Information for Dual-Eligible Members with Secondary Coverage through California January 1, 2011 December 31, 2011 Los Angeles County This publication is a supplement to the 2011 Positive (HMO SNP) Evidence of Coverage and is for dual-eligible members who are enrolled in Positive and have (fee-for-service). This publication explains which benefits are covered through Partners as primary Medicare payer, and which benefits are covered through Regular Medi-Cal (fee-for-service) as secondary payer and how these benefits are coordinated. Positive is a Medicare Advantage Prescription Drug (MA-PD) health plan with a Medicare contract. For help or information, please call Member Services at (800) 263-0067, Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. This information is available in different formats, including Spanish. Please call Member Services at the number listed above if you need plan information in another format or language. Esta información está disponible en un formato diferente, incluyendo el español. Por favor llame el Departamento de servicios para miembros en el número arriba, si usted necesita información del plan en otro formato o lengua. Benefits, formulary, pharmacy network, premium and/or copayments/coinsurance may change on January 1, 2012. H5852_1009 2011 1 101910 CMS Approved 10222010
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 Positive (HMO SNP) 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 Positive. Generally, Positive is the primary, or first, payer for your health care and prescription drugs. (fee-for-service) is the secondary, or second, payer. If Positive 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, Positive 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. You may be able to get Extra Help to pay for your prescription drug costs. To see if you qualify for extra help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week; The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or Your State Medicaid Office. Positive is available to all people with Medicare who have been diagnosed with HIV/AIDS. Members may enroll in Positive only during specific times of the year. Contact Member Services at the phone number on the front of this publication for more information or see Chapter 10 in the 2011 Evidence of Coverage. - 1 -
Covered Services by Payer The table below and on the following pages describes which services are covered by Positive and which are covered by (fee-forservice). For more information about benefits covered through Partners and their cost sharing and limitations, if any, see Chapter 4 in the 2011 Evidence of Coverage. Benefit Inpatient Care Inpatient Hospital Care In network. $0 copay. Plan covers 90 days each benefit period. If more than 90 days are required, plan covers up to 60 additional days lifetime reserve days. Includes substance abuse and rehabilitation services. 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) Long-Term Care (Care in a facility for longer than the month of admission plus one month.) 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. 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.) Hospice Outpatient Care Doctor Office Visits Chiropractic Services Medicare-covered home health visits. Authorization rules may Covered by Original Medicare at Medicarecertified hospice. Hospice consultation services covered by plan. each primary care and specialist doctor visit and in-area, network urgent care visit for Medicarecovered benefits. Medicare-covered chiropractic visits. Not covered. - 3 -
Podiatry Services Outpatient Mental Health Care Outpatient Substance Abuse Care Outpatient Services/Surgery Ambulance Services (medically necessary ambulance services) Emergency Care Medicare-covered podiatry benefits. Authorization rules may Medicare-covered mental health visits. Medicare-covered visits. each Medicare-covered ambulatory surgical center and outpatient hospital facility visit. Authorization rules may Medicare-covered ambulance benefits. $0 copay for each Medicare-covered emergency room visit. Not covered. Urgently Needed Care (This is not emergency care, and in most cases, is out of the service area.) Not covered outside the US except under limited circumstances. $0 copay for each Medicare-covered urgentcare visit. - 4 -
Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy, Respiratory Therapy Services, Social/ Psychological Services, and more) Medicare-covered Occupational Therapy, Physical and/or Speech and Language Therapy visits. $0 copay for Medicare-covered Cardiac Rehab services. Outpatient Medical Services and Supplies Durable Medical Equipment Medicare-covered items. (includes wheelchairs, oxygen, etc.) Prosthetic Devices (includes braces, artificial limbs and eyes, etc.) Diabetes Self-Monitoring Training, Nutrition Therapy and Supplies (includes coverage for glucose monitors, test strips, lancets, screening tests, self management training, retinal exam/glaucoma test, and foot exam/therapeutic soft shoes) Diagnostic Tests, X-Rays, Lab Services, and Radiology Services In network. 0% of the cost for Medicare-covered items. Authorization rules may diabetes self-monitoring training, nutrition therapy and diabetes supplies. In network. 0% of the cost for Medicare-covered services. Authorization rules may - 5 -
Preventive Services Bone Mass Measurement (for people with Medicare who are at risk) Case Management and Disease Management Services Colorectal Screening Exams (for people with Medicare age 50 and older) Immunizations (Flu vaccine, hepatitis B vaccine for people with Medicare who are at risk, pneumonia vaccine) Mammograms (Annual Screening) (for women with Medicare age 40 and older) Pap Smears and Pelvic Exams (for women with Medicare) Prostate Cancer Screen Exams (for men 50 and older) End-State Renal Disease (ESRD) Medicare-covered bone mass measurement. $0 copay for case management and disease management services provided by plan s nurses. Medicare-covered colorectal screenings. flu, pneumonia and hepatitis B vaccines. No referral needed for flu and pneumonia vaccines. In network. 0% of the cost for Medicare-covered screening mammograms. Medicare-covered pap smears and pelvic exams. Medicare-covered prostate cancer screening. Medicare-covered renal dialysis and nutrition therapy for ESRD. Not covered. - 6 -
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 Partners formulary. Help for copays may be available. See Chapter 6 of the 2011 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 for cost sharing information. In most cases, your prescriptions are covered only if they are filled at the plan s network pharmacies. Quantity limits and restrictions may Dental Services Medicare-covered dental benefits. Not covered. $0 copay for preventive dental benefits. Plan offers additional comprehensive dental benefits. $1,250 limit for dental benefits every year. - 7 -
Hearing Services Vision Services Medicare-covered diagnostic hearing exams. $0 copay for one (1) routine hearing test every year and fitting-evaluation for a hearing aid. $0 copay for one (1) hearing aid every year. $400 limit for hearing aid every year. diagnosis and treatment for diseases and conditions of the eye and one (1) routine eye exam 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 Positive ; $0 copay; requires prior authorization. $0 copay for one (1) pair of eyeglasses or contact lenses after cataract surgery one (1) pair of glasses, contacts, lenses, and/or frames. $100 plan coverage limit for eye wear every year. Plan additional vision benefits. - 8 -
Welcome to Medicare; and Annual Wellness Visit $0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits. Limited to one (1) exam every year. covers exams not covered by Medicare. Health/Wellness Education $0 copay for 24-hour nurse advice line. Members may choose either a gym membership or up to $250 worth of nutritional products every year for $0 copay. Not covered. $0 copay for each Medicare-covered smoking cessation counseling session. $0 copay for each Medicare-covered HIV screening. Transportation up to 12 round trips 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 Not covered. Not covered. - 9 -
Benefit covered by both Positive and (fee-forservice); however, Positive is primary payer and services will be provided through Positive network providers. There is no copay for covered services through Positive and (feefor-service). Outpatient mental health care is covered by both Positive and the Los Angeles County Department of Mental Health through a contract with Medi- Cal; however, Positive is primary payer and services will be provided through Positive network providers. Outpatient substance abuse care is covered by both Positive and the California Department of Alcohol and Drug Programs; however, Positive is primary payer and services will be provided through Positive network providers. Most prescription drugs are covered through Positive for dualeligible members. Some prescription drugs are not on Positive list of drugs (formulary). (fee-for-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 Member Services for more information at (800) 263-0067, Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. Benefit covered by Positive. Only eye exams and diagnostic tests for the evaluation of vision are covered by (fee-for-service). Positive is primary payer and services will be provided through Positive network providers. Coordination of Covered Services Positive coordinates the covered services provided to you by Positive. If you require services covered by (feefor-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 Positive has its own provider networks. (fee-forservice) has participating providers who contract with Medi-Cal to provide services to Medi-Cal recipients. Most of the Positive providers accept Regular - 10 -
Medi-Cal (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. For services you receive through Positive, you must generally receive your care from a network provider. In most cases, care you receive from a nonnetwork provider (a provider who is not part of the Positive network) will not be covered. See Chapter 3 of your 2011 Positive Evidence of Coverage for more information. Which Member Identification Card to Use As a dual eligible member enrolled in Positive and eligible for (fee-for-service) you receive a Positive member identification (ID) card. When you get covered services or fill prescriptions, show your Partners member identification (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 Positive member ID card, please call Member Services at (800) 263-0067, Monday through Friday, 8:00 a.m. to 8:00 p.m. 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, Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. - 11 -