H5859_1065_CO_1016 CMS Accepted

2016 CareOregon Advantage Plus (HMO-POS SNP) Summary of Benefits For Oregon counties: Clackamas, Clatsop, Columbia, Jackson, Josephine, Marion, Multnomah, Polk, Tillamook, Washington and Yamhill H5859_1065_CO_1016 CMS Accepted

CAREOREGON ADVANTAGE PLUS (HMO-POS SNP) (A Medicare Advantage Health Maintenance Organization with Point of Service Option (HMO-POS) offered by HEALTH PLAN OF CAREOREGON, INC. with a Medicare contract.) 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. Tips for comparing your Medicare choices: This Summary of Benefits booklet gives you a summary of what CareOregon Advantage Plus (HMO- POS 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 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits This document is available in other formats such as Braille or large print. This document may be available in a non-english language. For additional information, call us at 503-416-4279 or toll free at 1-888-712-3258. TTY/TDD users can call 1-800-735-2900 or 7-1-1. CareOregon Advantage Plus is an HMO-POS SNP with a Medicare/Medicaid contract. Enrollment in CareOregon Advantage Plus depends on contract renewal H5859_1065_CO_1016 CMS Accepted

Things to Know About Hours of Operation: From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m., Pacific time. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m., Pacific time. Phone Numbers and Website: If you are a member of this plan, call 503-416-4279 or toll free at 1-888-712-3258. TTY/TDD users can call 1-800-735-2900 or 7-1-1. If you are not a member of this plan, call 503-416-4279 or toll free at 1-888-712-3258. TTY/TDD users can call 1-800-735-2900 or 7-1-1. Our website: http://www.careoregonadvantage.org Who can join? To join, you must be entitled to Medicare Part A, be enrolled in Medicare Part B and The Oregon Health Plan, and live in our service area. Our service area includes the following counties in Oregon: Clackamas, Clatsop, Columbia, Jackson, Josephine, Marion, Multnomah, Polk, Tillamook, Washington, and Yamhill. Which doctors, hospitals, and pharmacies can I use? has a network of doctors, hospitals, pharmacies, and other providers. For some services you can use providers that are not in our network. 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.careoregonadvantage.org/providersearch). You can see our plan s pharmacy directory at our website (www.careoregonadvantage.org/pharmacy). 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. 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, www.careoregonadvantage.org/druglist. 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.

Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the monthly premium? How much is the deductible? $0 per month. In addition, you must keep paying your Medicare Part B premium. This plan has deductibles for some hospital and medical $0 or $147 per year for some in-network and out-ofnetwork services, depending on your level of Medicaid eligibility. This amount may change for 2016. $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 Medicarecovered services, depending on your level of Oregon Health Plan eligibility. Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers. $6,700 for services you receive from any provider. Is there any limit on how much I will pay for my covered services? Your limit for services received from in-network providers will count toward this limit. 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. Refer to the Medicare & You handbook for Medicare-covered For Oregon Health Plancovered services, refer to the Medicaid Coverage section in this document. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Is there a limit on how much the plan will pay? Our plan has a coverage limit every year for certain innetwork benefits. Contact us for the services that apply. 3

Outpatient Care and Services Covered Medical and Hospital Benefits Acupuncture Ambulance Chiropractic Care 1,2 Dental Services Diabetes Supplies and Services 1 Not covered Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): Diabetes monitoring supplies: In-network: You pay nothing Diabetes self-management training: In-network: You pay nothing Therapeutic shoes or inserts: In-network: You pay nothing Diagnostic radiology services (such as MRIs, CT scans): Diagnostic Tests, Lab and Radiology Services, and X-rays 2 (Costs for these services may vary based on place of service) Doctor s Office Visits 2 Diagnostic tests and procedures: Lab services: Outpatient x-rays: Therapeutic radiology services (such as radiation treatment for cancer): Primary care physician visit: Out-of-network: 20% of the cost. There is a limit to how much our plan will pay. Specialist visit: Out-of-network: 20% of the cost. There is a limit to how much our plan will pay. Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 4

Outpatient Care and Services Durable Medical Equipment 1 (wheelchairs, oxygen, etc.) Covered Medical and Hospital Benefits Emergency Care 0% or 20% of the cost ( up to $75) Foot Care 2 (podiatry services) Hearing Services Home Health Care 1,2 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: Routine foot care: In-network: You pay nothing. You are covered for up to 2 visits every year. Exam to diagnose and treat hearing and balance issues: In-network: You pay nothing 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. Mental Health Care 1,2 The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you re admitted as an inpatient and ends when you haven t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There s no limit to the number of benefit periods. 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. In-network: In 2015, the amounts for each benefit Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 5

Outpatient Care and Services Covered Medical and Hospital Benefits period were $0 or: $1,260 deductible for days 1 through 60 $315 copay per day for days 61 through 90 $630 copay per day for 60 lifetime reserve days These amounts may change for 2016. Outpatient group therapy visit: Outpatient individual therapy visit: Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): Outpatient Rehabilitation 1,2 Outpatient Substance Abuse 1,2 Outpatient Surgery 1,2 Over-the-Counter Items Occupational therapy visit: Physical therapy and speech and language therapy visit: Group therapy visit: Individual therapy visit: Ambulatory surgical center: Outpatient hospital: Please visit our website to see our list of covered overthe-counter items. Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 6

Outpatient Care and Services Covered Medical and Hospital Benefits Prosthetic Devices 1 (braces, artificial limbs, etc.) Renal Dialysis 2 Transportation Prosthetic devices: Related medical supplies: Not covered Urgently Needed Services 0% or 20% of the cost (up to $65) Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): Routine eye exam: In-network: $0 copayment. You are covered for up to 1 visit every year. Contact lenses: In-network: $0 copayment. You are covered for up to 1 every two years. Eyeglasses (frames and lenses): In-network: $0 copayment. You are covered for up to 1 every two years. Eyeglasses or contact lenses after cataract surgery: In-network: $0 copayment Our plan pays up to $110 every two years for contact lenses and eyeglasses (frames and lenses) from an innetwork provider. Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 7

Covered Medical and Hospital Benefits Preventive Care 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 (one-time) Yearly Wellness visit In-network: You pay nothing Any additional preventive services approved by Medicare during the contract year will be covered. Annual physical exam: In-network: You pay nothing Hospice Hospice You pay nothing for hospice care from a Medicare-certified 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. Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 8

Covered Medical and Hospital Benefits Inpatient Care The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you re admitted as an inpatient and ends when you haven t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There s no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay. Inpatient Hospital Care 1,2 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. In-network: In 2015, the amounts for each benefit period were $0 or: $1,260 deductible for days 1 through 60 $315 copay per day for days 61 through 90 $630 copay per day for 60 lifetime reserve days These amounts may change for 2016. Inpatient Mental Health Care For inpatient mental health care, see the Mental Health Care section of this booklet. Our plan covers up to 100 days in a SNF. Skilled Nursing Facility (SNF) 1,2 In-network: In 2015, the amounts for each benefit period were $0 or: You pay nothing for days 1 through 20 $157.50 copay per day for days 21 through 100 These amounts may change for 2016. Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 9

Prescription Drug Benefits How much do I pay? For Part B drugs such as chemotherapy drugs 1 : 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 Initial Coverage Stage 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. Catastrophic Coverage Catastrophic Coverage Stage 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. Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. 10

Medicaid Covered Services In this section, you can see a summary of the Medicaid benefits you may receive through the Oregon Health Plan. As long as you are eligible for the Oregon Health Plan and Medicare Parts A and B, the Medicaid Benefits Packages you can have through the Oregon Health Plan are the QMB + OHP Limited Drug Benefit Package, or the OHP with Limited Drug Benefit Package. Please contact your State Medicaid case worker if you do not know which benefit package you have through the Oregon Health Plan. This section does not list every Medicaid service covered or list every limitation or exclusion. To get a complete list of Medicaid benefits, please contact your Medicaid health plan Customer Service. You must be eligible for the Oregon Health Plan, Medicaid in order to receive the benefits listed in this section. Oregon Health Plan (OHP) Medicaid Benefit Packages: QMB + OHP with Limited Drug Benefit Package This benefit package is for people who qualify to have their Medicare Parts A and B cost sharing paid for by Medicaid. If you receive the QMB + OHP with Limited Drug Benefit Package you get the benefits listed in the chart below. The cost sharing amounts listed in Section II for the Medicare Parts A and B covered services are paid for you by your Medicaid health plan. Your provider cannot bill you for any amounts beyond what your Medicare and Medicaid plans pay. You will still have to pay your Medicare Part D prescription drug cost sharing. OHP with Limited Drug Benefit Package This benefit package is for people who only qualify to have their Medicare Parts A and B cost sharing paid for by Medicaid for services normally covered by the Oregon Health Plan. If you receive the OHP with Limited Drug Benefit Package you get the benefits listed in the chart below. The cost sharing amounts listed in Section II for Medicare Parts A and B covered services will be covered only for services that the Oregon Health Plan would normally cover. Your provider cannot balance bill you for any amounts beyond what your Medicare and Medicaid plans pay for services normally covered by the Oregon Health Plan. If you receive a Medicare covered service that is not normally covered by the Oregon Health Plan you will have to pay the Medicare Parts A and B cost sharing yourself. See page 17 for more information on services not covered by the Oregon Health Plan. You will still have to pay your Medicare Part D prescription drug cost sharing. 11

Below is a list of services that are covered by the Oregon Health Plan Medicaid and your Medicaidmanaged care plan (does not include every service available): Benefit Category Premium and Other Important Information Doctor and Hospital Choice (For more information, see the Emergency and Urgently Needed Care sections) Inpatient Care Benefit Category Inpatient Hospital Care Inpatient Mental Health Care Skilled Nursing Facility (In a Medicare-certified skilled nursing facility) Home Health Care (Includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.) Hospice Oregon Health Plan Medicaid (member costs) This is a brief summary. Please refer to OHP member handbook for a detailed description of Medicaid benefits available to eligible Oregonians. Allows Fee For Service patients to go to any provider that accepts Medicaid. Oregon Health Plan Medicaid (member costs) outpatient Your Medicaid-Managed Care Plan (member costs) This is a brief summary. Please refer to your Medicaid member handbook for a detailed description of Medicaid benefits available to eligible Oregonians. All cost sharing in this summary of benefits is based on your level of Medicaid eligibility. Allows patients to go to any provider that accepts Medicaid. You must go to network doctors, specialists, and hospitals. Referral required for network hospitals and specialists (for certain benefits). Your Medicaid-Managed Care Plan (member costs) outpatient 12

Outpatient Care Benefit Category Doctor Office Visits Chiropractic Services Podiatry Services Outpatient Mental Health Care Outpatient Substance Abuse Care Outpatient Services/Surgery Ambulance Services (Medically necessary ambulance services) Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care.) Urgently Needed Care (This is NOT emergency care, and in most cases, is out of the service area.) Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy) Oregon Health Plan Medicaid (member costs) outpatient outpatient outpatient outpatient outpatient outpatient outpatient outpatient Your Medicaid-Managed Care Plan (member costs) outpatient outpatient outpatient outpatient outpatient outpatient outpatient outpatient 13

Outpatient Medical Services and Supplies Benefit Category Durable Medical Equipment Prosthetic Devices Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies Diagnostic Tests, X-Rays, and Lab Services Preventive Services Oregon Health Plan Medicaid (member costs) Your Medicaid-Managed Care Plan (member costs) Bone Mass Measurement Colorectal Screening Exams Routine Immunizations Mammograms (Annual Screening) Covered annually under Medicaid Pap Smears and Pelvic Exams Covered annually under Medicaid Prostate Cancer Screening Exams End-Stage Renal Disease outpatient * outpatient * services, except immunizations given for travel and other reasons. outpatient outpatient outpatient 14 outpatient outpatient pap smears outpatient outpatient *Some services may not include a copayment if accessed in settings such as outpatient diagnostic settings at a hospital.

Benefit Category Prescription Drugs Dental Services Oregon Health Plan Medicaid (member costs) $0 copayment for preferred generic and preferred brand-name drugs $1 - $3 copayment for generic drugs and non-preferred brand name drugs. Mental health drugs are covered by the state and not your Medicaid managed care health plan. $3 copayment for restorative treatment. $0 copayment for Medicaid covered Dental diagnostic and preventative routine checkup services 15 Your Medicaid-Managed Care Plan (member costs) Part D medications - Covered by your Medicare health plan (See page 10 for details) Part B Medications - You pay $0 yearly deductible for Part B-covered drugs. In-Network $0 copayment for Medicaid covered service (not including Part B-covered chemotherapy drugs). Prior Authorization rules may apply In-Network $0 copayment for Medicaid covered service for Part B- covered chemotherapy drugs. Prior Authorization rules may apply Medicaid-covered Medications - Over the Counter drugs when accompanied by a prescription Benzodiazepine and Barbiturate drugs when accompanied by a prescription Drugs when used for the symptomatic relief of cough or colds when accompanied by a prescription Vitamins and minerals when accompanied by a prescription Mental Health Drugs are not covered by your Medicaid Managed Care Plan. Your Medicaid Managed Care Plan uses a drug list (formulary). You can see the formulary on the web site of your Managed Care Plan. outpatient

Hearing Services Vision Services Physical Exams outpatient outpatient outpatient Health/Wellness Education Not covered Not covered Other Non-Covered Medicare services that will be covered by the Oregon Health Plan: Preventative Services Maternity Case Management, including nutritional counseling. Maternity and newborn care Well-child exams and immunizations Family Planning Services: Including birth control pills, condoms, contraceptive implants, and Depo-Provera Sterilizations outpatient X-ray, lab, routine immunization and family planning services outpatient outpatient outpatient In-Network outpatient X-ray, lab, routine immunization and family planning In-Network Preventative and Family Planning Prior Authorization rules may apply Other Oregon Health Plan Services: Death with dignity services* Abortions* Services not covered by your Medicaid Managed Care Plan: Death with dignity services* Abortions* *Please Note: these services are covered by the state and not by your Medicaid Managed Care health plan. 16

Services That Are Not Covered by the Oregon Health Plan Medicaid (Exclusions): Not all medical treatments are covered. When you need medical treatment, contact your Primary Care Provider. These are some of the exclusions (does not include every exclusion): Medicare Part D covered prescription drugs Conditions where a home treatment is effective, such as applying an ointment, resting a painful joint, drinking plenty of fluids, or a soft diet. Such conditions include: o Canker sores o Diaper rash o Corns/calluses o Sunburn o Food poisoning o Sprains Personal comfort or convenience items (radios, telephones, hot tubs, treadmills, etc.) Services that are primarily cosmetic, such as: o Benign skin tumors o Cosmetic surgery o Removal of scars Conditions where treatment is not normally effective, such as: o Some back surgery o TMJ surgery o Some transplants Services performed by an immediate relative or member of your household Any services received outside the United States Non-emergency care if you go to a provider who is not a network provider. Other non-covered services include, but are not limited to, the following: o Circumcision (routine) o Weight loss program o Infertility services If you have questions about covered or non-covered services, contact your Medicaid Managed Health plan Customer Service. 17

CareOregon Advantage Customer Service CALL: 503-416-4279 or toll free 1-888-712-3258 TTY/TDD: 1-800-735-2900 or 7-1-1 HOURS OF OPERATION: every day, 8 a.m. to 8 p.m. WEBSITE: www.careoregonadvantage.org