(Cost) Summary of Benefits January 1, 2018 December 31, 2018 is a Medicare Cost plan with a Medicare contract. Enrollment in the Plan depends on contract renewal. The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the Evidence of Coverage. To join, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in Wisconsin: Grant, Crawford, Lafayette and Iowa. has a network of doctors, hospitals, pharmacies, and other providers. You can see our plan s provider directory on our website at www.mahealthcare.com. If you use providers in the network, the plan will pay for Medicare eligible services. If you use the providers that are not in our network, the plan may not pay for Medicare eligible services and Original Medicare cost sharing would apply. H5256 PBP 004_MAHP 909 CMS Accepted 09292017 2018 WI Freedom Plan
Monthly Plan Premium Deductible You pay $142; you must continue to pay your Medicare Part B premium. See Optional Benefits section for additional premium amount. This plan does not have a deductible. Maximum Out-of-Pocket Responsibility Inpatient Hospital None Our plan covers an unlimited number of days for an inpatient hospital stay. Inpatient hospital benefit based on medical necessity. Outpatient Hospital Doctor Visits o Primary o Specialists Preventive Care Any additional preventive services approved by Medicare during the contract year will be covered. Emergency Care Worldwide Coverage Urgently Needed Services Worldwide Coverage
Diagnostic Services/Labs/Imaging o Diagnostic radiology service (e.g., MRI) o Lab services o Diagnostic tests and procedures o Outpatient x-rays Hearing Services o Hearing exam (diagnose and treat hearing and balance Issues) o Routine Hearing exam One routine hearing exam per calendar year with network provider. Dental Services o Oral exam & Cleaning o Fillings o Complete Dentures Vision Services o Vision Exam (diagnose and treat diseases/conditions of the eye) o Routine Eye Exam One routine vision exam per calendar year with a network provider. o Eyeglasses or contact lenses after cataract surgery
Mental Health Services o Inpatient visit Our plan covers an unlimited number of days for an inpatient hospital stay. Inpatient hospital benefit based on medical necessity. o Outpatient group o Outpatient individual Skilled Nursing Facility Our plan covers up to 130 days in a SNF. You are eligible for 30 days each benefit period of non-medicare approved care which meets MAHP criteria for medical necessity and is ordered by a network physician. Physical Therapy o Occupational o Physical therapy and speech and language Ambulance Our plan covers up to the Medicare therapy limits. Our plan covers Medicare eligible ambulance services. Transportation Not covered Medicare Part B Drugs for chemotherapy drugs for other Part B drugs
Foot Care (podiatry services) o Foot exams and treatment o Routine foot care Six routine visits per calendar year with network provider. Medical Equipment/Supplies o Durable Medical Equipment (e.g., wheelchairs, oxygen) o Prosthetics (e.g., braces, artificial limbs) o Diabetes supplies Wellness Programs (e.g., fitness) Medicare Part D Drugs Not covered Package 1: Out of Network Benefit Monthly Plan Premium Optional Benefits Benefits include: Out of Network option You may use any provider who agrees to see Medicare beneficiaries for Medicare eligible services. Additional $26 per month in addition to your $142 monthly plan premium. You must continue to pay your Medicare Part B premium. Copayment Out of Network copayments: $15 per office visit $15 per outpatient rehabilitation visit $75 per outpatient surgery $100 per inpatient day, maximum of $500 per benefit period Out of Network Medicare eligible services covered up to Medicare allowable.
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. This document is available in other formats such as Braille, large print or audio. For more information, please call us at the phone number below or visit us at www.mahealthcare.com. 563-584-4885 or 1-866-821-1365 (toll-free), TTY users should call 1-800-735-2942. You can all us 7 days a week from 8:00 a.m. to 8:00 p.m. CST. Discrimination is Against the Law Medical Associates Health Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Medical Associates Health Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Medical Associates Health Plans provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats. Medical Associates Health Plans provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Member Services at 563-584-4885 or 1-866-821-1365. If you believe that Medical Associates Health Plans has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Member Services, Address: 1605 Associates Drive Dubuque, IA 52002, Phone: 563-584-4885 or 1-866-821-1365, TTY: 1-800-735-2942, Fax: 563-584-4760, Email: memberservices@mahealthcare.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Language Access Services: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866- 821-1365 (TTY: 1-800-735-2942). LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-866- 821-1365 (TTY: 1-800-735-2942)
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