FamilyCare Cmmunity (HMO SNP) January 1, 2018 December 31, 2018 This is a summary f drug and health services cvered by FamilyCare Cmmunity (HMO SNP). Fr mre infrmatin, please call us at the phne numbers n the next page. T jin FamilyCare Cmmunity (HMO SNP) yu must have Medicare Part A and Part B as well as Oregn Health Plan (Medicaid), and live in ur service area. Our service area includes the fllwing cunties in Oregn: Clackamas, Clatsp, Multnmah, and Washingtn. This plan has a netwrk f dctrs, hspitals, pharmacies and ther prviders. If yu use prviders that are nt in ur netwrk, the plan may nt pay fr these FamilyCare Cmmunity (HMO SNP) cvers Part D drugs. In additin, we cver Part B drugs such as chemtherapy and sme drugs administered by yur prvider. The benefit infrmatin prvided is a summary f what we cver and what yu pay. It des nt list every service that we cver r list every limitatin r exclusin. T get a cmplete list f services we cver, please request the Evidence f Cverage (EOC). Yu can see ur plan s Prvider/Pharmacy Directry and the Evidence f Cverage n ur website at www.familycareinc.rg. Yu can see the cmplete plan frmulary (list f Part D prescriptin drugs) and any restrictins n ur website at www.familycareinc.rg. This dcument is available electrnically and may be available in ther frmats. If yu want t knw mre abut the cverage and csts f Original Medicare, lk in yur current Medicare & Yu handbk. View it nline at www.medicare.gv r get a cpy by calling 800- MEDICARE (800-633-4227), 24 hurs a day, 7 days a week. TTY/TDD users shuld call 877-486- 2048. FamilyCare Cmmunity (HMO SNP) is a Medicare Advantage HMO SNP plan with a Medicare and Oregn Health Plan (Medicaid) cntract. Enrllment in FamilyCare Cmmunity (HMO SNP) depends n cntract renewal. Yu must cntinue t pay yur Medicare Part B premium. This infrmatin is nt a cmplete descriptin f benefits. Cntact the plan fr mre infrmatin. Limitatins, cpayments, and restrictins may apply. Benefits, premiums, and/r cpayments/cinsurance may change n January 1 f each year. The frmulary, pharmacy netwrk, and/r prvider netwrk may change at any time. Yu will receive ntice when necessary. Premiums, c-pays, cinsurance, and deductibles may vary based n the level f Extra Help yu receive. Please cntact the plan fr further details. If Y0103_KIT_00351 ACCEPTED
yu meet certain eligibility requirements fr Medicare and Medicaid, yur Medicare Part B premium may be paid n yur behalf by the Oregn Health Plan (Medicaid). FamilyCare Cmmunity (HMO SNP) Phne Numbers, Website, and Hurs f Operatin If yu are a member f this plan, call tll-free 866-798-2273. If yu are nt a member f this plan, call tll-free 866-225-2273 (TTY/TDD: 711). Our website: www.familycareinc.rg. Frm Octber 1 t February 14, yu can call us 7 days a week frm 8 a.m. t 8 p.m. (except Thanksgiving Day and Christmas Day). Frm February 15 t September 30, yu can call us Mnday thrugh Friday, 8 a.m. t 8 p.m., and Saturday and Sunday frm 9 a.m. t 5 p.m. (except Memrial Day, Independence Day, and Labr Day). SECTION 2: PREMIUMS AND OTHER COSTS Mnthly Premium, Deductible, and Limits n Hw Much Yu Pay fr Cvered Services Descriptin Cmmunity Plan Details Mnthly Premium $0 per mnth Yu must cntinue t pay yur Medicare Part B premium. Deductible Maximum Out-Of-Pcket Respnsibility (des nt include prescriptin drugs) This plan des nt have a deductible. $6,700 annually The mst yu pay fr cpays, cinsurance and ther csts fr Medicare-cvered Part A and Part B services fr the year. If yu reach this limit n ut-f-pcket csts, yu keep getting cvered hspital and medical services while we pay the full cst fr the rest f the year. 2
SECTION 3: BENEFITS COVERED MEDICAL AND HOSPITAL BENEFITS Descriptin Yur Cst Nte: Services with a 1 require prir authrizatin. Services with a 2 require a referral frm yur prvider. Inpatient Hspital Care 1,2 Our plan cvers an unlimited number f days fr an inpatient hspital stay. Outpatient Hspital Care 1,2 Ambulatry Surgery Center Outpatient Hspital Dctr s Office Visits Primary Care Physician visit Specialist visit 1 Preventive Care Only preventive services apprved by Medicare are cvered under this benefit. Any additinal preventive services apprved by Medicare during the cntract year will be cvered. Includes services such as the Welcme t Medicare Preventive visit and Annual Wellness visit. Emergency Care If yu are admitted t the hspital within 24 hurs, yu d nt have t pay yur share f the cst fr emergency care. Urgently Needed Services If yu are admitted t the hspital within 24 hurs, yu d nt have t pay yur share f the cst fr urgently needed 3
Descriptin Diagnstic Tests, Lab, Radilgy Services, and X-rays Csts fr these services may be different if received in an utpatient surgery setting. COVERED MEDICAL AND HOSPITAL BENEFITS Yur Cst Diagnstic radilgy services (such as MRIs, CT scans) 1,2 Diagnstic tests and prcedures 1 Lab services 1 Outpatient x-rays 1,2 Therapeutic radilgy services (such as radiatin treatment fr cancer) 1,2 Hearing Services Examinatins t diagnse and treat hearing and balance issues Dental Services 1 Limited dental This des nt include services in cnnectin with care, treatment, filling, remval, r replacement f teeth. Visin Services Nte: Our plan cvers cntact lenses r eyeglasses. Examinatin t diagnse and treat diseases and cnditins f the eye Rutine eye exam (ne per year) Eyeglasses r cntact lenses after cataract surgery Cntact lenses Frames (ne pair per year) up t $65 each year tward cntact lenses when using VSP prviders. up t $200 each year tward ne pair f eyeglass frames when using VSP prviders. Lenses (ne pair per year) when yu use VSP prviders. 4
COVERED MEDICAL AND HOSPITAL BENEFITS Descriptin Yur Cst Mental Health Care 1,2 Inpatient visit Outpatient grup therapy visit Outpatient individual therapy visit Skilled Nursing Facility 1,2 Our plan cvers up t 100 days in a skilled nursing facility. Physical Therapy 1,2 Ambulance 1 Transprtatin See Sectin 4 Medicare Part B Drugs 1 Other Services Fitness Benefit Reimbursed up t $40 a mnth/ up t $480 Ft Care (pdiatry services) 1 per year Ft exams and treatment if yu have diabetes-related nerve damage and/r meet certain cnditins. Rutine ft care is cvered fr up t 12 visits a year. Over-the-Cunter Items Members receive $50 mnthly credit t buy ver-the-cunter items at Rite-Aid, Walgreens, and Wal-Mart pharmacies. Please visit www.familycareinc.rg t see ur list f cvered ver-the-cunter items. Nursing Htline Medical advice is available t members n ur Nursing Htline 24 hurs a day, seven days a week. 5
PRESCRIPTION DRUG BENEFITS Part D Initial Cverage Phase Standard Retail/Mail Order Cst Sharing One-Mnth Supply Three-Mnth Supply Tier 1 (Preferred Generic) $0 cpay $0 cpay Tier 2 (Generic) Tier 3 (Preferred Brand) Tier 4 (Nn-Preferred Drug) Tier 5 (Specialty) Fr generic drugs (including brand drugs treated as generic), yu pay: $0 cpay r $1.25 cpay r $3.35 cpay Fr all ther drugs, yu pay: $0 cpay r $3.70 cpay r $8.35 cpay A 90-day supply is nt available frm ut-f-netwrk pharmacies r fr Tier 5 (Specialty) drugs. Cst sharing may change when yu enter anther phase f the Part D benefit. Fr mre infrmatin n the phases f the benefit, please call us r access ur Evidence f Cverage at www.familycareinc.rg. If yu reside in a lng-term care facility, yu pay the same as at a retail pharmacy. Yu may get drugs frm an ut-f-netwrk pharmacy, but yu may pay mre than yu pay at an in-netwrk pharmacy. 6
SECTION 4: MEDICAID-COVERED SERVICES In this sectin, yu can see a summary f the Medicaid benefits yu may receive thrugh the Oregn Health Plan. As lng as yu are eligible fr the Oregn Health Plan and Medicare Parts A and B, the Medicaid Benefits Packages yu can have thrugh the Oregn Health Plan are the QMB + OHP Limited Drug Benefit Package r the OHP with Limited Drug Benefit Package. Please cntact yur State Medicaid casewrker if yu d nt knw which benefit package yu have thrugh the Oregn Health Plan (Medicaid). This sectin des nt list every Medicaid service cvered. This sectin als des nt list every limitatin r exclusin. T get a cmplete list f Medicaid benefits, please cntact yur Medicaid health plan Custmer Service. Yu must be eligible fr the Oregn Health Plan (Medicaid) in rder t receive the benefits listed in this sectin. Oregn Health Plan (OHP) Benefit Packages: QMB + OHP with Limited Drug Benefit Package This benefit package is fr peple wh qualify t have their Medicare Parts A and B cst sharing paid fr by Medicaid. If yu receive the QMB + OHP with Limited Drug Benefit Package, yu get the benefits listed in the fllwing chart. The cst sharing amunts listed in this sectin fr the Medicare Parts A- and B-cvered services are paid fr yu by yur Medicaid health plan. Yur prvider cannt balance bill yu fr any amunts beynd what yur Medicare and Medicaid plans pay. OHP with Limited Drug Benefit Package This benefit package is fr peple wh nly qualify t have their Medicare Parts A and B cst sharing paid fr by Medicaid fr services nrmally cvered by the Oregn Health Plan. If yu receive the OHP with Limited Drug Benefit Package, yu get the benefits listed in the fllwing chart. The cst sharing amunts listed in this sectin fr Medicare Parts A- and B-cvered services will be cvered nly fr services that the Oregn Health Plan wuld nrmally cver. Yur prvider cannt balance bill yu fr any amunts beynd what yur Medicare and Medicaid plans pay fr services nrmally cvered by the Oregn Health Plan. If yu receive a Medicare-cvered service that is nt nrmally cvered by the Oregn Health Plan, yu will have t pay the Medicare Parts A and B cst sharing yurself. Yu will still have t pay yur Medicare Part D prescriptin drug cst sharing. On the next page is a list f services that are cvered by the Oregn Health Plan (Medicaid) and FamilyCare Cmmunity (HMO SNP) - ur Medicaid managed care plan. This chart des nt include every service available. 7
BENEFIT CATEGORY 1. Premium and Other Imprtant Infrmatin 2. Dctr and Hspital Chice (Fr mre infrmatin, see Emergency (#15) and Urgently Needed Care (#16) OREGON HEALTH PLAN (MEDICAID) Member csts This is a brief summary. Please refer t OHP member handbk fr a detailed descriptin f Medicaid benefits available t eligible Oregnians. Allws fee-fr-service patients t g t any prvider that accepts Medicaid. COMMUNITY HMO SNP Member csts All cst sharing in this summary f benefits is based n yur level f Medicaid eligibility. Yu must g t netwrk dctrs, specialists, and hspitals. (Referral required fr netwrk hspitals and specialists fr certain benefits.) INPATIENT CARE 3. Inpatient Hspital Care $0 cpayment fr Medicaidcvered $0 cpayment fr Medicare- r Medicaid-cvered 4. Inpatient Mental Health Care $0 cpayment fr Medicaidcvered $0 cpayment fr Medicare- r Medicaid-cvered 5. Skilled Nursing Facility $0 cpayment fr Medicaidcvered 6. Hme Health Care (includes medically necessary intermittent skilled nursing care, hme health aide services, and rehabilitatin services, etc.) dctr 7. Hspice $0 cpayment fr Medicaidcvered $0 cpayment fr Medicare- r Medicaid-cvered Medicaid-cvered $0 cpayment fr Medicare- r Medicaid-cvered OUTPATIENT CARE 8. Dctr Office Visits (includes Primary Care Physicians and Specialists) dctr Medicaid-cvered 9. Chirpractic Services dctr Medicaid-cvered 8
BENEFIT CATEGORY OREGON HEALTH PLAN (MEDICAID) Member csts COMMUNITY HMO SNP Member csts 10. Pdiatry Services dctr Medicaid-cvered 11. Outpatient Mental Health Care 12. Outpatient Substance Abuse Care 13. Outpatient Services/ Surgery 14. Ambulance Services (medically necessary ambulance services) 15. Emergency Care (Yu may g t any emergency rm if yu reasnably believe yu need emergency care.) 16. Urgently Needed Care (This is NOT emergency care, and in mst cases is utside the service area.) 17. Outpatient Rehabilitatin Services (ccupatinal therapy, physical therapy, speech and language therapy) dctr dctr dctr $0 cpayment fr Medicaidcvered $0 cpayment fr Medicaidcvered dctr dctr Medicaid-cvered Medicaid-cvered Medicaid-cvered $0 cpayment fr Medicare- r Medicaid-cvered $0 cpayment fr Medicare- r Medicaid-cvered Medicaid-cvered Medicaid-cvered OUTPATIENT MEDICAL SERVICES AND SUPPLIES 18. Durable Medical Equipment $0 cpayment fr Medicaidcvered $0 cpayment fr Medicare- r Medicaid-cvered 9
BENEFIT CATEGORY OREGON HEALTH PLAN (MEDICAID) Member csts COMMUNITY HMO SNP Member csts 19. Prsthetic Devices $0 cpayment fr Medicaidcvered $0 cpayment fr Medicare- r Medicaid-cvered 20. Diabetes Self-Mnitring Training, Nutritin Therapy, and Supplies 21. Diagnstic Tests, X-rays, and Lab Services $0 cpayment fr Medicaidcvered $0 cpayment fr Medicaidcvered $0 cpayment fr Medicare- r Medicaid-cvered $0 cpayment fr Medicare- r Medicaid-cvered PREVENTIVE SERVICES 22. Bne Mass Measurement dctr Medicaid-cvered 23. Clrectal Screening Examinatins dctr Medicaid-cvered 24. Rutine Immunizatins $0 cpayment fr Medicaidcvered services, except immunizatins given fr travel and ther reasns. Medicaid-cvered 25. Mammgrams (annual screening) 26. Pap Smears and Pelvic Examinatins 27. Prstate Cancer Screening Examinatins $0 cpayment fr Medicaidcvered dctr dctr $0 cpayment fr Medicare- r Medicaid-cvered $0 cpayment fr Medicare- r Medicaid-cvered Medicaid-cvered 28. End-Stage Renal Disease dctr Medicaid-cvered 10
BENEFIT CATEGORY OREGON HEALTH PLAN (MEDICAID) Member csts COMMUNITY HMO SNP Member csts 29. Prescriptin Drugs N cst fr cvered drugs. Mental health drugs are cvered by the state and nt by yur Medicaid managed care health plan. Cpays fr thse drugs vary. See the Oregn Health Authrity website fr mre infrmatin. Part D medicatins cvered by yur Medicare health plan (see Sectin 3 fr details) This plan uses a frmulary. The plan will send yu a cpy f the frmulary, r yu can see it at www.familycareinc.rg n the web. 30. Dental Services $0 cpayment fr restrative treatment. $0 cpayment fr Medicaidcvered dental diagnstic and preventive rutine checkup 31. Hearing Services dctr 32. Visin Services dctr 33. Physical Examinatins dctr $0 fr Medicare-cvered limited dental services (des nt include services in cnnectin with care, treatment, filling, remval r replacement f teeth.) Rutine dental care is cvered at n cst under the Oregn Health Plan. Cntact yur OHP crdinated care rganizatin r dental care rganizatin fr details. Medicaid-cvered Medicaid-cvered Members receive yearly credit f up t $65 fr cntact lenses OR up t $200 fr eyeglass frames. One pair f eyeglass lenses are cvered each year. Medicaid-cvered 34. Fitness Benefit Nt cvered Cmmunity (HMO SNP) reimburses members up t $40 a mnth fr dues fr access t 11
BENEFIT CATEGORY OREGON HEALTH PLAN (MEDICAID) Member csts COMMUNITY HMO SNP Member csts and use f a FamilyCare Health apprved facility. 35. Other Nn-Cvered Medicare Services that are cvered by the Oregn Health Plan: Preventive Services Maternity case management, including nutritinal cunseling Maternity and newbrn care Well-child examinatins and immunizatins Family Planning Services: Birth cntrl pills, cndms, cntraceptive implants, and Dep-Prvera Sterilizatins Other Oregn Health Plan Services: Death with Dignity services* Abrtins* *Please nte: These services are cvered by the state and nt by yur Medicaid managed care health plan. dctr $0 cpayment fr Medicaidcvered x-ray, lab, rutine immunizatin, and family planning 36. Transprtatin (medical) $0 cpayment fr Medicaidcvered services In-Netwrk $0 cpayment fr Medicaidcvered preventive and family planning Prir authrizatin rules may apply. Services nt cvered by Cmmunity (HMO SNP): Death with Dignity Services* Abrtins* *Please nte: These services are cvered by the state and nt by yur Medicaid managed care health plan. Rutine transprtatin is nt cvered. Medical transprtatin is cvered under the Oregn Health Plan. Cntact Ride t Care t schedule a ride: 503-416-3955 r www.ridetcare.cm 12
SECTION 5: SERVICES NOT COVERED BY THE OREGON HEALTH PLAN (MEDICAID) (EXCLUSIONS) Nt all medical treatments are cvered. When yu need medical treatment, cntact yur Primary care prvider. These are sme f the exclusins (des nt include every exclusin): Medicare Part D-cvered prescriptin drugs Cnditins where a hme treatment is effective, such as applying an intment, resting a painful jint, drinking plenty f fluids, r a sft diet. Such cnditins include: Canker sres Diaper rash Crns r calluses Sunburn Fd pisning Sprains Persnal cmfrt r cnvenience items (radis, telephnes, ht tubs, treadmills, etc.) Services that are primarily csmetic, such as: Benign skin tumrs Csmetic surgery Remval f scars Cnditins where treatment is nt nrmally effective, such as: Sme back surgery Temprmandibular Jint (TMJ) surgery Sme transplants Services perfrmed by an immediate relative r member f yur husehld Any services received utside the United States Nn-emergency care if yu g t a prvider wh is nt a FamilyCare Health Plan prvider Other nn-cvered services include, but are nt limited t, the fllwing: Circumcisin (rutine) Weight lss prgram Infertility services If yu have questins abut cvered and nn-cvered services, cntact yur Medicaid health plan Custmer Service. 13
Disclaimers FamilyCare Health cmplies with applicable Federal civil rights laws and des nt discriminate n the basis f race, clr, natinal rigin, age, disability, r sex. FamilyCare Health des nt exclude peple r treat them differently because f race, clr, natinal rigin, age, disability, r sex. FamilyCare Health: 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 Navigatins Services: 866-798-2273 If yu believe that FamilyCare Health 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: Appeals and Grievances Crdinatr, FamilyCare Health 825 NE Multnmah St., Suite 1400, Prtland, OR 97232 Phne: 866-798-2273, TTY/TDD: 711, Fax: 503-345-5720 Email: Appeals&Grievances@familycareinc.rg. Yu can file a grievance in persn r by mail, fax, r email. If yu need help filing a grievance, Navigatin Services 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/smartscreenl/main.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 800-368-1019, 800-537-7697 (TDD) Cmplaint frms are available at www.hhs.gv/cr/filing-with-cr/index.html. ATENCIÓN: si habla españl, tiene a su dispsición servicis gratuits de asistencia lingüística. Llame al 866-798-2273 (TTY/TDD: 711). ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 866-798-2273 (телетайп: 711). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành ch bạn. Gọi số 866-798-2273 (TTY/TDD: 711). 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 866-798-2273(TTY/TDD: 711) 14
ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان..)TTY/TTD:711 اتصل برقم 866-798-2273 )رقم هاتف الصم والبكم: 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다. 866-798-2273 (TTY/TDD: 711) 번으로전화해주십시오. ប រយ ត ន បរ ស នជ អ នកន យ យ ភ ស ខ ម រ, បសវ ជ ន យខ នកភ ស ប យម នគ ត ឈ ន ល គ អ ចម នស រ រ រ បរ អ នក ច រ ទ រស ព ទ 866-798-2273 (TTY/TDD: 711) ATTENTION : Si vus parlez français, des services d'aide linguistique vus snt prpsés gratuitement. Appelez le 866-798-2273 (ATS : 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kstenls sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 866-798-2273 (TTY/TDD: 711). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます 866-798-2273(TTY/TDD: 711) まで お電話にてご連絡ください XIYYEEFFANNAA: Afaan dubbattu Ormiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 866-798-2273 (TTY/TDD: 711). ATENȚIE: Dacă vrbiți limba rmână, vă stau la dispziție servicii de asistență lingvistică, gratuit. Sunați la 866-798-2273 (TTY/TDD: 711). เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร 866-798-2273 (TTY/TDD: 711). УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 866-798-2273 (телетайп: 711). توجه: اگر به زبان فارسی گفتگو می کنید تسهیالت زبانی بصورت رايگان برای شما فراهم می باشد. با( 711 (TTY/TDD: 866-798-2273 تماس بگیريد. 15