SUMMARY OF BENEFITS FOR

Blue Crss Cmmunity MMAI (Medicare-Medicaid Plan) SM SUMMARY OF BENEFITS FOR 2018 1-877-723-7702 (TTY/TDD: 711) We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai H0927_BEN_IL_SB18 Accepted 08092017 Effective January 2018

This is a summary f health services cvered by Blue Crss Cmmunity MMAI fr 2018. This is nly a summary. Please read the Member Handbk fr the full list f benefits. Blue Crss Cmmunity MMAI is a health plan that cntracts with bth Medicare and Illinis Medicaid t prvide benefits f bth prgrams t enrllees. It is fr peple with bth Medicare and Medicaid. Under Blue Crss Cmmunity MMAI yu can get yur Medicare and Medicaid services in ne health plan. A Blue Crss Cmmunity MMAI care crdinatr will help manage yur health care needs. This is nt a cmplete list. The benefit infrmatin is a brief summary, nt a cmplete descriptin f benefits. Fr mre infrmatin, cntact the plan r read the Blue Crss Cmmunity MMAI Member Handbk. Limitatins and restrictins may apply. Fr mre infrmatin, call Blue Crss Cmmunity MMAI Member Services at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Or read the Blue Crss Cmmunity MMAI Member Handbk. The List f Cvered Drugs and/r pharmacy and prvider netwrks may change thrughut the year. We will send yu a ntice befre we make a change that affects yu. Benefits may change n January 1 f each year. If yu speak Spanish, language assistance services, free f charge, are available t yu. Call 1-877-723-7702 (TTY/TDD: 711. We are available 24 hurs a day, seven (7) days a week. The call is free. Si habla españl, ls servicis de asistencia lingüística están a su dispsición sin cst algun para usted. Llame al 1-877-723-7702 (TTY/TDD: 711). Estams a su dispsición las 24 hras del día, ls siete (7) días de la semana. La llamada es gratuita. This dcument is available fr free in ther languages and frmats like large print, braille, r audi. Call 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Yu can request t always have yur materials sent t yu in the language and/r frmat (such as large print, braille, r audi) that yu need. Call 1-877-723-7702 (TTY/TDD: 711). We are available 24 hurs a day, seven (7) days a week. Once requested, Member Services will always send yu materials in yur chsen language and/r frmat until yu request t have it changed. This service is free. If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 1

Blue Crss and Blue Shield f Illinis cmplies with applicable Federal civil rights laws and des nt discriminate n the basis f race, clr, natinal rigin, age, disability, r sex. Blue Crss and Blue Shield f Illinis des nt exclude peple r treat them differently because f race, clr, natinal rigin, age, disability, r sex. Blue Crss and Blue Shield f Illinis: Prvides free aids and services t peple with disabilities t cmmunicate effectively with us, such as: Qualified sign language interpreters Written infrmatin in ther frmats (large print, audi, accessible electrnic frmats, ther frmats) Prvides free language services t peple whse primary language is nt English, such as: Qualified interpreters Infrmatin written in ther languages If yu need these services, cntact Civil Rights Crdinatr. If yu believe that Blue Crss and Blue Shield f Illinis has failed t prvide these services r discriminated in anther way n the basis f race, clr, natinal rigin, age, disability, r sex, yu can file a grievance with: Civil Rights Crdinatr, Office f Civil Rights Crdinatr, 300 E. Randlph St., 35 th flr, Chicag, Illinis 60601, 1-855-664-7270, TTY/TDD: 1-855-661-6965, Fax: 1-855-661-6960, Civilrightscrdinatr@hcsc.net. Yu can file a grievance in persn r by mail, fax, r email. If yu need help filing a grievance, Civil Rights Crdinatr is available t help yu. Yu can als file a civil rights cmplaint with the U.S. Department f Health and Human Services, Office fr Civil Rights, electrnically thrugh the Office fr Civil Rights Cmplaint Prtal, available at https://crprtal.hhs.gv/cr/prtal/lbby.jsf, r by mail r phne at: U.S. Department f Health and Human Services 200 Independence Avenue, SW Rm 509F, HHH Building Washingtn, D.C. 20201 1-800-368-1019, 800-537-7697 (TDD) Cmplaint frms are available at http://www.hhs.gv/cr/ffice/file/index.html. If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 2

English: ATTENTION: If yu speak a nn-english language, language assistance services, free f charge, are available t yu. Call 1-877-723-7702 (TTY/TDD: 711). Españl (Spanish): ATENCIÓN: si habla españl, tiene a su dispsición servicis gratuits de asistencia lingüística. Llame al 1-877- 723-7702 (TTY/TDD: 711). 繁體中文 (Chinese): 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 1-877-723-7702 (TTY/TDD: 711). Tagalg (Tagalg Filipin): PAUNAWA: Kung nagsasalita ka ng Tagalg, maaari kang gumamit ng mga serbisy ng tulng sa wika nang walang bayad. Tumawag sa 1-877-723-7702 (TTY/TDD: 711). Français (French): ATTENTION : Si vus parlez français, des services d'aide linguistique vus snt prpsés gratuitement. Appelez le 1-877-723-7702 (ATS : 711). Tiếng Việt (Vietnamese): CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành ch bạn. Gọi số 1-877-723-7702 (TTY/TDD: 711). Deutsch (German): ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kstenls sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-723-7702 (TTY/TDD: 711). 한국어 (Krean): 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. 1-877-723-7702 (TTY/TDD: 711) 번으로전화해주십시오. Русский (Russian): ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-877-723-7702 (телетайп: 711). (Arabic): العربية ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 2077-327-778-1 )رقم هاتف الصم والبكم: 117(. ह द (Hindi): ध य न द : यदद आप द द ब लत त आपक ललए म फ त म भ ष स यत स व ए उपलब ध 1-877-723-7702 (TTY/TDD: 711) पर क ल कर Italian (Italian): ATTENZIONE: In cas la lingua parlata sia l'italian, sn dispnibili servizi di assistenza linguistica gratuiti. Chiamare il numer 1-877-723-7702 (TTY/TDD: 711). If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 3

ગ જર ત (Gujarati): સ ચન : જ તમ ગ જર ત બ લત હ, ત નન:શ લ ક ભ ષ સહ ય સ વ ઓ તમ ર મ ટ ઉપલબ ધ છ. ફ ન કર 1-877-723-7702 (TTY/TDD: 711). کریں کال ہیں دستیاب میں مفت خدمات کی مدد کی زبان کو آپ تو ہیں بولتے اردو آپ اگر :خبردار (Urdu): ا رد و 1-877-723-7702 (TTY/TDD: 711). Plski (Plish): UWAGA: Jeżeli mówisz p plsku, mżesz skrzystać z bezpłatnej pmcy językwej. Zadzwń pd numer 1-877- 723-7702 (TTY/TDD: 711). λληνικά (Greek): ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκο νται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεά ν. Καλέστε 1-877-723-7702 (TTY/TDD: 711). If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 4

The fllwing chart lists frequently asked questins. Frequently Asked Questins (FAQ) What is a Medicare-Medicaid Plan? Answers A Medicare-Medicaid Plan is an rganizatin made up f dctrs, hspitals, pharmacies, prviders f lng-term services, and ther prviders. It als has care crdinatrs t help yu manage all yur prviders and services. They all wrk tgether t prvide the care yu need. What is a Blue Crss Cmmunity MMAI care crdinatr? A Blue Crss Cmmunity MMAI care crdinatr is ne main persn fr yu t cntact. This persn helps manage all yur prviders and services and makes sure yu get what yu need. What are lng-term services and supprts? Lng-term services and supprts are services prvided thrugh a Lng-Term Care Facility r thrugh a Hme and Cmmunity Based Waiver. Enrllees have the ptin t get lng-term services and supprts (LTSS) in the least restrictive setting when apprpriate, with a preference fr the hme and the cmmunity, and in accrdance with the Enrllee s wishes and Care Plan. If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 5

Frequently Asked Questins (FAQ) Will yu get the same Medicare and Medicaid benefits in Blue Crss Cmmunity MMAI that yu get nw? Answers Yu will get yur cvered Medicare and Medicaid benefits directly frm Blue Crss Cmmunity MMAI. Yu will wrk with a team f prviders wh will help determine what services will best meet yur needs. This means that sme f the services yu get nw may change. When yu enrll in Blue Crss Cmmunity MMAI, yu and yur care team will wrk tgether t develp an Individualized Care Plan t address yur health and supprt needs. During this time, yu can keep seeing yur dctrs and getting yur current services fr 90 days, r until yur care plan is cmplete. When yu jin ur plan, if yu are taking any Medicare Part D prescriptin drugs that Blue Crss Cmmunity MMAI des nt nrmally cver, yu can get a temprary supply. We will help yu get anther drug r get an exceptin fr Blue Crss Cmmunity MMAI t cver yur drug, if medically necessary. If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 6

Frequently Asked Questins (FAQ) Can yu g t the same dctrs yu see nw? What happens if yu need a service but n ne in Blue Crss Cmmunity MMAI s netwrk can prvide it? Where is Blue Crss Cmmunity MMAI available? D yu pay a mnthly amunt (als called a premium) under Blue Crss Cmmunity MMAI? What is prir authrizatin? Answers Often that is the case. If yur prviders (including dctrs, therapists, and pharmacies) wrk with Blue Crss Cmmunity MMAI and have a cntract with us, yu can keep ging t them. Prviders with an agreement with us are in-netwrk. Yu must use the prviders in Blue Crss Cmmunity MMAI s netwrk. If yu need urgent r emergency care r ut-f-area dialysis services, yu can use prviders utside f Blue Crss Cmmunity MMAI's plan. T find ut if yur dctrs are in the plan s netwrk, call Member Services r read Blue Crss Cmmunity MMAI s Prvider and Pharmacy Directry. If Blue Crss Cmmunity MMAI is new fr yu, yu can cntinue seeing the dctrs yu g t nw fr up t 180 days frm the start f the member s enrllment. We will wrk with yur dctr t be part f ur in netwrk prviders r find yu alternative care as part f yur care plan. Mst services will be prvided by ur netwrk prviders. If yu need a service that cannt be prvided within ur netwrk, Blue Crss Cmmunity MMAI will pay fr the cst f an ut-f-netwrk prvider. The service area fr this plan includes: Ck, DuPage, Lake, Kane, Kankakee, and Will Cunties, Illinis. Yu must live in ne f these areas t jin the plan. Yu will nt pay any mnthly premiums t Blue Crss Cmmunity MMAI fr yur health cverage. Prir authrizatin means that yu must get apprval frm Blue Crss Cmmunity MMAI befre yu can get a specific service r drug r see an ut-f-netwrk prvider. Blue Crss Cmmunity MMAI may nt cver the service r drug if yu dn t get apprval. If yu need urgent r emergency care r ut-f-area dialysis services, yu dn't need t get apprval first. If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 7

Frequently Asked Questins (FAQ) Wh shuld yu cntact if yu have questins r need help? Answers If yu have general questins r questins abut ur plan, services, service area, billing, r Member ID Cards, please call Blue Crss Cmmunity MMAI Member Services: CALL 1-877-723-7702 Calls t this number are free. We are available 24 hurs a day, seven (7) days a week. On weekends and Federal hlidays, vice messaging is available. If yu leave a vice message, a Member Services representative will return yur call n later than the next business day. Member Services als has free language interpreter services available fr peple wh d nt speak English. TTY TTY/TDD 711 This number is fr peple wh have hearing r speaking prblems. Yu must have special telephne equipment t call it. Calls t this number are free. We are available 24 hurs a day, seven (7) days a week. If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 8

Wh shuld yu cntact if yu have questins r need help? (cntinued) If yu have questins abut yur health, please call the Nurse Advice Call line: CALL 1-888-343-2697 Calls t this number are free. We are available 24 hurs a day, seven (7) days a week. On weekends and Federal hlidays, vice messaging is available. If yu leave a vice message, a Member Services representative will return yur call n later than the next business day. TTY TTY/TDD 711 This number is fr peple wh have hearing r speaking prblems. Yu must have special telephne equipment t call it. Calls t this number are free. We are available 24 hurs a day, seven (7) days a week. If yu need immediate behaviral health, please call the Behaviral Health Crisis Line: CALL 1-877-723-7702 Calls t this number are free. The Behaviral Health Crisis line is available 24 hurs a day, 7 days a week, 365 days a year fr emergency services. TTY TTY/TDD 711 This number is fr peple wh have hearing r speaking prblems. Yu must have special telephne equipment t call it. Calls t this number are free. The Behaviral Health Crisis line is available 24 hurs a day, 7 days a week, 365 days a year fr emergency services. If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 9

The fllwing chart is a quick verview f what services yu may need, yur csts and rules abut the benefits. Health need r prblem Yu want t see a dctr Yu need medical tests Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Visits t treat an injury r illness $0 Prir authrizatin is nt required fr services prvided by in netwrk prviders. Wellness visits, such as a physical $0 Prir authrizatin is nt required fr services prvided by in netwrk prviders. Transprtatin t a dctr s ffice $0 Specialist care $0 Prir Authrizatin rules may apply. Yu must use in netwrk prviders. Care t keep yu frm getting sick, such as flu shts Welcme t Medicare preventive visit (ne time nly) $0 $0 Lab tests, such as bld wrk $0 Prir authrizatin rules may apply. Yu must use in netwrk prviders. X-rays r ther pictures, such as CAT scans Screening tests, such as tests t check fr cancer $0 $0 If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 10

Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need drugs t treat yur illness r cnditin (cntinued) Generic drugs (n brand name) $0 fr a 30-day r 90-day supply There may be limitatins n the types f drugs cvered. Please see Blue Crss Cmmunity MMAI s List f Cvered Drugs (Drug List) fr mre infrmatin. The plan may require yu t first try ne drug t treat yur cnditin befre it will cver anther drug fr that cnditin. Sme drugs have quantity limits. Sme drugs that yu take n a regular basis are available thrugh retail r mail rder services fr a 90 day supply. Yur cpay fr a 90-day supply is the same as yur c pay fr a 30-day supply. Yur dctr must get prir authrizatin fr certain drugs. Yu need drugs t treat yur illness r cnditin (cntinued) Brand name drugs $0 fr a 30-day r 90-day supply There may be limitatins n the types f drugs cvered. Please see Blue Crss Cmmunity MMAI s List f Cvered Drugs (Drug List) fr mre infrmatin. The plan may require yu t first try ne drug t treat yur cnditin befre it will cver anther drug fr that cnditin. Sme drugs have quantity limits. Yur dctr must get prir authrizatin fr certain drugs. Sme drugs that yu take n a regular basis are available thrugh retail r mail rder services fr a 90 day supply. Yur c pay fr a 90-day supply is the same as it is fr a 30-day supply. If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 11

Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need drugs t treat yur illness r cnditin Over-the-cunter drugs $0 fr a 30-day r 90-day supply There may be limitatins n the types f drugs cvered. Please see Blue Crss Cmmunity MMAI s List f Cvered Drugs (Drug List) fr mre infrmatin. The plan cvers certain ver the cunter (OTC) drugs with a prescriptin. Medicare Part B prescriptin drugs $0 Part B drugs include drugs given by yur dctr in his r her ffice, sme ral cancer drugs, and sme drugs used with certain medical equipment. Read the Member Handbk fr mre infrmatin n these drugs. Yu need therapy after a strke r accident Occupatinal, physical, r speech therapy $0 Prir authrizatin rules may apply; ccupatinal therapy is nt cvered fr mental health treatment. Limited t $1,900 f cmbined Physical Therapy/Speech Therapy services. There is n visit limit if the services are medically necessary. Limited t $1,900 f Occupatinal Therapy services, fllwed by 20 additinal Occupatinal Therapy services/year. Yu must use in netwrk prviders. If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 12

Health need r prblem Yu need emergency care Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Emergency rm services $0 Prir authrizatin is nt required. Nt cvered utside the U.S. and its territries except under limited circumstances. Cntact plan fr details. Yu may g t any emergency rm if yu reasnably believe yu need emergency care. Ambulance services $0 Air Ambulance, fixed wing, and rtary wing services are all services cvered with a prir authrizatin. Urgent care $0 Prir authrizatin is nt required. Urgent care is nt cvered utside f the United States and its territries. If yu require urgently needed care, yu shuld first try t get it frm a netwrk prvider r call ur 24/7 Nurse Advice Call Line. Hwever, yu can use ut fnetwrk prviders when yu cannt get t a netwrk prvider. If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 13

Health need r prblem Yu need hspital care Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Hspital stay $0 Prir authrizatin rules may apply, except in an emergency. Yur dctr must tell the health plan that yu are ging t be admitted t the hspital. Yu must use in netwrk hspitals when nt an emergency. Dctr r surgen care $0 Prir Authrizatin is required. Yu must use in netwrk prviders. Yu need help getting better r have special health needs Rehabilitatin services $0 Medical equipment fr hme care $0 Prir authrizatin/referral NOT required in 2018 if amunt is $2,500 r less. Amunts abve $2,500 require prir authrizatin. Fr a detailed list call Member Services. Prir authrizatin is required fr Pwer Wheelchairs, specialty hspital beds, and any equipment set up that csts mre than $2,500. Yu must use in netwrk prviders. If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 14

Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Skilled nursing care $0 Prir authrizatin is required fr acute skilled nursing. Lng Term Care prir authrizatin is nt required fr members wh live in the facility and have had their stay apprved by the state. Yu must g t an in netwrk Skilled Nursing Facility (SNF) r receive services frm in netwrk hme health prviders. Yu need eye care Eye exams $0 Yu must use in netwrk visin care prviders. Limited t ne rutine eye exam every year. Glasses r cntact lenses $0 Limited t ne pair f eyeglasses lenses and/r eyeglass frames every tw years. Additinal eyewear benefit f $130 upgrade twards nn standard frame every tw years. If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 15

Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need dental care Dental check-ups $0 Prir authrizatin rules may apply. Yu must use in netwrk prviders. Plan cvers dental services cvered by Medicare and Medicaid. Fr a detailed list, please call Member Services. Additinal tw ral exams, tw preventative cleanings, and ne fluride treatment ffered every year. The plan ffers a $500 allwance as a supplemental benefit each year t help pay fr dental services that wuld NOT therwise be cvered by Medicare. If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 16

Health need r prblem Yu need hearing/auditry services Yu have a chrnic cnditin, such as Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Hearing screenings $0 Hearing screenings are nt cvered; exams cvered nly when experiencing symptms f hearing lss. Prir authrizatin rules may apply. Yu must use in netwrk prviders. The plan cvers hearing and balance tests dne by yur prvider when yu have signs f hearing lss. These tests tell yu whether yu need medical care. They are cvered as utpatient care when yu get them frm a dctr, audilgist, r ther trained prvider. The plan als cvers the fllwing: One pair f hearing aids every three years Hearing aids shuld include the fllwing services: Fitting/evaluatin fr a hearing aid Hearing aid cunseling Hearing aid repair and replacement f parts Hearing aids $0 Hearing Aids require Prir Authrizatin Services t help manage yur disease $0 Services must be included as part f yur care plan. If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 17

Health need r prblem diabetes r heart disease Yu have a mental health cnditin Yu have a substance abuse prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Diabetes supplies and services $0 Services must be included as part f yur care plan. Mental r behaviral health services $0 Prir authrizatin may be required. Fr a detailed list f services that require a prir authrizatin, please call ur Member Services. Yu must use in netwrk prviders. Substance abuse services $0 Prir authrizatin may be required. Fr a detailed list f services that require a prir authrizatin, please call ur Member Services. Yu must use in netwrk prviders. If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 18

Health need r prblem Yu need lng-term mental health services Services yu may need Inpatient care fr peple wh need mental health care Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) $0 Yu must use in netwrk prviders. Prir authrizatin rules may apply; except in an emergency, yur dctr must tell the plan that yu are ging t be admitted t the hspital. All inpatient hspital psychiatric services are subject t cncurrent review by the department s cntracted review agent. Limitatins f admissin/length f stay based n medical necessity. Outpatient mental health services rendered in the Encunter Rate Clinic (ERC), Federally Qualified Health Center (FQHC), and Rural Health Clinic (RHC) setting are cvered. Family cunseling cvered nly when member is present. If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 19

Health need r prblem Yu need durable medical equipment (DME) Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Wheelchairs $0 Prir authrizatin/referral NOT required in 2018 if amunt is $2,500 r less. ALL custm chairs r cmpnents must have a prir authrizatin regardless Nebulizers $0 Crutches $0 Walkers $0 Oxygen equipment and supplies $0 f the amunt. Fr a detailed list call Member Services. Prir authrizatin is required fr Pwer Wheelchairs, specialty hspital beds, and any equipment set up that csts mre than $2,500. Yu must use in netwrk prviders. If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 20

Health need r prblem Yu need help living at hme Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Meals brught t yur hme $0 Prir authrizatin is nt needed if receiving waiver services and this service Hme services, such as cleaning r $0 has been identified as part f the husekeeping member s service plan. Changes t yur hme, such as ramps and $0 Yu must use in netwrk prviders. wheelchair access Persnal care assistant (Yu may be able t emply yur wn assistant. Call Member Services fr mre infrmatin.) $0 Training t help yu get paid r unpaid jbs $0 Hme health care services $0 Services t help yu live n yur wn $0 Yu need a place t live with peple available t help yu Yur caregiver needs sme time ff Adult day services r ther supprt services Assisted living r ther husing services $0 $0 Nursing hme care $0 Respite care $0 If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 21

Other services that Blue Crss Cmmunity MMAI cvers: Other services Blue Crss Cmmunity MMAI cvers (This is nt a cmplete list. Call Member Services r read the Member Handbk t find ut abut ther cvered services.) Over-the-Cunter Drugs & Supplies - Part C Persnal health related items Yu d nt need a prescriptin. Blue Crss Cmmunity MMAI cvers up t $30.00 per calendar quarter per member plus a $5 shipping fee. Yu are limited t ne (1) rder per quarter; requires pre apprval. There is n carryver f benefits r verage allwed. Call member services fr mre infrmatin. N Pharmacy Cpay Additinal pharmacy related benefit: Blue Crss Cmmunity MMAI cvers Generic/Brand Prescriptin drug c pays fr members f LICS Level 1. N Pharmacy Cpay Blue Crss Cmmunity MMAI cvers Generic/Brand Prescriptin drug c pays fr members f LICS Level 2. Cell phne Prir authrizatin required and must be identified as part f yur care plan. Eligible fr members wh d nt have reliable access t a telephne. Mnthly plan with limited minutes t cntact Dctr, Prvider, Care Crdinatr, r 911 emergency services; fr eligible members. If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 22

Services that Blue Crss Cmmunity MMAI, Medicare, and Medicaid d nt cver This is nt a cmplete list. Call Member Services t find ut abut ther excluded services. Services nt cvered by Blue Crss Cmmunity MMAI, Medicare, r Medicaid Services that are prvided in a State Facility perated as a psychiatric hspital as a result f a frensic cmmitment. Services that are prvided thrugh a Lcal Educatin Agency (LEA). Experimental r investigatinal in nature. Services that are prvided withut a required referral r prir authrizatin. Medical and surgical services that are prvided slely fr csmetic purpses If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 23

Yur rights as a member f the plan As a member f Blue Crss Cmmunity MMAI, yu have certain rights. Yu can exercise these rights withut being punished. Yu can als use these rights withut lsing yur health care services. We will tell yu abut yur rights at least nce a year. Fr mre infrmatin n yur rights, please read the Member Handbk. Yur rights include, but are nt limited t, the fllwing: Yu have a right t respect, fairness and dignity. This includes the right t: Get cvered services withut cncern abut race, ethnicity, natinal rigin, religin, gender, age, mental r physical disability, sexual rientatin, genetic infrmatin, ability t pay, r ability t speak English. Get infrmatin in ther frmats (e.g., large print, braille, audi). Be free frm any frm f physical restraint r seclusin. Nt be billed by prviders. Yu have the right t get infrmatin abut yur health care. This includes infrmatin n treatment and yur treatment ptins. This infrmatin shuld be in a frmat yu can understand. These rights include getting infrmatin n: Descriptin f the services we cver Hw t get services Hw much services will cst yu Names f health care prviders and care managers Yu have the right t make decisins abut yur care, including refusing treatment. This includes the right t: Chse a Primary Care Prvider (PCP) and yu can change yur PCP at any time. See a wmen s health care prvider withut a referral. Get yur cvered services and drugs quickly. Knw abut all treatment ptins, n matter what they cst r whether they are cvered. Refuse treatment, even if yur dctr advises against it Stp taking medicine. Ask fr a secnd pinin. Blue Crss Cmmunity MMAI will pay fr the cst f yur secnd pinin visit. Yu have the right t timely access t care that des nt have any cmmunicatin r physical access barriers. This includes the right t: Get medical care timely. Get in and ut f a health care prvider s ffice. This means barrier free access fr peple with If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 24

disabilities, in accrdance with the Americans with Disabilities Act. Have interpreters t help with cmmunicatin with yur dctrs and yur health plan. Yu have the right t seek emergency and urgent care when yu need it. This means yu have the right t: Get emergency services withut prir apprval in an emergency. See an ut f netwrk urgent r emergency care prvider, when necessary. Ask fr and get a cpy f yur medical recrds in a way that yu can understand and ask fr yur recrds t be changed r crrected. Have yur persnal health infrmatin kept private. Yu have the right t make cmplaints abut yur cvered services r care. This includes the right t: File a cmplaint r grievance against us r ur prviders. Ask fr a state fair hearing. Get a detailed reasn fr why services were denied. Yu have a right t cnfidentiality and privacy. This includes the right t: Fr mre infrmatin abut yur rights, yu can read the Blue Crss Cmmunity MMAI Member Handbk. If yu have questins, yu can als call Blue Crss Cmmunity MMAI Member Services at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. If yu have a cmplaint r think we shuld cver smething we denied If yu have a cmplaint r think Blue Crss Cmmunity MMAI shuld cver smething we denied, call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Yu may be able t appeal ur decisin. Fr questins abut cmplaints and appeals, yu can read Chapter 9 f the Blue Crss Cmmunity MMAI Member Handbk. Yu can als call Blue Crss Cmmunity MMAI Member Services at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 25

If yu suspect fraud Mst health care prfessinals and rganizatins that prvide services are hnest. Unfrtunately, there may be sme wh are dishnest. If yu think a dctr, hspital r ther pharmacy is ding smething wrng, please cntact us. Call us at Blue Crss Cmmunity MMAI Member Services at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Or, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users shuld call 1-877-486-2048. Yu can call these numbers fr free, 24 hurs a day, 7 days a week. Call the State f Illinis Fraud Htline at 1-844-453-7283. Yu can call this number fr free, 24 hurs a day, seven (7) days week If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. 26

If yu have questins, please call Blue Crss Cmmunity MMAI at 1-877-723-7702 (TTY/TDD 711). We are available 24 hurs a day, seven (7) days a week. The call is free. Fr mre infrmatin, visit www.bcbsil.cm/mmai. Fr questins abut enrlling call: Illinis Client Enrllment Services 1-877-912-8880 (TTY: 1-866-565-8576) Website: enrllhfs.illinis.gv