 copay Three month supply: $0.00 copay Stage 3: Catastrophic Coverage Because you receive "Extra Help," this stage does not apply to you. Amerivantage Dual 21

22 Additional services covered under the plan For each benefit listed below, you can see what NJ FamilyCare (Medicaid) covers and what our plan covers. Benefit NJ FamilyCare (Medicaid) Amerivantage Dual Acupuncture Covered Covered Chiropractic Covers manipulation of the spine, as well as clinical laboratory services; certain medical supplies; durable medical equipment; prefabricated orthoses; physical therapy services; and diagnostic radiological services, when they are prescribed by a chiropractor within their scope of practice. Covers manipulation of the spine, as well as clinical laboratory services; certain medical supplies; durable medical equipment; prefabricated orthoses; physical therapy services; and diagnostic radiological services, when they are prescribed by a chiropractor within their scope of practice. Clinical Trials Covered Coverage includes benefits outlined by NJFamilyCare per guidelines in addition to Medicare benefits. Colorectal Screening Covers any expenses incurred in conducting colorectal cancer screening at regular intervals for beneficiaries 50 years of age or older, and for those of any age deemed to be at high risk of colorectal cancer. Covers any expenses incurred in conducting colorectal cancer screening at regular intervals for beneficiaries 50 years of age or older, and for those of any age deemed to be at high risk of colorectal cancer. 22 Amerivantage Dual

23 Colorectal Screening continued Flexible Sigmoidoscopy: Covered once every 48 months for those 50 or older. Flexible Sigmoidoscopy: Covered once every 48 months for those 50 or older. Dental Services Barium Enema: When used instead of a flexible sigmoidoscopy or colonoscopy, covered once every 48 months for those 50 or older. Colonoscopy: Covered once every 120 months, or 48 months after a screening flexible sigmoidoscopy. Fecal Occult Blood Test: Covered once every 12 months for those 50 or older. Covered care includes (but is not limited to): Diagnostics (X rays and exams twice per year) Preventive (cleanings and fluoride treatments) Restorative (crowns, silver or tooth colored fillings) Barium Enema: When used instead of a flexible sigmoidoscopy or colonoscopy, covered once every 48 months for those 50 or older. Colonoscopy: Covered once every 120 months, or 48 months after a screening flexible sigmoidoscopy. Fecal Occult Blood Test: Covered once every 12 months for those 50 or older. Covered care includes (but is not limited to): Diagnostics (X rays and exams twice per year) Preventive (cleanings and fluoride treatments) Restorative (crowns, silver or tooth colored fillings) Amerivantage Dual 23

24 Dental Services continued Endodontics (root canals) Periodontal (gum treatments/therapies) Prosthetics (dentures and fixed bridges) Oral and maxillofacial surgical (extractions) Adjunctive services (treatment for dental trauma) Diabetes Screenings Coverage includes (but is not limited to) yearly exams for diabetic retinopathy for those with diabetes. Diabetes Supplies Covers blood glucose monitors, test strips, insulin, injection aids, syringes, insulin pumps, insulin infusion devices, and oral agents for blood sugar control. Covers therapeutic shoes or inserts for those with diabetic foot disease. The shoes or inserts must be prescribed by a podiatrist (or other qualified doctor) and provided by a Endodontics (root canals) Periodontal (gum treatments/therapies) Prosthetics (dentures and fixed bridges) Oral and maxillofacial surgical (extractions) Adjunctive services (treatment for dental trauma) Coverage includes (but is not limited to) yearly exams for diabetic retinopathy for those with diabetes. Covers blood glucose monitors, test strips, insulin, injection aids, syringes, insulin pumps, insulin infusion devices, and oral agents for blood sugar control. Covers therapeutic shoes or inserts for those with diabetic foot disease. The shoes or inserts must be prescribed by a podiatrist (or other qualified doctor) and provided by a 24 Amerivantage Dual

25 Diabetes Supplies continued podiatrist, orthotist, prosthetist, or pedorthist. podiatrist, orthotist, prosthetist, or pedorthist. Diabetes Testing and Monitoring Diagnostic and Therapeutic Radiology and Laboratory Services Durable Medical Equipment (DME) Family Planning Services and Supplies Covers yearly eye exams for diabetic retinopathy, as well as foot exams every six months for members with diabetic peripheral neuropathy and loss of protective sensations. Covered, including (but not limited to) CT scans, MRIs, EKGs, and X rays. Coverage includes (but is not limited to) the rental or purchase of iron lungs, oxygen tents, hospital beds, wheelchairs, hearing aids, prosthetics, and orthotics. Services furnished by outof network providers are covered directly by Medicaid fee for service. Covered services include medical history and physical examination (including pelvis and breast), diagnostic and laboratory tests, drugs and biologicals, medical supplies and devices Covers yearly eye exams for diabetic retinopathy, as well as foot exams every six months for members with diabetic peripheral neuropathy and loss of protective sensations. Covered, including (but not limited to) CT scans, MRIs, EKGs, and X rays. Coverage includes (but is not limited to) the rental or purchase of iron lungs, oxygen tents, hospital beds, wheelchairs, hearing aids, prosthetics, and orthotics. Services furnished by outof network providers are covered directly by Medicaid fee for service. Covered services include medical history and physical examination (including pelvis and breast), diagnostic and laboratory tests, drugs and biologicals, medical supplies and devices Amerivantage Dual 25

26 Family Planning Services and Supplies continued Federally Qualified Health Centers (FQHC) Health/Wellness Education, including preventive healthcare and counseling, health promotion Hearing Services (including pregnancy test kits, condoms, diaphragms, Depo Provera injections, and other contraceptive supplies and devices), counseling, continuing medical supervision, continuity of care and genetic counseling. Includes outpatient and primary care services from community based organizations. Coverage includes (but is not limited to) medical nutrition therapy for members with diabetes or kidney disease, diabetes education, tobacco use cessation counseling, alcohol misuse counseling, and depression screenings. Covers routine hearing exams, diagnostic hearing exams and balance exams, otologic and hearing aid examinations prior to prescribing hearing aids, exams for the purpose of fitting hearing aids, and follow up exams and (including pregnancy test kits, condoms, diaphragms, Depo Provera injections, and other contraceptive supplies and devices), counseling, continuing medical supervision, continuity of care and genetic counseling. Includes outpatient and primary care services from community based organizations. Coverage includes (but is not limited to) medical nutrition therapy for members with diabetes or kidney disease, diabetes education, tobacco use cessation counseling, alcohol misuse counseling, and depression screenings. Covers routine hearing exams, diagnostic hearing exams and balance exams, otologic and hearing aid examinations prior to prescribing hearing aids, exams for the purpose of fitting hearing aids, and follow up exams and 26 Amerivantage Dual

27 Hearing Services continued Home Health Hospice Care Services adjustments, and repairs after warranty expiration. Hearing aids, as well as associated accessories and supplies, are covered. Coverage includes nursing services by a registered nurse and/or licensed practical nurse; home health aide service; medical supplies and equipment, and appliances suitable for use in the home; audiology services; physical therapy; speechlanguage pathology; and occupational therapy. Covers drugs for pain relief and symptoms management; medical, nursing, and social services; and certain durable medical equipment and other services, including spiritual and grief counseling. adjustments, and repairs after warranty expiration. Hearing aids, as well as associated accessories and supplies, are covered. Coverage includes nursing services by a registered nurse and/or licensed practical nurse; home health aide service; medical supplies and equipment, and appliances suitable for use in the home; audiology services; physical therapy; speechlanguage pathology; and occupational therapy. Covers drugs for pain relief and symptoms management; medical, nursing, and social services; and certain durable medical equipment and other services, including spiritual and grief counseling. Covered in the community as well as in institutional settings. Room and board services are included only Covered in the community as well as in institutional settings. Room and board services are included only Amerivantage Dual 27

28 Hospice Care Services continued when services are delivered in institutional (non private residence) setting. Hospice care for enrollees under 21 years of age shall cover both palliative and curative care. Covered for services rendered beyond Medicare Part A & B limits. Immunizations Influenza, Hepatitis B, pneumococcal vaccinations, and other vaccinations recommended for adults are covered. The full childhood immunization schedule is covered as a component of EPSDT. See the EPSDT entry later in this chart. Inpatient Hospital Care Covers stays in critical access hospitals; inpatient rehabilitation facilities; inpatient mental health care; semi private room accommodations; physicians and surgeons services; anesthesia; lab, x ray, and other diagnostic services; drugs and when services are delivered in institutional (non private residence) setting. Hospice care for enrollees under 21 years of age shall cover both palliative and curative care. Covered for services rendered beyond Medicare Part A & B limits. Influenza, Hepatitis B, pneumococcal vaccinations, and other vaccinations recommended for adults are covered. The full childhood immunization schedule is covered as a component of EPSDT. See the EPSDT entry later in this chart. Covers stays in critical access hospitals; inpatient rehabilitation facilities; inpatient mental health care; semi private room accommodations; physicians and surgeons services; anesthesia; lab, x ray, and other diagnostic services; drugs and 28 Amerivantage Dual

29 Inpatient Hospital Care continued medication; therapeutic services; general nursing; and other services and supplies that are usually provided by the hospital. medication; therapeutic services; general nursing; and other services and supplies that are usually provided by the hospital. Inpatient Mental Health Acute Care: Coverage includes room and board; nursing and other related services; use of hospital/ Critical Access Hospital facilities; drugs and biologicals; supplies, appliances, and equipment; certain diagnostic and therapeutic services, medical or surgical services provided by certain interns or residents in training; and transportation services (including transportation by ambulance). For Medicaid beneficiaries, all Inpatient Mental Health services are covered by Medicaid Fee for Service. Services in a general hospital, psychiatric unit of an acute care hospital, Short Term Care Facility Acute Care: Coverage includes room and board; nursing and other related services; use of hospital/ Critical Access Hospital facilities; drugs and biologicals; supplies, appliances, and equipment; certain diagnostic and therapeutic services, medical or surgical services provided by certain interns or residents in training; and transportation services (including transportation by ambulance). Inpatient mental health services are covered by the plan (except where noted) for all SNP members for up to 190 days. Inpatient mental health services beyond 190 days are covered directly by Medicaid Fee for Service. Amerivantage Dual 29

30 Inpatient Mental Health continued (STCF), or critical access hospital are covered. Inpatient psychiatric services in a general hospital are covered for patients of any age. Covers services in a general hospital, psychiatric unit of an acute care hospital, Short Term Care Facility (STCF), or critical access hospital. Psychiatric Acute Partial Hospital: Covered by Medicaid Feefor Service. Admission is only through a psychiatric emergency screening center or post psychiatric inpatient discharge. Limited to 6 months. Institutional: Covers inpatient psychiatric hospital services in a State, private, or county hospital, and nursing facility services for individuals under age 21 or age 65 or older in an institution for mental diseases. Inpatient psychiatric services in State, private, or county hospitals are covered for those under age 21 or age 65 and older. Inpatient psychiatric services in a general hospital are covered for patients of any age. Psychiatric Acute Partial Hospital: Covered by the plan. Admission is only through a psychiatric emergency screening center or post psychiatric inpatient discharge. Limited to 6 months. 30 General Hospital: Institutional: Inpatient psychiatric Covers inpatient services in a general psychiatric hospital services in a State, private, Amerivantage Dual

31 Inpatient Mental Health continued hospital covered for patients of any age. Substance Abuse (Inpatient): Detoxification in a medical acute care inpatient setting is covered. Substance Abuse (Residential): Covers a minimum of 30 days per year in a facility licensed to provide residential alcohol and substance abuse services. Services provided in a State or County operated psychiatric facility are generally not covered. Services provided in an inpatient psychiatric institution (other than an acute care hospital) to individuals under 65 years of age and over 21 years of age are not covered. or county hospital, and nursing facility services for individuals under age 21 or age 65 or older in an institution for mental diseases. General Hospital: Inpatient psychiatric services in a general hospital are covered for patients of any age. Substance Abuse (Inpatient): Detoxification in a medical acute care inpatient setting is covered. Substance Abuse (Residential): Covered by Medicaid Feefor Service. Covers a minimum of 30 days per year in a facility licensed to provide residential alcohol and substance abuse services. Services provided in a State or County operated psychiatric facility are generally not covered. Amerivantage Dual 31

32 Inpatient Mental Health continued Services provided in an inpatient psychiatric institution (other than an acute care hospital) to individuals under 65 years of age and over 21 years of Mammograms Medical Day Care Covers a baseline mammogram for women age 35 to 39, and a mammogram every year for those 40 and over, and for those with a family history of breast cancer or other risk factors. Additional screenings are available if medically necessary. Provides preventive, diagnostic, therapeutic and rehabilitative services under medical and nursing supervision in an ambulatory care setting to meet the needs of individuals with physical and/or cognitive impairments in order to support their community age are not covered. Covers a baseline mammogram for women age 35 to 39, and a mammogram every year for those 40 and over, and for those with a family history of breast cancer or other risk factors. Additional screenings are available if medically necessary. Provides preventive, diagnostic, therapeutic and rehabilitative services under medical and nursing supervision in an ambulatory care setting to meet the needs of individuals with physical and/or cognitive impairments in order to support their community living. living. Medical Supplies Covered Coverage includes benefits outlined by NJFamilyCare 32 Amerivantage Dual

33 Medical Supplies continued per guidelines in addition to Medicare benefits. Non Physician Services Nurse Midwife Services Organ Transplants Outpatient Hospital Service/Surgery Covered for services rendered beyond Medicare Part B limits (within the scope of practice and in accordance with state certification/ licensure requirements, standards and practices) by certified nurse midwives, certified nurse practitioners, clinical nurse specialists, physician assistants, social workers, physical therapists, and psychologists. Covered Covers medically necessary organ transplants including, liver, lung, heart, heart lung, pancreas, kidney, liver, cornea, intestine, and bone marrow transplants (including autologous bone marrow transplants). Includes donor and recipient costs. Covered Covered for services rendered beyond Medicare Part B limits (within the scope of practice and in accordance with state certification/ licensure requirements, standards and practices) by certified nurse midwives, certified nurse practitioners, clinical nurse specialists, physician assistants, social workers, physical therapists, and psychologists. Coverage includes benefits outlined by NJFamilyCare per guidelines. Covers medically necessary organ transplants including, liver, lung, heart, heart lung, pancreas, kidney, liver, cornea, intestine, and bone marrow transplants (including autologous bone marrow transplants). Includes donor and recipient costs. Coverage includes benefits outlined by NJFamilyCare Amerivantage Dual 33

34 Outpatient Hospital Service/Surgery continued per guidelines in addition to Medicare benefits. Outpatient Mental Health / Substance Abuse Services For Medicaid beneficiaries, Medicaid Fee for Service covers outpatient psychiatric services in general hospitals and private psychiatric hospitals for patients of all ages. The plan covers mental health and substance abuse services in hospitalbased and communitybased settings, and covers screening, referrals, prescription drugs, and the treatment of conditions. Methadone cost, administration, and maintenance are covered by Medicaid Fee For Service, except for MLTSS members, for whom the services are covered by the plan. Private Psychiatric Hospital: Outpatient psychiatric services in private psychiatric hospitals are covered by Medicaid Feefor Service for patients of all ages, except for MLTSS members and clients of the Division of Developmental Disabilities (DDD), for Private Psychiatric Hospital: The plan covers outpatient psychiatric services in private psychiatric hospitals for members of all ages. General Hospital Outpatient: The plan covers outpatient psychiatric services provided in a general hospital outpatient setting for members of all ages. Methadone cost, administration, and maintenance are covered by Medicaid Fee For 34 Amerivantage Dual

35 Outpatient Mental whom the services are Service, except for MLTSS Health / Substance covered by the plan. members, for whom the Abuse Services services are covered by the continued General Hospital plan. Outpatient: Outpatient psychiatric services provided in a general hospital outpatient setting are covered by Medicaid Fee for Service for patients of all ages, except for MLTSS members and clients of the Division of Developmental Disabilities (DDD), for whom the services are Outpatient Rehabilitation (OT, PT, Speech, Cognitive) Over the Counter Items covered by the plan. Covers physical therapy, occupational therapy, speech pathology, and cognitive rehabilitation therapy. Covers physical therapy, occupational therapy, speech pathology, and cognitive rehabilitation therapy. Not covered. Covered; you have a $41 allowance every month. This plan covers certain approved non prescription over the counter drugs and health related items. Unused OTC amounts do not roll over from month to month. Orders are limited to one per month. Amerivantage Dual 35

36 Over the Counter Items continued Please visit our website to see our list of covered Partial Hospitalization Acute Pap Smear and Pelvic Exams Personal Care Assistant Medicaid intensive and time limited acute psychiatric service for beneficiaries of all ages, covered directly by Medicaid fee for service. Pap tests and pelvic exams are covered every 12 months for all women, regardless of determined level of risk for cervical or vaginal cancers. Clinical breast exams for all women are covered once every 24 months. All laboratory costs associated with the listed tests are covered. Tests are covered on a more frequent basis in cases where they are deemed necessary for medical diagnostic purposes. Covers health related tasks performed by a qualified individual in a beneficiary's home, under the supervision of a registered over the counter items. Medicaid intensive and time limited acute psychiatric service for beneficiaries of all ages, covered by the plan for all SNP members. Pap tests and pelvic exams are covered every 12 months for all women, regardless of determined level of risk for cervical or vaginal cancers. Clinical breast exams for all women are covered once every 24 months. All laboratory costs associated with the listed tests are covered. Tests are covered on a more frequent basis in cases where they are deemed necessary for medical diagnostic purposes. Covers health related tasks performed by a qualified individual in a beneficiary's home, under the supervision of a registered 36 Amerivantage Dual

37 Personal Care Assistant continued Podiatry Prescription Drugs, including Medicare Part B and Medicare Part D Physician Services Primary and Specialty Care Private Duty Nursing professional nurse, as certified by a physician in accordance with a beneficiary's written plan of care. Services limited to 40 hours per week. The plan may approve more than 40 hours per week for members with MLTSS. Covers routine exams and medically necessary podiatry services, as well as therapeutic shoes or inserts for those with severe diabetic foot disease, and exams to fit those shoes or inserts. Covered Covered Private duty nursing is covered for members under 21 years of age who live in the community and whose medical condition and treatment plan justify the need. Available to professional nurse, as certified by a physician in accordance with a beneficiary's written plan of care. Services limited to 40 hours per week. The plan may approve more than 40 hours per week for members with MLTSS. Covers routine exams and medically necessary podiatry services, as well as therapeutic shoes or inserts for those with severe diabetic foot disease, and exams to fit those shoes or inserts. Covered Covered Private duty nursing is covered for members under 21 years of age who live in the community and whose medical condition and treatment plan justify the need. Available to Amerivantage Dual 37

38 Private Duty MLTSS members of any MLTSS members of any Nursing continued age. age. Prostate Cancer Screening Prosthetics/ Orthotics Covers annual diagnostic examination including digital rectal exam and Prostate Specific Antigen (PSA) test for men 50 and over who are asymptomatic, and for men 40 and over with a family history of prostate cancer or other prostate cancer risk factors. Coverage includes (but is not limited to) arm, leg, back, and neck braces; artificial eyes; artificial limbs and replacements; certain breast prostheses following mastectomy; and prosthetic devices for replacing internal body parts or functions. Also covers certified shoe repair, hearing aids, and dentures. Renal Dialysis Covered Covered Routine Physical Covered Covered Exam 1/year Blood and Blood Products Whole blood and derivatives, as well as necessary processing and Covers annual diagnostic examination including digital rectal exam and Prostate Specific Antigen (PSA) test for men 50 and over who are asymptomatic, and for men 40 and over with a family history of prostate cancer or other prostate cancer risk factors. Coverage includes (but is not limited to) arm, leg, back, and neck braces; artificial eyes; artificial limbs and replacements; certain breast prostheses following mastectomy; and prosthetic devices for replacing internal body parts or functions. Also covers certified shoe repair, hearing aids, and dentures. Whole blood and derivatives, as well as necessary processing and 38 Amerivantage Dual

39 Blood and Blood Products continued administration costs, are covered. administration costs, are covered. Bone Mass Measurement Cardiovascular Screenings Coverage is unlimited (no limit on volume or number of blood products). Coverage begins with the first pint of blood. Covers one measurement every 24 months (more often if medically necessary), as well as physician s interpretation of results. For all persons 20 years of age and older, annual cardiovascular screenings are covered. More frequent testing is covered when determined to be medically necessary. Emergency Care Covered Covered Early Periodic Screening and Diagnostic Treatment (EPSDT) Coverage includes (but is not limited to) well child care, preventive screenings, medical examinations, vision and hearing screenings and services, immunizations, lead screening, and private duty nursing services. Private duty nursing is covered for Coverage is unlimited (no limit on volume or number of blood products). Coverage begins with the first pint of blood. Covers one measurement every 24 months (more often if medically necessary), as well as physician s interpretation of results. For all persons 20 years of age and older, annual cardiovascular screenings are covered. More frequent testing is covered when determined to be medically necessary. Coverage includes (but is not limited to) well child care, preventive screenings, medical examinations, vision and hearing screenings and services, immunizations, lead screening, and private duty nursing services. Private duty nursing is covered for Amerivantage Dual 39

40 Early Periodic Screening and Diagnostic Treatment (EPSDT) continued eligible EPSDT beneficiaries under 21 years of age who live in the community and whose medical condition and treatment plan justify eligible EPSDT beneficiaries under 21 years of age who live in the community and whose medical condition and treatment plan justify Managed Long Term Services and Supports (MLTSS) Note: MLTSS has medical and financial requirements for eligibility that are additional to the eligibility requirements for enrolling in the SNP plan. Urgent Care the needs. MLTSS includes services for members who need the level of care typically provided in a nursing facility, and provides the support needed to allow them to receive the care they need in their home or community. This includes services such as meal delivery, physical therapy and residential modification (such as ramp installation), among others. Ask your care manager for more information. Covers care to treat a sudden illness or injury that isn t a medical emergency. the needs. MLTSS includes services for members who need the level of care typically provided in a nursing facility, and provides the support needed to allow them to receive the care they need in their home or community. This includes services such as meal delivery, physical therapy and residential modification (such as ramp installation), among others. Ask your care manager for more information. Covers care to treat a sudden illness or injury that isn t a medical emergency. 40 Amerivantage Dual

41 More ways we support your health Amerigroup: We re here to help. Amerigroup is more than a company that provides medical coverage. We re a group of people committed to your health. Now, when times are tougher for many of us, Amerigroup is committed to helping everyone get the tools and solutions they need to lead healthier lives. Looking for Medicare coverage that goes beyond original Medicare? Amerigroup works with the federal government to bring you even more benefits than you get with Original Medicare. Extra benefits, pharmacy and medical coverage, advice from nurses and many other important health benefits are yours from one company all with $0 monthly plan premiums. Our plan gives you extra benefits not included in Original Medicare, such as: Amerivantage Dual Personal Emergency Response System (PERS): Coverage of a Personal Emergency Response System (PERS) which includes the monitoring device and monitoring service. Members should contact customer service to initiate this service and installation. Please refer to the Evidence of Coverage for additional information. Remote Access Technologies: This service provides members with access to a doctor via live, two way video on a computer, smartphone or tablet. Telemonitoring: Coverage of in home equipment and telecommunication technology to monitor specific health conditions. 24/7 Nurse HelpLine: 24 hour access to a nurse helpline, 7 days a week, 365 days a year. Meals Benefit: $0.00 copay for up to 10 post hospitalization discharge meals each year. Amerivantage Dual 41