Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services

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. section i - introduction to summary of benefits 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 Denver Health Medicare Choice (HMO SNP)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what Denver Health Medicare Choice (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 Denver Health Medicare Choice (HMO SNP) 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 and large print. This document may be available in a non-english language. For additional information, call us at 1-877-956-2111. TTY 711 Este documento puede estar disponible en un idioma que no sea ingles. Para obtener mas informacion llamenos al 1-877-956-2111. TTY 711 Things to Know About Denver Health Medicare Choice (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. Mountain time. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Mountain time. H5608_1065_001SB16v2_accepted

Denver Health Medicare Choice (HMO SNP) Phone Numbers and Website If you are a member of this plan, call toll-free 1-877-956-2111. TTY 711 If you are not a member of this plan, call toll-free 1-877-956-2111. TTY 711 Our website: www.denverhealthmedicalplan.org Who can join? To join Denver Health Medicare Choice (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and Full Medicaid, and live in our service area. Our service area includes the following county in Colorado: Denver Which doctors, hospitals, and pharmacies can I use? Denver Health Medicare Choice (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 services. You must generally use the network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan s provider directory at our website (https://www.viiad.com/dhmp/provider_main.asp) You can see our plan s pharmacy directory at our website (www.denverhealthmedicalplan.org). 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, http://www.denverhealthmedicalplan.org 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.

section ii - summary of benefits Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the $0 per month. In addition, you must keep paying your Medicare Part B premium. monthly premium? How much is the This plan has deductibles for some hospital and medical services, and Part D deductible? prescription drugs. $0 or $166 per year for in-network services, depending on your level of Medicaid eligibility. $0 to $74 per year for Part D prescription drugs. 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? Covered Medical And Hospital Benefits Note: 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 Medicare-covered services, depending on your level of Medicaid eligibility. Your yearly limit(s) in this plan: $6,700 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. Refer to the Medicare &You handbook for Medicare-covered services. For Medicaid-covered services, refer to the Medicaid Coverage section in this document. Please note that you will still need to pay your monthly premiums and costsharing 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. Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Outpatient Care and Services Acupuncture Not Covered Ambulance If you are admitted to the hospital, you do not have to pay for the ambulance services. 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): Dental Services 1,2 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): Diabetes Supplies and Services 1,2 Diabetes monitoring supplies: Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: Diabetic glucometers and test strips are limited to Nipro products. (Glucometers and test strips made by other manufactures require an organizational determination)

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 Doctor s Office Visits 1,2 Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 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): 0% or 20% of the cost Authorization rules may apply. Primary care physician visit: Specialist visit: Emergency Care (up to $75) If you are admitted to the hospital within 3 days, you do not have to pay your share of the cost for emergency care. See the Inpatient Hospital Care section of this booklet for other costs. Foot Care (podiatry Foot exams and treatment if you have diabetes-related nerve damage and/or services) 1,2 meet certain conditions: Hearing Services 2 Exam to diagnose and treat hearing and balance issues: Routine Hearing exam (for up to 1 every three years): $0 copay Hearing aid fitting/evaluation (for up to 1 every three years): $0 copay Hearing aid: $0 copay Our plan pays up to $1,500 every three years for hearing aids. Home Health Care 1,2 You pay nothing 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. 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 2016 the amounts for each benefit period are $0 or: $1,288 deductible for days 1 through 60 $322 copay per day for days 61 through 90 $644 copay per day for 60 lifetime reserve days. These amounts may change in 2017. Outpatient group therapy visit: Outpatient individual therapy visit: Authorization rules may apply.

Outpatient Rehabilitation 1,2 Outpatient Substance Abuse 1,2 Outpatient Surgery 1,2 Over-the-Counter Items Prosthetic Devices (braces, artificial limbs, etc) 1 Renal Dialysis 1,2 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): Occupational therapy visit: Physical therapy and speech and language therapy visit: Authorization rules may apply. Group therapy visit: Individual therapy visit: Authorization rules may apply. Ambulatory surgical center: Outpatient hospital: Authorization rules may apply. Not Covered Prosthetic devices: Related medical supplies: Authorization rules may apply. Authorization rules may apply. Transportation 1 You pay nothing 12 round trip(s) to plan-approved location every year Urgently Needed Services (up to $65) If you are admitted to the hospital within 3 days, you do not have to pay your share of the cost for urgently needed services. See the Inpatient Hospital Care section of this booklet for other costs. Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): Routine eye exam (for up to 1 every year): $0 copay Contact lenses: $0 copay Eyeglasses (frames and lenses) (for up to 1 every year): $0 copay Eyeglasses or contact lenses after cataract surgery: $0 copay Our plan pays up to $300 every year for contact lenses and eyeglasses (frames and lenses).

Preventive Care You pay nothing 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 Any additional preventive services approved by Medicare during the contract year will be covered. Hospice Inpatient Care Inpatient Hospital Care 1,2 Annual physical exam: You pay nothing 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. You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice. 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 days, your inpatient hospital coverage will be limited to 90 days. In 2016, the amount for each benefit period are $0 or: $1,288 deductible for days 1 through 60. $322 copay per day for days 61 through 90. $644 copay per day for 60 lifetime reserve days. These amounts may change for 2017.

Inpatient Hospital Care Cont. Inpatient Mental Health Care Skilled Nursing Facility (SNF) 1,2 You will not be charged additional cost sharing for professional services. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. For inpatient mental health care, see the Mental Health Care section of this booklet. Our plan covers up to 100 days in a SNF In 2016, the amount for each benefit period are $0 or: You pay nothing for days 1 through 20 $161 copay per day for days 21 through 100 Prescription Drug Benefits How much do I pay? Initial Coverage These amounts may change in 2017. For Part B drugs such as chemotherapy drugs 1 : Other Part B drugs 1 : 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. Retail Pharmacy Contact your plan if you have questions about cost-sharing or billing less than a one-month supply is dispensed. You can get drugs the following way(s): One-month (30) day supply Three-month (90) day supply Long term care pharmacy Long term care pharmacies must dispense brand name drugs in amounts less than a 14-day supply at a time. They may also dispense less than a month s supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. Mail Order Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed. You can get drugs the following way(s) Three-month (90-day) supply

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. 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 cost-sharing 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 Denver Health Medicare Choice (HMO SNP). You can get out-of-network drugs the following way(s): -10 day supply Out-of-Network Initial Coverage Depending on your income and institutional status, you will be reimbursed by Denver Health Medicare Choice (HMO SNP) up to the plan s cost of the drug minus the following: For generic drugs purchased out-of-network (including brand drugs treated as generic), either: -A $0 copay; or -A $1.20 copay; or -A $2.95 copay; or -25% coinsurance For all other drugs purchased out-of-network, either: -A $0 copay; or -A $3.60 copay; or -A $7.40 copay; or -25% coinsurance 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.

Summary of Benefits For Contract H5608, Plan 001 Denver Health Medicare Choice (HMO SNP) Medicare Part A (hospital insurance), Part B (Medical Insurance) and Part D (prescription drug coverage) benefits provide your primary insurance coverage. Your eligibility for Title XIX Medicaid pays all remaining hospital, medical and prescription drug coverage cost-sharing including deductibles and coinsurance. The services listed below are available only to those SNP members eligible under Medicaid for Medical Services Benefit Category Medicaid Denver Health Medicare Choice (HMO SNP) Inpatient Hospital Care (includes substance abuse and rehabilitation) Benefit Covered at 100% In 2016, the amount for each benefit period are $0 or: $1,288 deductible for days 1 through 60 $10.00 copay per covered day or $322 copay per day for 50% of the averaged allowable days 61 through 90. $644 copay per day for 60 daily rate whichever is less under lifetime reserve days. Medicaid fee-for-service (FFS). These amounts may change for 2017. Inpatient Mental Health Care Benefit covered at 100%. Copay may apply. In 2016 the amounts for each benefit period are $0 or: $1,288 deductible for days 1 through 60 $322 copay per day for days 61 through 90 $644 copay per day for 60 lifetime reserve days. Skilled Nursing Facility Benefit covered at 100%. $0 copay. These amounts may change in 2017. Our plan covers up to 100 days in a SNF In 2016, the amount for each benefit period are $0 or: Acute Home Health and Long Term with Acute Episode Home Health Benefit covered at 100%. $0 copay. You pay nothing for days 1 through 20 $161 copay per day for days 21 through 100 These amounts may change in 2017. Covered, $0 copay

Benefit Category Medicaid Denver Health Medicare Choice (HMO SNP) Home Health Services Benefit covered at 100%. provided specifically as benefits through the Home and Community Based Services Program $0 copay. Long Term Home Health Benefit covered at 100%. $0 copay. Hospice Benefit covered at 100%. $0 copay. Primary Care Benefit covered at 100%. Covered, Original Medicare $2.00 copay per visit under Specialty Care Benefit covered at 100%. $2.00 copay per visit under Physical Exams Benefit covered at 100%. $2.00 copay per visit under Podiatry, medically necessary Benefit covered at 100%. $2.00 copay per visit under Chiropractic Care, Medicare- Not a covered benefit under Covered Medicaid Choice or Outpatient Substance Abuse Benefit covered at 100%. $3.00, $2.00 copay per visit or $.50 per unit of service copay (1 unit = 15 minutes) under Group therapy visit: 0% or 20% of the cost Individual therapy visit: 0% or 20% of the cost

Benefit Category Medicaid Denver Health Medicare Choice (HMO SNP) Outpatient Mental Health Benefit Covered at 100% Outpatient group therapy visit: 0% or 20% of the cost Outpatient individual therapy visit: Physical Therapy, Occupational Therapy/Speech Therapy $3.00, $2.00 copay per visit or $.50 per unit of service copay (1 unit = 15 minutes) under Benefit Covered at 100%. Physical therapy and speech and language therapy visit: 0% or 20% of the cost $3.00 copay per visit under Ambulance Benefit Covered at 100%. $0 copay under Medicaid Choice and Emergency Care Benefit Covered at 100%. $0 copay under Medicaid Choice and Urgent Care Benefit Covered at 100%. $0 copay under Medicaid Choice and Outpatient Services/Surgery Benefit Covered at 100%. $3.00 copay per visit under Outpatient Rehabilitation Benefit Covered at 100%. If you are admitted to the hospital, you do not have to pay for the ambulance services. (up to $75) If you are admitted to the hospital within 3 days, you do not have to pay your share of the cost for emergency care. See the Inpatient Hospital Care section of this booklet for other costs. (up to $65) If you are admitted to the hospital within 3 days, you do not have to pay your share of the cost for urgently needed services. See the Inpatient Hospital Care section of this booklet for other costs. Ambulatory surgical center: 0% or 20% of the cost Outpatient hospital: 0% or 20% of the cost Occupational therapy visit: 0% or 20% of the cost $3.00 copay per visit under

Benefit Category Medicaid Denver Health Medicare Choice (HMO SNP) Durable Medical Equipment Benefit Covered at 100%. Including Oxygen Prosthetic Devices Benefit Covered at 100%. Diabetes self-monitoring, training, nutrition therapy and supplies $3.00 copay per visit under Benefit Covered at 100%. Lab Services Benefit Covered at 100%. Prosthetic devices: 0% or 20% of the cost Related medical supplies: 0% or 20% of the cost Diabetes monitoring supplies: 0% or 20% of the cost Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: 0% or 20% of the cost X-Rays Benefit Covered at 100%. Diagnostic Radiology Benefit Covered at 100%. Therapeutic Radiology Benefit Covered at 100%.

Benefit Category Medicaid Denver Health Medicare Choice (HMO SNP) Bone Mass Measurement Benefit Covered at 100%. Colorectal Screening Benefit Covered at 100%. Immunizations Benefit Covered at 100%. $2.00 copay per visit under Mammograms Benefit Covered at 100%. Pap Smears Benefit Covered at 100%. $0 copay under Medicaid Choice and Prostate Cancer Screenings Benefit Covered at 100%. $2.00 copay per visit under $1.00 copay per claim under Renal Dialysis Benefit Covered at 100%. $3.00 copay per visit under

Benefit Category Medicaid Denver Health Medicare Choice (HMO SNP) Part D Prescription Drugs - covered under Medicare $0 Premium Medicaid benefits cover the following Medicare exclusions at 100%: Cough and Cold Products, Over-the-Counter Medications and certain allowed Prescription Vitamin and Mineral Products. $0 Deductible Initial Coverage Depending on your income and institutional status, you pay the following: $1.00 copay for generic drugs and $3.00 copay for brand name and single-source drugs under 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 Dental Medicaid benefits include: basic dental preventive, diagnostic and minor restorative dental services (such as x-rays and minor fillings), root canals, crowns, dentures, periodontal scaling, root planning. Dental benefit has an annual limit of $1,000 per state fiscal year (July 1st - June 30th) A $0 copay; or A $3.60 copay; or A $7.40 copay Extra Help copay applies to Part D Prescription Drugs. Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth):

Benefit Category Medicaid Denver Health Medicare Choice (HMO SNP) Hearing Aids Benefit is covered at 100% under Medicaid Choice. Our plan pays up to $1,500 every three years for hearing aids. Benefit is covered at 100% under Medicaid FFS for members under age 20 or adult members on the Supported Living Services (SLS) Waiver. $0 copay under Hearing Exams/Tests Benefits covered at 100%. $2.00 copay per visit under Eyewear Benefit covered at 100% and $0 copay under Medicaid Choice. Covered following eye surgery only and $2.00 copay per visit under Eye Exams Benefit Covered at 100%. Our plan pays up to $300 every year for contact lenses and eyeglasses (frames and lenses). $2.00 copay per visit under Transportation Benefit covered at 100%. $0 copay under Medicaid Choice and Health Club Membership Not a covered benefit under Medicaid Choice or Health/Wellness including smoking cessation, newsletters, health coaches/care management, nutritional training and Nursing Hotline Benefit covered at 100%. $0 copay under Medicaid Choice and Covered, $0 copay up to 12 round trips $0 copay Covered at Denver Parks & Recreation Centers Covered, $0 copay

Benefit Category Medicaid Denver Health Medicare Choice (HMO SNP) Interpreter Services Benefit covered at 100%. $0 copay under Medicaid Choice Interpreter services are available to help you get services. One interpretation is available for any language. and Spoken language interpreter services. Hearing interpreter services