Information for Dual-Eligible Members with Secondary Coverage through California January 1, 2015 December 31, 2015 Los Angeles County This publication is a supplement to the 2015 Evidence of Coverage and is for dual-eligible members who are enrolled in PHP and have California Regular Medi- Cal (fee-for-service). This publication explains which benefits are covered through PHP as primary Medicare payer, and which benefits are covered through (fee-for-service) as secondary payer and how these benefits are coordinated. This information is available for free in other languages. Please contact our Member Services number at (800) 263-0067 for additional information. (TTY users should call 711). Hours are 8:00 a.m. to 8:00 p.m., seven days a week. Member Services also has free language interpreter services available for non-english speakers. Esta información está disponible gratis en otros idiomas. Por favor, póngase en contacto con el número de nuestro Departamento de servicios para miembros (800) 263-0067 para obtener información adicional. (Los usuarios de TTY deben llamar al 711). El horario es de 8:00 a.m. a 8:00 p.m., siete días a la semana. El Departamento de servicios para miembros también tiene servicios de intérprete gratis para personas que no hablan inglés. PHP is an HMO plan with a Medicare contract. Enrollment in PHP depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may Benefits, formulary, pharmacy network, premium, deductible and/or copyaments/coinsurance may change on January 1 of each year. H5852_2081 2015 122414 Approved
Introduction You have received this publication because you are dual-eligible. This means that you are eligible for health care coverage through Medicare and Medi-Cal. You are enrolled in for your Medicare medical (Part C) and prescription drug (Part D) coverage and have (fee-for-service) that covers certain health care services that Medicare does not. Medi-Cal also covers some of the costs of your Medicare coverage such as Medicare Part B premium and deductible. You and/or Medi- Cal must continue to pay your Medicare Part B premium to be eligible for PHP. Generally, PHP is the primary, or first, payer for your health care and prescription drugs. (fee-for-service) is the secondary, or second, payer. If PHP does not cover a service or has limitations on a service you need that you have exhausted, (fee-for-service) will usually cover that service. For example, PHP does not cover long-term care, however, (fee-for-service) does. Please refer to the table on the following pages for all Medi-Cal-covered services. If you have any questions about covered services through PHP or Medi-Cal, please call Member Services at (800) 263-0067, 8:00 a.m. to 8:00 p.m., seven days a week. TTY users call 711. Covered Services by Payer The table on the following pages describes which services are covered by PHP and which are covered by (fee-for-service). For more information about benefits covered through PHP and their cost sharing and limitations, if any, see Chapter 4 in the 2015 Evidence of Coverage. Covered services are based on medical necessity as determined by your provider. Some limitations shown in the column do not apply to children and pregnant women. - 1 -
Inpatient Care Inpatient Hospital Care In network. $100 copay per day for days 1 through 6; $0 copay per day for days 7 through 90 Plan covers 90 days each benefit period. If more than 90 days are required, plan covers up to 60 additional days lifetime reserve days. Lifetime reserve days can only be used once. Includes substance abuse and rehabilitation services. covers the inpatient hospital costsharing of $100 per day for days 1 through 6. If inpatient stay is greater than 90 days and lifetime reserve days are exhausted, covers additional medically necessary inpatient care; no limits; $0 copay; requires prior authorization. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. Inpatient Mental Health Care In network. $0 copay. 190-day lifetime limit in a psychiatric hospital. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. Coverage when 190-day lifetime limit is exhausted is provided by the Los Angeles County Department of Mental Health through a contract with Medi-Cal. $0 copay. - 2 -
Skilled Nursing Facility (SNF) In network in a Medicarecertified SNF. $0 copay. Plan covers up to 100 days each benefit period. No prior hospital stay is required. If SNF stay is longer than 100 days, covers additional days. See Long-Term Care. Long-Term Care (Care in a facility for longer than the month of admission plus one month.) Not covered. Covered; no limits; $0 copay; requires prior authorization. Home Health Care (includes medically necessary intermittent skilled nursing care, home health aide services, rehabilitation services, etc.) home health visits. Authorization rules may Hospice Covered by Original Medicare at Medicarecertified hospice. Hospice consultation services covered by plan. Outpatient Care Doctor Office Visits each primary care doctor and specialist visit and urgent care visit for benefits. - 3 -
Chiropractic Services chiropractic visits. Podiatry Services chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part). podiatry benefits. Authorization rules may podiatry visits are for medically necessary foot care. Outpatient Mental Health Care Outpatient Substance Abuse Care Outpatient Services mental health visits and partial hospitalization program services. Authorization rules may visits. each ambulatory surgical center and outpatient hospital facility visit. Authorization rules may - 4 -
Ambulance Services (medically necessary ambulance services) ambulance benefits. Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care.) $0 copay for each emergency room visit. Not covered outside the US except under limited circumstances. Urgently Needed Care (This is not emergency care, and in most cases, is out of the service area.) $0 copay for each urgentcare visit. Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy) occupational therapy, physical therapy, and speech and language therapy visits. Outpatient Medical Services and Supplies Durable Medical Equipment items. (includes wheelchairs, oxygen, etc.) - 5 -
Prosthetic Devices (includes braces, artificial limbs and eyes, etc.) prosthetic devices and medical supplies related prosthetics, splints and other devices. Diabetes Programs and Supplies diabetes self-management training, diabetes monitoring supplies and therapeutic shoes or inserts. Diagnostic Tests, X-Rays, Lab Services, and Radiology Services lab services, diagnostic procedures and tests, X- rays, diagnostic radiology services and therapeutic radiology services. Cardiac and Pulmonary Rehabilitation Services cardiac rehabilitation services, intensive cardiac rehabilitation services and pulmonary rehabilitation services. Authorization rules may - 6 -
Preventive Services Case Management and Disease Management Services $0 copay for case management and disease management services provided by plan s nurses. Not covered. Preventive Services all preventive services. preventive services are those covered under Original Medicare. $0 copay for annual physical exam. Authorization rules may apply for certain preventive services. Kidney Disease and Conditions renal dialysis and kidney disease education services. - 7 -
Outpatient Prescription Drugs $0 copay for Part B- covered drugs. Part D drugs are covered, but there may be cost sharing. Covers some drugs not on PHP formulary. Help for copays may be available. See Chapter 6 of the 2015 Evidence of Coverage for a complete description of Part D coverage and your Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (also called Low Income Subsidy Rider or LIS Rider) for cost sharing information that applies to you. In most cases, your prescriptions are covered only if they are filled at the plan s network pharmacies Quantity limits and restrictions may - 8 -
Dental Services dental benefits. $0 copay for preventive dental services: Oral exams Up to 2 cleanings a year 1 dental x-ray a year Up to 2 fluoride treatments a year $0 copay for comprehensive dental services such as: Non-routine services Diagnostic services Restorative services Endodontics/ periodontics/ extractions Prosthodontics, other oral/maxillofacial surgery, other services If the following medically necessary dental services exceed $800 in a year, will cover them. You must use a dentist that accepts. Emergency dental services Denture-related procedures; usually requires prior authorization Dental implants and implant-retained prostheses; usually requires prior authorization Comprehensive dental services are limited to $800 every year. - 9 -
Hearing Services diagnostic hearing exams. $0 copay for one (1) supplemental routine hearing exam every year and fitting-evaluation for a hearing aid. $0 copay each for up to two (2) supplemental hearing aids every year. $400 plan coverage limit for supplemental hearing aids every year. Hearing exams not covered. If cost of hearing aid(s) exceeds $400 in a year, covers difference up to the current yearly Medi-Cal limit for the type of hearing aid required. Annual limit computation includes $400 coverage through PHP; $0 copay; requires prior authorization. - 10 -
Vision Services diagnosis and treatment for diseases and conditions of the eye, including an annual glaucoma screening for people at risk. $0 copay for one (1) pair of eyeglasses (lenses and frames) or contact lenses after cataract surgery. $0 copay for one (1) pair of eyeglasses (lenses and frames), contact lenses, eyeglass lenses, and/or eyeglass frame every year. $100 plan coverage limit for supplemental eye wear every year. - 11 -
Health/Wellness Education and Other Supplemental Benefits & Services $0 copay for 24-hour nurse advice line, health education information and additional smoking and tobacco use cessation visits. Not covered. Members may choose either a gym membership or up to $200 worth of over-the-counter items, such as vitamins, fiber supplements, first aid supplies, sunscreen, tooth brushes and pastes, cold medication, antacids, etc., every year for $0 copay. Transportation up to 12 round trip(s) to plan-approved location every year. Authorization rules may If number of medically necessary round trips exceeds 12, Regular Medi- Cal covers transportation when specialist is 10 miles or more from your primary care provider s (PCP s) office; $0 copay; requires prior authorization. Acupuncture and Other Alternative Therapies Not covered. Not covered. - 12 -
Benefit covered by both PHP and (fee-for-service); however, PHP is primary payer and services will be provided through PHP network providers. There is no copay for covered services for dual-eligible members regardless if the service is covered by PHP or (fee-for-service). Outpatient mental health care is covered by both PHP and the Los Angeles County Department of Mental Health through a contract with Medi-Cal; however, PHP is primary payer and services will be provided through PHP network providers. Outpatient substance abuse care is covered by both PHP and the California Department of Alcohol and Drug Programs; however, PHP is primary payer and services will be provided through PHP network providers. Most prescription drugs are covered through PHP for dual-eligible members. Some prescription drugs are not on PHP s list of drugs (formulary). (feefor-service) will generally cover those drugs that are not on our formulary with no copay. Help to pay copays for certain drugs may be available through California s AIDS Drug Assistance Program (ADAP), but you must apply for it. Call the Ramsell Public Health Rx Customer Service Help Desk at (888) 311-7632. The California Department of Public Health, Office of AIDS has contracted with Ramsell Public Health Rx to administer the California ADAP. Benefit covered by PHP. Only eye exams and diagnostic tests for the evaluation of vision are covered by (fee-for-service). PHP is primary payer and services will be provided through PHP network providers. Coordination of Covered Services PHP coordinates the covered services provided to you by PHP. If you require services covered by (fee-for-service), your primary care provider or specialist will refer you to the appropriate participating Medi-Cal provider and get authorization from Medi-Cal for that service, if required. Getting Covered Services from Network Providers PHP has its own provider networks. (fee-for-service) has participating providers who contract with Medi-Cal to provide services to Medi-Cal recipients. Most of the PHP providers accept (fee-for-service), but not all. If you need a referral for a service that is covered by (fee-for-service), your primary care provider will refer you to a participating Medi-Cal provider. - 13 -
For services you receive through PHP, you must generally receive your care from a network provider. In most cases, care you receive from a non-network provider (a provider who is not part of the PHP network) will not be covered. See Chapter 3 of your 2015 PHP Evidence of Coverage for more information. Which Member Identification Card to Use As a dual eligible member enrolled in PHP and eligible for (fee-forservice) you receive a PHP member identification (ID) card. When you get covered services or fill prescriptions, show your PHP member ID card and your Medi-Cal Beneficiary ID Card (BIC). Do not use your red, white and blue Medicare ID card. Put it away for safe keeping in case you need to use it later if you change Medicare coverage. If you lose your PHP member ID card, please call Member Services at (800) 263-0067, 8:00 a.m. to 8:00 p.m., seven days a week. TTY users call 711. For More Information If you have questions about your covered services or their coordination, please call Member Services at (800) 263-0067, 8:00 a.m. to 8:00 p.m., seven days a week. TTY users call 711. - 14 -