Plan Year 2016 CCHP Senior Select Program (HMO SNP) 東華智選 (HMO SNP) 計劃 Summary of Benefits 保障簡要 H0571_2016_05 Accepted
Summary of Benefits January 1, 2016 - December 31, 2016 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 every limitation or exclusion. To get a complete list of services we cover, call us and ask for the "Evidence of Coverage." 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). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Medicare health plan (such as CCHP Senior Select Program (HMO SNP)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what CCHP Senior Select Program (HMO SNP) covers and what you pay. If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on http://www.medicare.gov. If you want to know more about the coverage and costs of Original Medicare, look in your current "Medicare & You" handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Sections in this booklet Things to Know About CCHP Senior Select Program (HMO SNP) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits Summary of Medi-Cal (Medicaid) -Covered Benefits This document is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call us at 1-888-775-7888 (TTY 1-877-681-8898). Este documento puede ser disponible en un idioma otro que inglés. Para mas informacion, por favor llame al 1-888-775-7888 (TTY 1-877-681-8898) 此文件有其它的語言版本提供 了解詳情請致電 1-888-775-7888 (TTY 1-877- 681-8898) 與我們聯絡 H0571_2016_05 Accepted 1
Things to Know About CCHP Senior Select Program (HMO SNP) Hours of Operation From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Pacific time. From February 15 to September 30, you can call us Monday from 8:00 a.m. to 8:00 p.m. Pacific time, Tuesday from 8:00 a.m. to 8:00 p.m. Pacific time, Wednesday from 8:00 a.m. to 8:00 p.m. Pacific time, Thursday from 8:00 a.m. to 8:00 p.m. Pacific time, Friday from 8:00 a.m. to 8:00 p.m. Pacific time, Saturday from 8:00 a.m. to 8:00 p.m. Pacific time. CCHP Senior Select Program (HMO SNP) Phone Numbers and Website If you are a member of this plan, call toll-free 1-888-775-7888. If you are not a member of this plan, call toll-free 1-888-371-3060. Our website: http://www.cchphealthplan.com/medicare Who can join? To join CCHP Senior Select Program (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and Medi-Cal (Medicaid), and live in our service area. Our service area includes the following county in California: San Francisco. Which doctors, hospitals, and pharmacies can I use? CCHP Senior Select Program (HMO SNP) 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 You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan's provider directory at our website (www.cchphealthplan.com/medicare). You can see our plan's pharmacy directory at our website (www.cchphealthplan.com/medicare-rx-benefit-information-including-part-d). Or, call us and we will send you a copy of the provider and pharmacy directories. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers - and more. Our plan members get all of the benefits covered by Original Medicare. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. 2
We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, http://www.cchphealthplan.com/medicare-rx-benefitinformation-including-part-d. Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? The amount you pay for drugs depends on the drug you are taking and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage. 3
Summary of Benefits January 1, 2016 - December 31, 2016 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the monthly premium? How much is the deductible? Is there any limit on how much I will pay for my covered services? Is there a limit on how much the plan will pay? $14.20 per month. In addition, you must keep paying your Medicare Part B premium. $0 to $74 per year for Part D prescription drugs. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. In this plan, you may pay nothing for some services, depending on your level of Medi- Cal (Medicaid) eligibility. Your yearly limit(s) in this plan: $3,400 for services you receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Covered Medical and Hospital Benefits Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Outpatient Care and Services Acupuncture 1,2 For up to 18 visit(s) every year: Ambulance 1 Chiropractic Care 1,2 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): 4
Dental Services Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): Diabetes Supplies and Services 1 Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts: Diagnostic Tests, Lab and Radiology Services, and X-Rays (Costs for these services may be different if received in an outpatient surgery setting) 1,2 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): Doctor's Office Visits 2 Primary care physician visit: Specialist visit: Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Emergency Care Foot Care (podiatry services) 1,2 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing Hearing Services 1,2 Exam to diagnose and treat hearing and balance issues: Routine hearing exam: Home Health Care 1,2 5
Mental Health Care 1,2 Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. Outpatient group therapy visit: Outpatient individual therapy visit: Outpatient Rehabilitation 1,2 Cardiac (heart) rehab services (for a maximum of 2 onehour sessions per day for up to 36 sessions up to 36 weeks): Occupational therapy visit: Physical therapy and speech and language therapy visit: Outpatient Substance Abuse 1,2 Group therapy visit: Individual therapy visit: Outpatient Surgery 1,2 Ambulatory surgical center: Outpatient hospital: Over-the-Counter Items Not Covered Prosthetic Devices (braces, artificial limbs, etc.) 1 Prosthetic devices: Related medical supplies: Renal Dialysis 1,2 Transportation 1 Our Plan covered up to 24 one-way trips to planapproved locations each year. 6
Urgent Care Vision Services 1,2 Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing Routine eye exam (for up to 1 every year): $0 copay Eyeglasses (frames and lenses) (for up to 1 every two years): $0 copay Eyeglasses or contact lenses after cataract surgery: $0 copay Our plan pays up to $80 every two years for eyeglasses (frames and lenses). Preventive Care 1,2 Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screenings HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Sexually transmitted infections screening 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) Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. 7
Annual physical exam: Hospice for hospice care from a Medicarecertified hospice. You may have to pay part of the cost for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. Inpatient Care Inpatient Hospital Care 1,2 Our plan covers an unlimited number of days for an inpatient hospital stay. Inpatient Mental Health Care Skilled Nursing Facility (SNF) 1,2 For inpatient mental health care, see the "Mental Health Care" section of this booklet. Our plan covers up to 100 days in a SNF. Prescription Drug Benefits How much do I pay? For Part B drugs such as chemotherapy drugs 1 : You pay nothing Other Part B drugs 1 : Initial Coverage Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs, either: $0 copay; or $3.60 copay; or $7.40 copay You may get your drugs at network retail pharmacies and mail order pharmacies. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. 8
Depending on your income and institutional status, you may have to pay 15% to 25% of the cost of your drugs. Please refer to the Evidence of Coverage booklet for more details. Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay nothing for all drugs. 9
Summary of Medi-Cal (Medicaid) -Covered Benefits COMPREHENSIVE WRITTEN STATEMENT The tables in this section show the benefits that Medi-Cal offers to eligible beneficiaries. For each benefit, you can see what Original Medi-Cal (Medi-Cal alone) covers and what our plan covers. You may not qualify for all of the Medi-Cal benefits listed. If you qualify for a Medi-Cal benefit that CCHP Senior Select Program (HMO SNP) does not offer, then please contact our Member Services Center. We may be able to help you find the right provider and coordinate the benefit for you. Please review above Sections of this Summary of Benefits for more information on the benefits you will receive as part of CCHP Senior Select Program (HMO SNP). All Members Who Qualify for Full Medi-Cal May Receive the Following Medi-Cal and Health Plan Services: State of California Medi-Cal (Medicaid) Program Covered Benefits for Dual Eligible (Medicare and Medi-Cal Beneficiaries) CCHP Senior Select Program Benefit Category Medi-Cal (Medicaid) 1 Inpatient hospital services (HMO SNP) No limit to the number of days covered by the plan each hospital stay. $0 copay. 2 Outpatient hospital services Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. $0 copay for each Medicare-covered ambulatory surgical center visit. 3 Rural health clinic services 4 Federally qualified health center services $0 copay for each Medicare-covered outpatient hospital facility visit. 5 Laboratory 10
State of California Medi-Cal (Medicaid) Program Covered Benefits for Dual Eligible (Medicare and Medi-Cal Beneficiaries) Benefit Category Medi-Cal (Medicaid) CCHP Senior Select Program (HMO SNP) services 6 X-rays : - Lab services - Diagnostic procedures and tests 7 Skilled nursing facility care for over 21 years of age Subacute care 8 Family planning services & supplies 9 Physician services 11 : - X-rays - Diagnostic radiology services (not including X-rays) - Therapeutic radiology services Plan covers up to 100 days each benefit period. No prior hospital stay is required. $0 copay for SNF You must go to network doctors, specialists, and hospitals. Referral required for network hospitals and specialists (for certain benefits). $0 copay for each Medicarecovered primary care doctor visit.
State of California Medi-Cal (Medicaid) Program Covered Benefits for Dual Eligible (Medicare and Medi-Cal Beneficiaries) CCHP Senior Select Program Benefit Category Medi-Cal (Medicaid) (HMO SNP) $0 copay for each Medicarecovered specialist visit. 10 Medical & surgical dental services 11 Ophthalmologist services 12 Optometry services 13 Nurse anesthetist services 14 Medical supplies (does not include incontinence creams and washes products) 15 Durable medical equipment 12 dental benefits. diagnosis and treatment for diseases and conditions of the eye. $0 copay for up to 1 supplemental routine eye exam(s) every year. diagnosis and treatment for diseases and conditions of the eye. $0 copay for up to 1 supplemental routine eye exam(s) every year. items.
State of California Medi-Cal (Medicaid) Program Covered Benefits for Dual Eligible (Medicare and Medi-Cal Beneficiaries) CCHP Senior Select Program Benefit Category Medi-Cal (Medicaid) (HMO SNP) 16 Hearing aids durable medical equipment. 17 Enteral formulae 18 Licensed midwife services 19 Home health services through a home health agency (including home health nursing and aide services, physical and occupational therapy, speech pathology and audiology services, intermittent nursing, home health aid care, medical supplies, equipment and appliances) 20 Physical therapy and related services 21 Rehabilitation facilities benefits. home health visits. Physical Therapy visits. 13
State of California Medi-Cal (Medicaid) Program Covered Benefits for Dual Eligible (Medicare and Medi-Cal Beneficiaries) Benefit Category Medi-Cal (Medicaid) CCHP Senior Select Program (HMO SNP) Occupational Therapy visits. Physical Therapy and/or Speech and Language Pathology visits. 22 Clinic (Organized outpatient clinic, Indian Health Services, alternate birthing centers, ambulatory surgical centers) 23 Occupational therapy 24 Pharmaceutical services and prescribed drugs $0 copay for drugs excluded from Medicare Part D coverage. visits. Occupational Therapy visits. Drugs covered under Medicare Part B $0 copay for Medicare Part B drugs. $0 yearly deductible for Medicare Part B drugs. $0 copay for Part B chemotherapy drugs and other Part-B drugs. Drugs covered under Medicare Part D You pay a $0 annual deductible. 14
State of California Medi-Cal (Medicaid) Program Covered Benefits for Dual Eligible (Medicare and Medi-Cal Beneficiaries) Benefit Category Medi-Cal (Medicaid) CCHP Senior Select Program (HMO SNP) Initial Coverage Depending on your income and institutional status, you pay the following: 15 For generic drugs (including brand drugs treated as generic), either: - A $0 copay or - A $1.20 copay or - A $2.95 copay For all other drugs, either: - A $0 copay or - A $3.60 copay or - A $7.40 copay. Retail Pharmacy You can get drugs the following way(s): - one-month (31-day) supply - two-month (60-day) supply - three-month (90-day) supply Long Term Care Pharmacy You can get drugs the following way(s): - one-month (31-day) supply of generic drugs - one-month (31-day) supply of brand drugs Please note that brand drugs must be dispensed incrementally in long-term care facilities. Generic drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/collection when less than a one-month supply is dispensed.
State of California Medi-Cal (Medicaid) Program Covered Benefits for Dual Eligible (Medicare and Medi-Cal Beneficiaries) Benefit Category Medi-Cal (Medicaid) CCHP Senior Select Program (HMO SNP) Mail Order You can get drugs the following way(s): - three-month (90-day) supply Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,850, you pay a $0 copay. Out-of-Network Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal costsharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from CCHP Senior Select Program (HMO SNP). You can get out-of-network drugs the following way: - one-month (31-day) supply Out-of-Network Initial Coverage Depending on your income and institutional status, you will be reimbursed by CCHP Senior Select Program (HMO SNP) up to the plan's cost of the drug minus the following: 16 For generic drugs purchased outof-network (including brand drugs
State of California Medi-Cal (Medicaid) Program Covered Benefits for Dual Eligible (Medicare and Medi-Cal Beneficiaries) Benefit Category Medi-Cal (Medicaid) CCHP Senior Select Program (HMO SNP) treated as generic), either: - A $0 copay or - A $1.20 copay or - A $2.95 copay For all other drugs purchased outof-network, either: - A $0 copay or - A $3.60 copay or - A $7.40copay. Out-of-Network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,850, you will be reimbursed in full for drugs purchased out-of-network. 25 Prosthetic appliances (Orthotic appliances) prosthetic eyes 26 Comprehensive Perinatal Services Program (Preventive services) 27 Adult day health care 28 Chronic dialysis services prosthetic devices. renal dialysis. 17
State of California Medi-Cal (Medicaid) Program Covered Benefits for Dual Eligible (Medicare and Medi-Cal Beneficiaries) Benefit Category Medi-Cal (Medicaid) CCHP Senior Select Program (HMO SNP) kidney disease education 29 Rehabilitation services (ADHC, chronic dialysis, outpatient heroin detoxification, rehabilitative mental health, drug Medi- Cal, independent rehabilitation centers) 30 Institutes for Mental Diseases (for under 21 years of age and over 65 years of age, including inpatient psychiatric care) visits. You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. $0 copay. 31 Intermediate Care Facility 32 Nurse midwife 33 - Hospice 34 TB-related services 18 Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice.
State of California Medi-Cal (Medicaid) Program Covered Benefits for Dual Eligible (Medicare and Medi-Cal Beneficiaries) CCHP Senior Select Program Benefit Category Medi-Cal (Medicaid) (HMO SNP) 35 Respiratory care for ventilatordependent patients 36 Family nurse practitioner 37 Rural primary care hospital 38 Nonmedical health facilities benefits. benefits. office visits. 39 Emergency hospital services 40 Transportation (State provides emergency and nonemergency medical transportation. Meets federal requirement for assurance of transportation to medically necessary services) emergency room visits. Worldwide coverage. ambulance benefits. $0 copay for up to 24 one-way trip(s) to plan-approved location every year. 19
445 Grant Avenue, Suite 700, San Francisco, CA 94108 Tel 1-415-955-8800 Fax 1-415-955-8818 www.cchphealthplan.com/medicare