Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a customer service representative at 503-574-8000 or 1-800-603-2340 (TTY: 711), 8am to 8pm (Pacific time), seven days a week. Understanding the Benefits Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services for which you routinely see a doctor. Visit www.providencehealthassurance.com or call 503-574-8000 or 1-800-603-2340 (TTY: 711) to view a copy of the EOC. Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select a new doctor. Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions. Understanding Important Rules In addition to your monthly plan premium (including $0 premium plans), you must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month. The Part B premium is covered for full-dual enrollees who are eligible for Providence Medicare Dual Plus (HMO SNP). Benefits, premiums and/or copayments/co-insurance may change on January 1, 2019. When selecting an HMO product, remember that except in emergency or urgent situations, we do not cover services by out-of-network providers (doctors who are not listed in the provider directory). Our HMO-POS plans allow you to see providers outside of our network (non-contracted providers). However, while we will pay for certain covered services provided by a noncontracted provider, the provider must agree to treat you. Except in an emergency or urgent situations, non-contracted providers may deny care. In addition, you will pay a higher co-pay for services received by non-contracted providers. Providence Medicare Dual Plus (HMO SNP) is a dual eligible special needs plan (D- SNP). Your ability to enroll will be based on verification that you are entitled to both Medicare and medical assistance from a state plan under Medicaid. Providence Medicare Advantage Plans is an HMO, HMO-POS, and HMO SNP plan with Medicare and Oregon Health Plan contracts. Enrollment in Providence Medicare Advantage Plans depends on contract renewal. You must continue to pay your Medicare Part B premium. H9047_2019PHA86_C
Summary of Benefits January 1, 2019 December 31, 2019 Providence Medicare Dual Plus (HMO SNP) This plan is available in Clackamas, Multnomah and Washington counties in Oregon for members who are eligible for Medicare and full Oregon Health Plan (Medicaid) benefits. 2019
Providence Medicare Advantage Plans is an HMO, HMO-POS, and HMO SNP with Medicare and Oregon Health Plan contracts. Enrollment in Providence Medicare Advantage Plans depends on contract renewal. This booklet gives you a summary of what Providence Medicare Dual Plus (HMO SNP) covers and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please refer to The Evidence of Coverage. To obtain a copy of the EOC please contact customer service at 1-800-603-2340 or visit us online to request one at www.providencehealthassurance.com/eoc. If you have any questions about this plan s benefits or costs, please contact Providence Health Assurance for details. 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://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. THINGS TO KNOW ABOUT PROVIDENCE MEDICARE DUAL PLUS (HMO-SNP) You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Pacific Time. PROVIDENCE MEDICARE DUAL PLUS (HMO SNP), PHONE NUMBERS AND WEBSITE If you are a member of this plan, call toll free 1-800-603-2340, TTY users call 711. If you are not a member of this plan, call toll free 1-800-457-6064, TTY users call 711. Our website: www.providencehealthassurance.com Our plan members get all of the benefits covered by Original Medicare. Some of the extra benefits are outlined in this booklet. WHO CAN JOIN To join Providence Medicare Dual Plus (HMO SNP) you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in Oregon: Clackamas, Multnomah and Washington counties in Oregon for members who are eligible for Medicare and full Oregon Health Plan (Medicaid) benefits. You can see our plan s Provider and Pharmacy Directory at our website: www.providencehealthassurance.com/providerdirectoy or, call us and we will send you a copy of the Provider and Pharmacy Directory. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, www.providencehealthassurance.com/formulary
Providence Medicare Dual Plus (HMO SNP) Monthly Plan Premium Deductible Maximum Out of Pocket Responsibility $0 You must continue to pay your Medicare Part B premium. $0 or $183 per year* $0 per year for Part D prescription drugs. In this plan, you might pay nothing for Medicare covered services, depending on your level of Oregon Health Plan eligibility. Your yearly limit(s) in this plan In-network: $3,400 For Oregon Health Plan covered services, refer to the Medicare Coverage section of this document. SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR $0 or: $1340 deductible for each benefit period. Inpatient Hospital Coverage $0 for days 1-60 1 $335 for days 61-90 $670 for days 91+ Outpatient Hospital Coverage 1 Doctor Visits 2 Primary Care Provider Visit Specialist visit *These amounts may change for 2019 and depends on your level of Medicaid eligibility. 0% or 20% of the total cost for each visit for each visit Preventive Care Emergency Care Urgently Needed Services You pay nothing, up to $120 If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care., up to $65 If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for urgent care.
Diagnostic Services/Labs/ Imaging 1 Vision Services Mental Health Services 1 Benefits Hearing Services 2 Medicare-covered Dental Services 1,2 Medicare-covered Diagnostic radiology services (such as MRIs, ultrasounds, CT Scans) Therapeutic radiology services Diagnostic test and procedures Lab Services Outpatient X-rays Routine eye exam Routine eyeglasses or contact lenses Inpatient visit Outpatient individual and group therapy visit $0 copay Allowance of up to $45 allowance per calendar year for a routine vision exam (including refraction) Allowance of up to $150 every two years for any combination of routine prescription eyewear. $0 or $1340 deductible $0 days 1-60 $0 or $335 days 61-90 Skilled Nursing Facility 1 You pay nothing for days 1-20 $0 or $167.50 copay per day for days 21-100 Physical therapy Ambulance 1 Transportation Medicare Part B Drugs 1 Not covered
Prescription Drug Benefits For Providence Medicare Dual Plus (HMO SNP) Plan Yearly deductible: Because there is no deductible for the plan, this payment stage does not apply to you. If you receive Extra Help to pay your prescription drugs, this payment stage does not apply to you. Initial Coverage You pay the following until your total yearly out-of-pocket costs reach $5,100. For generic drugs (including brand drugs treated as generic), either: $0 copay; or $1.25 copay; or $3.40 copay For all other drugs, either: $0 copay; or $3.80 copay; or $8.50 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, but may pay more than you pay at an in-network pharmacy. You may get drugs from a standard in-network pharmacy, but may pay more than you pay at a preferred in-network pharmacy. Coverage Gap Catastrophic Coverage Because there is no coverage gap for the plan, this payment stage does not apply to you. After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $5,100, you pay nothing for all drugs.
SUMMARY OF BENEFITS Summary of Oregon Health Plan (Medicaid) Covered Services In this section, you can see a summary of 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 with Limited Drug Benefit Package, or 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. Oregon Health Plan (OHP) Medicaid Benefits 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 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 14 for more information on services not covered by Oregon Health Plan. You will still have to pay your Medicare Part D prescription drug cost sharing.
SUMMARY OF BENEFITS Below is a list of services that are covered by the Oregon Health Plan Medicaid and your Medicaid- Managed 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 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 and rehabilitation services, home health aide services, etc.) Hospice Oregon Health Plan Medicaid (member costs) Your Medicaid- Managed Care Plan (member costs) This is a brief summary. Please refer to OHP member handbook This is a brief summary. Please refer for a detailed description of to OHP member handbook for a Medicaid benefits available to detailed description of Medicaid eligible Oregonians. benefits available to eligible All cost sharing in this summary Oregonians. of benefits is based on your level of Medicaid eligibility. Allows Fee for Service patients to go to any provider that accepts Medicaid. Inpatient Care You must go to network doctors, specialists, and hospitals. Referral required for network hospitals and specialists (for certain benefits) other health care provider for
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) Outpatient Care Oregon Health Plan Medicaid (member costs) other outpatient other outpatient other outpatient other outpatient other outpatient other outpatient other outpatient Your Medicaid-Managed Care Plan (member costs) $0 copay for visits to a doctor or other health care provider for Medicaid-covered outpatient
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 Bone Mass Measurement Colorectal Screening Exam Oregon Health Plan Medicaid (member costs) Preventive Services other outpatient other outpatient Your Medicaid-Managed Care Plan (member costs) Routine Immunizations services, except immunizations given for travel and other reasons. Mammograms (Annual Screening) Covered annually under Medicaid Pap Smears and Pelvic Exams Covered annually under Medicaid Prostate Cancer Screening Exams End-Stage Renal Disease other outpatient other outpatient
Prescription Drugs Preventive Services $0 copayment for preferred generic and preferred brand-name drugs. $0 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. Part D medications- Covered by your Medicare health plan (see page 7 for details) Part B Medications- You pay $0 yearly deductible for Part B- covered drugs. In-Network: $0 copay for Medicaid covered service (not including Part B-covered chemotherapy drugs). Prior Authorization rules may apply In-network: $0 copay 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 cold 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 website for your Managed Care Plan Dental Services Please refer to your OHP dental carrier for this information Please refer to your OHP dental carrier for this information
Hearing Services Vision Services Physical Exams SUMMARY OF BENEFITS Preventive Services 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 Other Oregon Health Plan Services: Death with dignity services* Termination of Pregnancy* *Please Note: These services are covered by the state not by your Medicaid Managed Care health plan. X- ray, lab, routine immunization and family planning In-network other health care provider for X- ray, lab, routine immunizations and family planning In-network Preventative and Family Planning Prior Authorization rules may apply. Services not covered by your Medicaid Managed Care Plan Death with dignity services * Termination of Pregnancy *
Services That Are Not Covered by the Oregon Health Plan Medicaid (Exclusions): Not all medical treatments are covered. When you need medical treatment, please 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 ointment, resting a painful joint, drinking plenty of fluids, or a soft diet. Such conditions include: Canker sores Diaper rash Corns/calluses Sunburn Food poisoning Sprains Personal comfort or convenience items (radios, telephones, hot tubs, treadmills, etc.) Services that are primarily cosmetic, such as: Benign skin tumors Cosmetic surgery Removal of scars Conditions where treatment is not normally effective such as: Some back surgery TMJ surgery 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 not a network provider Other non-covered services include, but are not limited to, the following: Weight loss program Infertility services If you have any questions about covered or non-covered services, contact your Medicaid Managed Health Plan Customer Service. This information is not a complete description of benefits. Call 1-800-603-2340, TTY users call 711 for more information. The Part B premium is covered for full-dual enrollees who are eligible for Providence Medicare Dual Plus. Premium, co- pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.