INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 SUMMARY OF BENEFITS January 1, 2015 - December 31, 2015 CARE1ST HEALTH PLAN California: Alameda,,,, San Francisco and Counties H5928_15_029_SB_TD_2
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 Plan (HMO SNP)). Tips for comparing your Medicare choices This Summary of s booklet gives you a summary of what Plan (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 s 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 Plan (HMO SNP) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital s Prescription Drug s 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 (800) 544-0088 (TTY/TDD 711). Este documento puede ser disponible en un idioma que no sea inglés. Para obtener más información, llame al servicio al cliente al número de teléfono indicado arriba. 此文件包括其他語言 若需要獲得更多資 訊, 請撥打以上所列的電話號碼聯絡我們 的會員服務部 Things to Know About Plan (HMO SNP) Hours of Operation From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Pacific time. SECTION I From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Pacific time. Care1st TotalDuak Phone Numbers and Website If you are a member of this plan, call toll-free (800) 544-0088 (TTY/TDD 711). If you are not a member of this plan, call tollfree (800) 847-1222 (TTY/TDD 711). Our website: http://www.care1stmedicare.com Who can join? To join, you must be entitled to Medicare Part A, be enrolled in Medicare Part B and Medi-Cal, and live in our service area. Our service area includes the following counties in California: Alameda,, Orange*, San Bernardino,, San Francisco and counties. * denotes partial county Alameda County 94501; 94502; 94601; 94602; 94603; 94604; 94605; 94606; 94607; 94608; 94609; 94610; 94611; 94612; 94613; 94614; 94617; 94618; 94619; 94620; 94621; 94623; 94624; 94661; 94662; 94701; 94702; 94703; 94704; 94705; 2
INTRODUCTION TO SUMMARY OF BENEFITS SECTION I 94706; 94707; 94708; 94709; 94710; 94712; 94720 County All ZIP Codes Orange County 90620; 90621; 90622; 90623; 90624; 90630; 90631; 90632; 90633; 90638; 90680; 90720; 90740; 90742; 90743; 92609; 92610; 92617; 92619; 92620; 92626; 92637; 92646; 92647; 92648; 92649; 92655; 92657; 92673; 92683; 92685; 92694; 92697; 92698; 92701; 92702; 92703; 92704; 92705; 92706; 92707; 92708; 92725; 92735; 92801; 92802; 92803; 92804; 92805; 92806; 92807; 92808; 92809; 92812; 92814; 92815; 92816; 92817; 92821; 92822; 92823; 92825; 92831; 92832; 92833; 92834; 92835; 92836; 92837; 92838; 92840; 92841; 92842; 92843; 92844; 92845; 92846; 92850; 92868; 92870; 92871; 92885; 92886; 92887; 92899 San Bernardino: 91701, 91708, 91709, 91710, 91730, 91737, 91739, 91761, 91762, 91763, 91764, 91784, 91786, 92301, 92307, 92308, 92313, 92316, 92318, 92324, 92334, 92335, 92336, 92337, 92344, 92345, 92346, 92350, 92354, 92357, 92359, 92368, 92369, 92371, 92373, 92374, 92376, 92377, 92392, 92394, 92395, 92399, 92401, 92402, 92403, 92404, 92405, 92406, 92407, 92408, 92410, 92411, 92412, 92413, 92414, 92415, 92418, 92420, 92423, 92424, 92427 County All ZIP Codes San Francisco County All ZIP Codes County All ZIP Codes Which doctors, hospitals, and pharmacies can I use? 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 network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan s provider and pharmacy directory at our website (http://www. care1stmedicare.com). 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. For some 3 of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. 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. care1stmedicare.com. Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? For County, 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. For Orange County, San Bernardino County, and County our plan groups each medication into one of five tiers. You will need to use your formulary to locate what tier your
INTRODUCTION TO SUMMARY OF BENEFITS drug is on to determine how much it will cost you. The amount you pay depends on the drug s tier 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 I If you have any questions about this plan s benefits or costs, please contact Care1st Health Plan for details. 4
SUMMARY OF BENEFITS Section II - MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is the monthly premium? How much is the deductible? Is there any limit on how much I will pay for my covered services? $27.00 per month. In addition, you must keep paying your Medicare Part B premium This plan does not have a deductible. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your outof-pocket costs for medical and hospital care. In this plan, you may pay for Medicare-covered services, depending on your level of Medi- Cal eligibility. Refer to the Medicare & You handbook for Medicare-covered services. For Medi-Cal-covered services, refer to the Medicaid Coverage section in this document. $27.50 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your outof-pocket costs for medical and hospital care. In this plan, you may pay for Medicare-covered services, depending on your level of Medi- Cal eligibility. Refer to the Medicare & You handbook for Medicare-covered services. For Medi-Cal-covered services, refer to the Medicaid Coverage section in this document. $28.80 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your outof-pocket costs for medical and hospital care. In this plan, you may pay for Medicare-covered services, depending on your level of Medi- Cal eligibility. Refer to the Medicare & You handbook for Medicare-covered services. For Medi-Cal-covered services, refer to the Medicaid Coverage section in this document. $28.80 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your outof-pocket costs for medical and hospital care. In this plan, you may pay for Medicare-covered services, depending on your level of Medi- Cal eligibility. Refer to the Medicare & You handbook for Medicare-covered services. For Medi-Cal-covered services, refer to the Medicaid Coverage section in this document. 5
MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES (continued) Your yearly limit(s) in this plan: $1 for services you receive from in-network providers. Your yearly limit(s) in this plan: $1 for services you receive from in-network providers. Your yearly limit(s) in this plan: $1 for services you receive from in-network providers. Your yearly limit(s) in this plan: $1 for services you receive from in-network providers. Is there any limit on how much I will pay for my covered services? (continued) If you reach the limit on out-ofpocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. If you reach the limit on out-ofpocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. If you reach the limit on out-ofpocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. If you reach the limit on out-ofpocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. 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 in-network benefits. Contact us for the services that apply. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Care1st Health Plan is an HMO and an HMO SNP plan with a Medicare contract and a contract with the California State Medicaid Program. Enrollment in Care1st Health Plan depends on contract renewal. This plan is also available to anyone who has both Medical Assistance from the State and Medicare. 6
OUTPATIENT CARE AND SERVICES COVERED MEDICAL AND HOSPITAL BENEFITS NOTE: SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION. SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR. Acupuncture and Other Alternative Therapies 1,2 For up to 15 visit(s) every year: You pay For up to 15 visit(s) every year: You pay For up to 15 visit(s) every year: You pay For up to 15 visit(s) every year: You pay Ambulance 1 You pay You pay You pay You pay 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): You pay Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): You pay Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): You pay Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): You pay Routine chiropractic visit (for up to 15 every year): You pay Routine chiropractic visit (for up to 15 every year): You pay Routine chiropractic services not covered. Routine chiropractic visit (for up to 15 every year): You pay 7
OUTPATIENT CARE AND SERVICES (continued) Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): You pay Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): You pay Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): You pay Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): You pay Dental Services 1,2 Diabetes Supplies and Services 1,2 Preventive dental services: Cleaning (for up to 1 every six months): You pay Dental x-ray(s) (for up to 1 every two years): You pay Fluoride treatment (for up to 1 every six months): You pay Oral exam: You pay *Additional co-pays may apply for other preventive dental services and comprehensive dental services. Refer to your Dental Handbook for details. Diabetes monitoring supplies: You pay Diabetes self-management training: You pay Therapeutic shoes or inserts: You pay Preventive dental services: Cleaning (for up to 1 every six months): You pay Dental x-ray(s) (for up to 1 every two years): You pay Fluoride treatment (for up to 1 every six months): You pay Oral exam: You pay *Additional co-pays may apply for other preventive dental services and comprehensive dental services. Refer to your Dental Handbook for details. Diabetes monitoring supplies: You pay Diabetes self-management training: You pay Therapeutic shoes or inserts: You pay Preventive dental services: Cleaning (for up to 1 every six months): You pay Dental x-ray(s) (for up to 1 every two years): You pay Fluoride treatment (for up to 1 every six months): $5 copay Oral exam: You pay *Additional co-pays may apply for other preventive dental services and comprehensive dental services. Refer to your Dental Handbook for details. Diabetes monitoring supplies: You pay Diabetes self-management training: You pay Therapeutic shoes or inserts: You pay Preventive dental services: Cleaning (for up to 1 every six months): You pay Dental x-ray(s) (for up to 1 every two years): You pay Fluoride treatment (for up to 1 every six months): You pay Oral exam: You pay *Additional co-pays may apply for other preventive dental services and comprehensive dental services. Refer to your Dental Handbook for details. Diabetes monitoring supplies: You pay Diabetes self-management training: You pay Therapeutic shoes or inserts: You pay 8
OUTPATIENT CARE AND SERVICES (continued) Diagnostic radiology services (such as MRIs, CT scans): You pay Diagnostic radiology services (such as MRIs, CT scans): You pay Diagnostic radiology services (such as MRIs, CT scans): You pay Diagnostic radiology services (such as MRIs, CT scans): You pay Diagnostic Tests, Lab and Radiology Services, and X-Rays 1,2 Diagnostic tests and procedures: You pay Lab services: You pay Outpatient x-rays: You pay Diagnostic tests and procedures: You pay Lab services: You pay Outpatient x-rays: You pay Diagnostic tests and procedures: You pay Lab services: You pay Outpatient x-rays: You pay Diagnostic tests and procedures: You pay Lab services: You pay Outpatient x-rays: You pay Doctor s Office Visits 1,2 Therapeutic radiology services (such as radiation treatment for cancer): You pay Primary care physician visit: You pay Specialist visit: You pay Therapeutic radiology services (such as radiation treatment for cancer): You pay Primary care physician visit: You pay Specialist visit: You pay Therapeutic radiology services (such as radiation treatment for cancer): You pay Primary care physician visit: You pay Specialist visit: You pay Therapeutic radiology services (such as radiation treatment for cancer): You pay Primary care physician visit: You pay Specialist visit: You pay Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Emergency Care You pay You pay You pay You pay You pay You pay You pay You pay 9
OUTPATIENT CARE AND SERVICES (continued) Foot Care (podiatry services) 1,2 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay Routine foot care: You pay Exam to diagnose and treat hearing and balance issues: You pay Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay Routine foot care: You pay Exam to diagnose and treat hearing and balance issues: You pay Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay Routine foot care: You pay Exam to diagnose and treat hearing and balance issues: You pay Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay Routine foot care: You pay Exam to diagnose and treat hearing and balance issues: You pay Routine hearing exam (for up to 1 every year): You pay Routine hearing exam (for up to 1 every year): You pay Routine hearing exam (for up to 1 every year): You pay Routine hearing exam (for up to 1 every year): You pay Hearing Services 1,2 Hearing aid fitting/evaluation (for up to 1 every year): You pay Hearing aid fitting/evaluation (for up to 1 every year): You pay Hearing aid fitting/evaluation (for up to 1 every year): You pay Hearing aid fitting/evaluation (for up to 1 every year): You pay Hearing aid: You pay Our plan pays up to $1,000 every year for hearing aids. Hearing aid: You pay Our plan pays up to $1,000 every year for hearing aids. Hearing aid: You pay Our plan pays up to $1,000 every year for hearing aids. Hearing aid: You pay Our plan pays up to $1,000 every year for hearing aids. Limit 2 hearing aids every two years. Limit 2 hearing aids every two years. Limit 2 hearing aids every two years. Limit 2 hearing aids every two years. Home Health Care 1,2 You pay You pay You pay You pay 10
OUTPATIENT CARE AND SERVICES (continued) 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. 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. 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. Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Our plan covers 90 days for an inpatient hospital stay. Our plan covers 90 days for an inpatient hospital stay. Our plan covers 90 days for an inpatient hospital stay. Mental Health 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. 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. 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. 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. You pay You pay You pay You pay 11
OUTPATIENT CARE AND SERVICES (continued) Mental Health Care 1,2 (continued) Outpatient Rehabilitation 1,2 Outpatient group therapy visit: You pay Outpatient individual therapy visit: You pay Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): You pay Occupational therapy visit: You pay Outpatient group therapy visit: You pay Outpatient individual therapy visit: You pay Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): You pay Occupational therapy visit: You pay Outpatient group therapy visit: You pay Outpatient individual therapy visit: You pay Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): You pay Occupational therapy visit: You pay Outpatient group therapy visit: You pay Outpatient individual therapy visit: You pay Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): You pay Occupational therapy visit: You pay Outpatient Substance Abuse 1,2 Physical therapy and speech and language therapy visit: You pay Group therapy visit: You pay Individual therapy visit: You pay Physical therapy and speech and language therapy visit: You pay Group therapy visit: You pay Individual therapy visit: You pay Physical therapy and speech and language therapy visit: You pay Group therapy visit: You pay Individual therapy visit: You pay Physical therapy and speech and language therapy visit: You pay Group therapy visit: You pay Individual therapy visit: You pay 12
OUTPATIENT CARE AND SERVICES (continued) Outpatient Surgery 1,2 Over-the-Counter Items Prosthetic Devices (braces, artificial limbs, etc.) 1 Ambulatory surgical center: You pay Outpatient hospital: You pay Please visit our website to see our list of covered over-thecounter items. Limited to a $60 allowance per quarter. Prosthetic devices: You pay Related medical supplies: You pay Ambulatory surgical center: You pay Outpatient hospital: You pay Please visit our website to see our list of covered over-thecounter items. Limited to a $60 allowance per quarter. Prosthetic devices: You pay Related medical supplies: You pay Ambulatory surgical center: You pay Outpatient hospital: You pay Please visit our website to see our list of covered over-thecounter items. Limited to a $40 allowance per quarter. Prosthetic devices: You pay Related medical supplies: You pay Ambulatory surgical center: You pay Outpatient hospital: You pay Please visit our website to see our list of covered over-thecounter items. Limited to a $75 allowance per quarter. Prosthetic devices: You pay Related medical supplies: You pay Renal Dialysis 1,2 You pay You pay You pay You pay 13
OUTPATIENT CARE AND SERVICES (continued) You pay You pay You pay You pay Transportation 1 Urgent Care $0 copay for up to 24 round trips to plan approved locations per year. Care1st offers transportation to plan-approved locations such as doctors offices in order to access medical services. Transportation must be arranged 24 hours in advance by contacting the plan-designated vendor or Care1st Member Services Department. $0 copay for up to 24 round trips to plan approved locations per year. Care1st offers transportation to plan-approved locations such as doctors offices in order to access medical services. Transportation must be arranged 24 hours in advance by contacting the plan-designated vendor or Care1st Member Services Department. $0 copay for up to 12 round trips to plan approved locations per year. Care1st offers transportation to plan-approved locations such as doctors offices in order to access medical services. Transportation must be arranged 24 hours in advance by contacting the plan-designated vendor or Care1st Member Services Department. You pay You pay You pay You pay $0 copay for up to 24 round trips to plan approved locations per year. Care1st offers transportation to plan-approved locations such as doctors offices in order to access medical services. Transportation must be arranged 24 hours in advance by contacting the plan-designated vendor or Care1st Member Services Department. 14
OUTPATIENT CARE AND SERVICES (continued) Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay Routine eye exam (for up to 1 every year): You pay Routine eye exam (for up to 1 every year): You pay Routine eye exam (for up to 1 every year): You pay Routine eye exam (for up to 1 every year): You pay Contact lenses (for up to 1 every year): You pay Contact lenses (for up to 1 every two years): You pay Contact lenses (for up to 1 every year): You pay Contact lenses (for up to 1 every year): You pay Vision Services 1 Eyeglasses (frames and lenses) (for up to 1 every year): You pay Eyeglasses (frames and lenses) (for up to 1 every two years): You pay Eyeglasses (frames and lenses) (for up to 1 every year): You pay Eyeglasses (frames and lenses) (for up to 1 every year): You pay Eyeglasses or contact lenses after cataract surgery: You pay Eyeglasses or contact lenses after cataract surgery: You pay Eyeglasses or contact lenses after cataract surgery: You pay Eyeglasses or contact lenses after cataract surgery: You pay Our plan pays up to $200 every year for contact lenses and eyeglasses (frames and lenses). Our plan pays up to $200 every two years for contact lenses and eyeglasses (frames and lenses). Our plan pays up to $200 every year for contact lenses and eyeglasses (frames and lenses). Our plan pays up to $200 every year for contact lenses and eyeglasses (frames and lenses). 15
OUTPATIENT CARE AND SERVICES (continued) Vision Services 1 (continued) Non-Standard additional upgrade items such as progressive lenses, lens coating or tinting, and frames are not covered. Care1st covers the refraction test once every year when the eye doctor has determined that the member may need prescription glasses. Non-Standard additional upgrade items such as progressive lenses, lens coating or tinting, and frames are not covered. Care1st covers the refraction test once every year when the eye doctor has determined that the member may need prescription glasses. Non-Standard additional upgrade items such as progressive lenses, lens coating or tinting, and frames are not covered. Care1st covers the refraction test once every year when the eye doctor has determined that the member may need prescription glasses. Non-Standard additional upgrade items such as progressive lenses, lens coating or tinting, and frames are not covered. Care1st covers the refraction test once every year when the eye doctor has determined that the member may need prescription glasses. 16
OUTPATIENT CARE AND SERVICES (continued) You pay You pay You pay You pay Preventive Care 1,2 Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling 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 Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling 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 Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling 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 Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling 17
OUTPATIENT CARE AND SERVICES (continued) Preventive Care 1,2 (continued) 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. 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. 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. 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. Annual physical exam: You pay You pay for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. Annual physical exam: You pay You pay for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. Annual physical exam: You pay You pay for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. Annual physical exam: You pay You pay for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. Hospice 18
OUTPATIENT CARE AND SERVICES (continued) Inpatient Hospital Care 1,2 Our plan covers an unlimited number of days for an inpatient hospital stay. Our plan covers an unlimited number of days for an inpatient hospital stay. Our plan covers an unlimited number of days for an inpatient hospital stay. Our plan covers an unlimited number of days for an inpatient hospital stay. Inpatient Mental Health Care Skilled Nursing Facility (SNF) 1,2 You pay For inpatient mental health care, see the Mental Health Care section of this booklet. Our plan covers up to 100 days in a SNF. You pay PRESCRIPTION DRUG BENEFITS You pay For inpatient mental health care, see the Mental Health Care section of this booklet. Our plan covers up to 100 days in a SNF. You pay You pay For inpatient mental health care, see the Mental Health Care section of this booklet. Our plan covers up to 100 days in a SNF. You pay You pay For inpatient mental health care, see the Mental Health Care section of this booklet. Our plan covers up to 100 days in a SNF. You pay How much do I pay? For Part B drugs such as chemotherapy drugs 1 : You pay For Part B drugs such as chemotherapy drugs 1 : You pay For Part B drugs such as chemotherapy drugs 1 : You pay For Part B drugs such as chemotherapy drugs 1 : You pay Other Part B drugs 1 : You pay Other Part B drugs 1 : You pay Other Part B drugs 1 : You pay Other Part B drugs 1 : You pay 19
PRESCRIPTION DRUG BENEFITS (continued) Our plan does not have a deductible for Part D prescription drugs. Our plan does not have a deductible for Part D prescription drugs. Our plan does not have a deductible for Part D prescription drugs. Our plan does not have a deductible for Part D prescription drugs. Initial Coverage You pay the following: You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing Tier 1 (Preferred Generic) - One-month supply $0 - Three-month supply $0 Tier 2 (Non-Preferred Generic) - One-month supply: For generic drugs (including brand drugs treated as generic), either: You pay the following: You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing Tier 1 (Preferred Generic) - One-month supply $0 - Three-month supply $0 Tier 2 (Non-Preferred Generic) - One-month supply: For generic drugs (including brand drugs treated as generic), either: Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: 1.20 copay; or $6.60 copay You may get your drugs at network retail pharmacies and mail order pharmacies. You pay the following: You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing Tier 1 (Preferred Generic) - One-month supply $0 - Three-month supply $0 Tier 2 (Non-Preferred Generic) - One-month supply: For generic drugs (including brand drugs treated as generic), either: 20
PRESCRIPTION DRUG BENEFITS (continued) generic drugs (including brand drugs treated as generic), either: generic drugs (including brand drugs treated as generic), either: If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an outof-network pharmacy, but may pay more than you pay at an in-network pharmacy. drugs treated as generic), either: Initial Coverage (continued) Tier 3 (Preferred Brand) - One-month supply: For generic drugs (including brand drugs treated as generic), either: Tier 3 (Preferred Brand) - One-month supply: For generic drugs (including brand drugs treated as generic), either: Tier 3 (Preferred Brand) - One-month supply For generic drugs (including brand drugs treated as generic), either: 21
PRESCRIPTION DRUG BENEFITS (continued) drugs treated as generic), either: drugs treated as generic), either: drugs treated as generic), either: Initial Coverage (continued) Tier 4 (Non-Preferred Brand) - One-month supply: For generic drugs (including brand drugs treated as generic), either: Tier 4 (Non-Preferred Brand) - One-month supply: For generic drugs (including brand drugs treated as generic), either: Tier 4 (Non-Preferred Brand) - One-month supply: For generic drugs (including brand drugs treated as generic), either: 22
Alameda, San Francisco, PRESCRIPTION DRUG BENEFITS (continued) Initial Coverage (continued) drugs treated as generic), either: Tier 5 (Specialty Tier) - One-month supply: For generic drugs (including brand drugs treated as generic), either: drugs treated as generic), either: Tier 5 (Specialty Tier) - One-month supply: For generic drugs (including brand drugs treated as generic), either: drugs treated as generic), either: Tier 5 (Specialty Tier) - One-month supply: For generic drugs (including brand drugs treated as generic), either: 23
PRESCRIPTION DRUG BENEFITS (continued) drugs treated as generic), either: drugs treated as generic), either: drugs treated as generic), either: Initial Coverage (continued) Standard Mail Order Cost- Sharing Tier 1 (Preferred Generic) - Three-month supply: $0 Standard Mail Order Cost- Sharing Tier 1 (Preferred Generic) - Three-month supply: $0 Standard Mail Order Cost- Sharing Tier 1 (Preferred Generic) - Three-month supply: $0 Tier 2 (Non-Preferred Generic) drugs treated as generic), either: Tier 2 (Non-Preferred Generic) drugs treated as generic), either: Tier 2 (Non-Preferred Generic) drugs treated as generic), either: 24
PRESCRIPTION DRUG BENEFITS (continued) $6.60 copay $6.60 copay $6.60 copay Initial Coverage (continued) Tier 3 (Preferred Brand) drugs treated as generic), either: Tier 3 (Preferred Brand) drugs treated as generic), either: Tier 3 (Preferred Brand) drugs treated as generic), either: Tier 4 (Non-Preferred Brand) drugs treated as generic), either: Tier 4 (Non-Preferred Brand) drugs treated as generic), either: Tier 4 (Non-Preferred Brand) drugs treated as generic), either: 25
PRESCRIPTION DRUG BENEFITS (continued) Initial Coverage (continued) Tier 5 (Specialty Tier) drugs treated as generic), either: Tier 5 (Specialty Tier) drugs treated as generic), either: Tier 5 (Specialty Tier) drugs treated as generic), either: If you reside in a long-term care facility, you pay the same as at a retail pharmacy. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an outof-network pharmacy, but may pay more than you pay at an in-network pharmacy. You may get drugs from an outof-network pharmacy, but may pay more than you pay at an in-network pharmacy. You may get drugs from an outof-network pharmacy, but may pay more than you pay at an in-network pharmacy. 26
PRESCRIPTION DRUG BENEFITS (continued) Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay for all drugs. After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay for all drugs. After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay for all drugs. After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay for all drugs. 27
I COMPREHENSIVE WRITTEN STATEMENT FOR PROSPECTIVE ENROLLEES The benefits described below are covered by Medicaid. The benefits described in the Covered Medical and Hospital s section of the Summary of s are covered by Medicare. For each benefit listed below, you can see what Medi-Cal covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility SUMMARY OF MEDICAID-COVERED BENEFITS for Contract H5928, Plans 001, 005, 009, 025 All Members Who Qualify for Full Medi-Cal May Receive the Following Medi-Cal and Health Plan Services Medi-Cal Plan (HMO SNP) 1. Inpatient hospital services $0 copay for Medi-Cal covered services $0 copay 2. Outpatient hospital services $0 copay for Medi-Cal covered services 3. Rural health clinic services $0 copay for Medi-Cal covered services 4. Federally qualified health center services $0 copay for each Medicare-covered outpatient hospital facility visit. Not covered beyond Original Medicare. Covered under Medicare effective with the date of clinic's approval for participation. $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. 5. Laboratory services $0 copay for Medi-Cal covered services 6. X-rays $0 copay for Medi-Cal covered services $0 copay for Medicare-covered lab services, and diagnostic procedures and tests. $0 copay for Medicare-covered X-rays, diagnostic radiology services (not including X-rays), and therapeutic radiology services. 28
Medi-Cal I Plan (HMO SNP) 7. Skilled nursing facility care for over 21 years of age - Subacute care $0 copay for Medi-Cal covered services $0 copay for Skilled Nursing Facility (SNF) services 8. Family planning services & supplies $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. 9. Physician services $0 copay for Medi-Cal covered services $0 copay for each primary care doctor visit for Medicare-covered benefits. 10. Medical & surgical dental services $0 copay for Medi-Cal covered services $0 copay for Medicare-covered dental benefits. 11. Ophthalmologist services $0 copay for Medi-Cal covered services 12. Optometry services $0 copay for Medi-Cal covered services $0 copay for diagnosis and treatment for diseases and conditions of the eye, and up to 1 routine eye exam(s) every year. $0 copay for diagnosis and treatment for diseases and conditions of the eye, and up to 1 routine eye exam(s) every year. 13. Nurse anesthetist services $0 copay for Medi-Cal covered services $0 copay for Medicare-covered benefits 14. Medical supplies (does not include incontinence creams and washes) $0 copay for Medi-Cal covered services $0 copay for Medicare-covered medial supplies 15. Durable medical equipment $0 copay for Medi-Cal covered services $0 copay for Medicare-covered items. 16. Hearing aids $0 copay for Medi-Cal covered services $0 copay for up to 2 hearing aid(s) every two years. $1000 limit for hearing aids every year. 29
Medi-Cal I Plan (HMO SNP) 17. Enteral formula $0 copay for Medi-Cal covered services $0 copay for Medicare-covered benefits. 18. Licensed midwife services $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. 19. Home health services through a home health agency (including home health nursing and aide services, physical and occupational therapy, speech pathology and audiology services, intermittent nursing, home health aid care, medical supplies, equipment and appliances) 20. Physical therapy and related services $0 copay for Medi-Cal covered services $0 copay for Medi-Cal covered services $0 copay for Medicare-covered home health services $0 copay for Medicare-covered Physical Therapy visits. 21. Rehabilitation facilities $0 copay for Medi-Cal covered services $0 copay 22. Clinic (Organized outpatient clinic, Indian Health Services, alternate birthing centers, ambulatory surgical centers) 23. Occupational therapy $0 copay for Medi-Cal covered services $0 copay for Medi-Cal covered services $0 copay for Medicare-covered visits. $0 copay for Medicare-covered Occupational Therapy visits 30
24. Pharmaceutical services and prescribed drugs 25. Prosthetic appliances (Orthotic appliances) prosthetic eyes 26. Comprehensive Perinatal Services Program (Preventive services) Medi-Cal $0 copay for drugs excluded from Medicare Part D coverage I Plan (HMO SNP) Initial Coverage Generic drugs, either a $0, $1.20 or $2.65 copay, or a 15% coinsurance All other drugs, either a $0, $3.60 or $6.60 copay, or a 15% coinsurance Catastrophic Coverage $0 copay after yearly out-of-pocket costs reach $4,700. $0 copay for Medi-Cal covered services $0 copay for Medicare-covered items $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. 27. Adult day health care $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. 28. Chronic dialysis services $0 copay for Medi-Cal covered services $0 copay for renal dialysis. 29. Rehabilitation services (CBAS, chronic dialysis, outpatient heroin detoxification, rehabilitative mental health, drug Medi-Cal, independent rehabilitation centers) 30. Institutes for Mental Diseases (for under 21 years of age and over 65 years of age, including inpatient psychiatric care). $0 copay for Medi-Cal covered services $0 copay for Medicare-covered visits. $0 copay for Medi-Cal covered services $0 copay for Medicare-covered benefits 31
Medi-Cal I Plan (HMO SNP) 31. Intermediate Care Facility $0 copay for Medi-Cal covered services $0 copay for Medicare-covered benefits. 32. Nurse midwife $0 copay for Medi-Cal covered services $0 copay for Medicare-covered benefits. 33. Hospice $0 copay for Medi-Cal covered services You must get care from a Medicare-certified hospice. $0 copay for one-time hospice consultation services. 34. TB-related services $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. 35. Respiratory care for ventilatordependent patients $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. 36. Family nurse practitioner $0 copay for Medi-Cal covered services $0 copay for Medicare-covered services 37. Rural primary care hospital $0 copay for Medi-Cal covered services $0 copay for Medicare-covered services 38. Nonmedical health facilities $0 copay for Medi-Cal covered services 39. Emergency hospital services $0 copay for Medi-Cal covered services $0 copay for care received in a religious non-medical health care institution $0 copay for Medicare-covered emergency room visits. $25,000 limit for emergency services outside the U.S. every year. 32
40. Transportation (State provides emergency and non-emergency medical transportation. Meets federal requirement for assurance of transportation to medically necessary services) Medi-Cal $0 copay for Medi-Cal covered services I Plan (HMO SNP) Ambulance: $0 copay for Medicare-covered ambulance benefits. For Alameda,, San Francisco and Counties: Routine Transportation: $0 copay for each round trip to plan-approved location. Up to 24 round-trips per year. For County: Routine Transportation: $0 copay for each round trip to plan-approved location. Up to 12 round-trips per year. 33
I Members Who Qualify for Medi-Cal Waiver Programs or Meet Specific Medical Eligibility Criteria May Also Receive the Following Medi-Cal Services* STATE OF CALIFORNIA MEDI-CAL PROGRAM COVERED BENEFITS FOR DUAL ELIGIBLE (MEDICARE AND MEDI-CAL BENEFICIARIES) Medi-Cal Plan (HMO SNP) 1. Private duty nursing (Waiver only) $0 copay for Medi-Cal covered services Not covered. 2. Home and community care for functionally disabled elderly (Waiver only) 3. Community-supported living arrangements (Waiver only) $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. $0 copay for Medi-Cal covered services Not covered. 4. Personal care services $0 copay for Medi-Cal covered services Not covered. 5. Services for pregnant women that treat a condition that may impact the woman and/or the fetus (Not specifically stated as a benefit but is a mandated provision under federal regulations) $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. 34
6. Marriage and family counselor services (Early & periodic screening, diagnosis, and treatment services & waiver only) 7. Licensed clinical social worker services (Early & periodic screening, diagnosis, and treatment services & waiver only) 8. Case management (Early & periodic screening, diagnosis, and treatment services & waiver only) 9. Private duty nursing agency services (Early & periodic screening, diagnosis, and treatment services & waiver only) 10 Individual nurse provider services (Early & periodic screening, diagnosis, and treatment services & waiver only) Medi-Cal I Plan (HMO SNP) $0 copay for Medi-Cal covered services $0 copay for Medicare-covered services. $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. $0 copay for Medi-Cal covered services $0 copay for Medicare-covered services. $0 copay for Medi-Cal covered services Not covered. $0 copay for Medi-Cal covered services Not covered. 11. Nonmedical services (Waiver only) $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. 12. Pediatric nursing facility care for under 21 years of age - Subacute services (Early & periodic screening, diagnosis, and treatment supplemental services) $0 copay for Medi-Cal covered services Not covered beyond Original Medicare. *Note: You must meet specific eligibility criteria in order to receive benefits under the early & periodic screening, diagnosis, and treatment (EPSDT) program or through other Medi-Cal Waiver programs. 35
I Certain Members Who Have Full Medi-Cal May Also Receive the Following s**: STATE OF CALIFORNIA MEDI-CAL PROGRAM COVERED BENEFITS FOR DUAL ELIGIBLE (MEDICARE AND MEDI-CAL BENEFICIARIES) Medi-Cal Plan (HMO SNP) 1. Psychology services $0 copay for Medi-Cal covered services $0 copay for Medicare-covered Mental health visits. $0 copay for one pair of eyeglasses or contact lenses after cataract surgery. 2. Optician and optical fabricating lab services $0 copay for Medi-Cal covered services For San Bernardino and Orange Counties: $0 copay for up to 1 pair(s) of glasses or contacts every two years. $200 limit for eye wear every two years. For Alameda,, San Francisco, Santa Clara, : $0 copay for up to 1 pair(s) of glasses or contacts every year. $200 limit for eye wear every year. 36
Medi-Cal I Plan (HMO SNP) For Alameda,, San Francisco and Counties*: Preventive (Routine): $0 copay for: 2 oral exams every year 1x-ray every two years *Copays may apply for additional dental benefits. 3. Dental services $0 copay for Medi-Cal covered services For County*: Preventive (Routine): $0 copay for: 2 oral exams every year 2 Cleaning each year 1x-ray Every two years $5 Copay for every 1 fluoride treatment every 6 months *Copays may apply for additional dental benefits. 37