Genesis @ Home Constellation Health (HMO SNP) 2017 H3054_2017_E009 CMS Accepted Aprobado CEE SA-16 #12051 Constellation Health is an HMO plan with a Medicare contract and a contract with the Puerto Rico Medicaid program. Enrollment in Constellation Health depends on contract renewal. This plan is available to anyone who has both Medical Assistance from the State and Medicare.
2 Summary of Benefits January 1, 2017 - December 31, 2017 This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the "Evidence of Coverage." 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 Genesis @ Home Constellation Health (HMO SNP). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what Genesis @ HomeConstellation Health (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 Benefits 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 Genesis @ Home Constellation Health (HMO SNP) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits 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 1-866-714-0724 (Toll Free), 787-304-4040 (Metro Area) or 1-866-805-7777 (Hearing impaired).
3 Este documento está disponible en otros formatos como Braille y letra grande. Este documento puede estar disponible en idioma que no sea inglés. Para información adicional llámenos al 1-866-714-0724 (Libre de Costo), 787-304-4040 (Área Metro) o 1-866-805-7777 (Audioimpedidos). Things to Know About Genesis @ Home Constellation Health (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. Atlantic time. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Atlantic time. Genesis @ Home Constellation Health (HMO SNP) Phone Numbers and Website If you are a member of this plan, call toll-free 1-866-714-0724. If you are not a member of this plan, call toll-free 1-844-304-4040. TTY users must call 1-866-805-7777. Our website: http://www.constellationhealthpr.com Who can join? To join Genesis @ Home Constellation Health (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and Puerto Rico Government Health Plan (PRGHP), and live in our service area. Our service area includes the following counties in Puerto Rico: Bayamón, Caguas, Canóvanas, Carolina, Cataño, Ceiba, Culebra, Fajardo, Guaynabo, Loíza, Luquillo, Río Grande, San Juan, Toa Baja, Trujillo Alto, and Vieques. Which doctors, hospitals, and pharmacies can I use? Genesis @ Home Constellation Health (HMO SNP) 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 Providers and Pharmacies Directory at our website (http://www.constellationhealthpr.com). Or, call us and we will send you a copy of the Providers and Pharmacies Directory.
4 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 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.constellationhealthpr.com. Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? Our plan groups each medication into one of four "tiers". You will need to use your formulary to locate what tier your 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.
5 Summary of Benefits January 1, 2017 - December 31, 2017 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? $0 per month. In addition, you must continue to pay 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 out-of-pocket costs for medical and hospital care. In this plan, you may pay nothing for Medicare-covered services, depending on your level of the Puerto Rico Government Health Plan (PRGHP) eligibility. Your yearly limit(s) in this plan: $3,400 for services you receive from in network providers. If you reach the limit on out-of-pocket 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. Refer to the "Medicare & You" handbook for Medicarecovered services. For the Puerto Rico Government Health Plan (PRGHP) - covered services, refer to the Medicaid Coverage section in this document. 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. Covered Medical and Hospital Benefits Note: Services with a 1 may require prior authorization.
6 Inpatient Hospital Care 1 Our plan covers 90 days for an inpatient hospital stay. 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. Doctor's Office Visits Primary care physician visit: Specialist visit: Preventive Care 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 Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy) Depression screening Diabetes screenings HIV screening Medical nutrition therapy services Obesity screening and counseling 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
7 Welcome to Medicare preventive visit (one-time) Yearly Wellness visit Any additional preventive services approved by Medicare during the contract year will be covered. Emergency Care Urgently Needed Care Diagnostic Tests, Lab and Radiology Services, and X-Rays (Costs for these services may vary based on place of service) 1 for Urgent Care Services at an innetwork provider. Lab services: Diagnostic tests and procedures: Diagnostic radiology services (such as MRIs, CT scans): Outpatient X-Rays: Therapeutic radiology services (such as radiation treatment for cancer): Hearing Services Dental Services Exam to diagnose and treat hearing and balance issues: Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $0 copay Preventive dental services: Cleaning (for up to 1 every six months): $0 copay Dental X-ray(s): o One (1) full series of intra oral radiographies, including bite, every three (3) years o One (1) initial periapical intra-oral radiography
8 o Up to five (5) additional periapical/intra-oral radiographies per year o One (1) single film-bite radiography per year o One (1) two-film bite radiography per year o One (1) panoramic radiography every three (3) years Fluoride treatment (for up to 1 every six months): Oral exam (for up to 1 every six months): $0 copay Our plan pays up to $275 every year for preventive dental services. The following services are Not Covered on the Dental Coverage: Periodontics, Prosthodontics, including repair of and Crowns. Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): Eyeglasses or contact lenses after cataract surgery: Mental Health Care 1 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 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
9 these extra 60 days, your inpatient hospital coverage will be limited to 90 days. Outpatient group therapy visit: Outpatient individual therapy visit: Outpatient Substance Abuse 1 Group therapy visit: Individual therapy visit: Skilled Nursing Facility (SNF) 1 Our plan covers up to 100 days in a SNF. Outpatient Rehabilitation 1 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): Occupational therapy visit: Physical therapy and speech and language therapy visit: Ambulance Transportation Our plan covers up to 4 one-way trips every year to plan-approved locations. Foot Care (podiatry services) Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Diabetes Supplies and Services 1 Prosthetic Devices (braces, artificial limbs, etc.) 1 Foot exams and treatment if you have diabetesrelated nerve damage and/or meet certain conditions: Part B Drugs 1 For Part B drugs such as chemotherapy drugs: $0 copay
10 Other Part B drugs: Chiropractic Care 1 Home Health Care 1 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): Includes interactive sessions by Health professionals to primarily provide health information and encourage the adoption of healthy behaviors by enrollees, aligned with the overall goal of improving participants health. These sessions may include written material or website content to support the interactive sessions. Outpatient Surgery Ambulatory surgical center: Outpatient hospital: Renal Dialysis 1 Hospice Remote Access Technology for hospice care from a Medicarecertified hospice. You may have to pay part of the cost for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. A contracted provider may diagnose and treat some conditions via telephone, and/or real time interactive audio and video technologies. This type of service will not be used as a substitute for an effective, ongoing doctor-patient relationship, but rather, will be supportive of that relationship and of efficient delivery of needed care. Bathroom Safety Devices
11 Our plan covers up to $150 per member, per year after an In-home safety assessment by an Occupational Therapist. Health Education Group sessions in which the educator provides information or skills instruction; One-on-one instructional sessions; and/or; Interactive web- and/or telephone-based coaching to reinforce what you have learned in a group or individual session. In-home Safety Assessment Our plan covers up to 1 in-home safety assessment by an Occupational Therapist focused on the beneficiary s risk for falls or injuries and identification of how falls may be prevented. Diapers and underpads 1 Box of adult diapers or 1 box of underpads per member per month. Weight Management Program Program designed to promote healthy behaviors that helps you to lose weight and keep it off. Includes in-person lectures offered by a registered nutritionist and/or dietician as well as on-line services in support of a healthy lifestyle. Counseling Services Individual or group counseling sessions to address general topics such as: coping with life changes; conflict resolution; or grief counseling. Sessions are up to 25 minutes. Medical Nutrition Therapy
12 This benefit is for people with diabetes, renal (kidney) disease (but not on dialysis), or after a kidney transplant when ordered by your doctor. We cover 3 hours of one-on-one counseling services during your first year that you receive medical nutrition therapy services under Medicare (this includes our plan, any other Medicare Advantage plan, or Original Medicare), and 2 hours each year after that. If your condition, treatment, or diagnosis changes, you may be able to receive more hours of treatment with a physician s order. A physician must prescribe these services and renew their order yearly if your treatment is needed into the next calendar year. Our plan covers up to four (4) additional individual or group counseling sessions provided by a certified or licensed practitioner which includes physician, nurse, registered dietitian or nutritionist. This benefit is available to all members of Genesis @ Home Constellation Health. Nutritional / Dietary Benefit Post-Discharge In-home Medication Reconciliation Our plan covers up to 4 additional general nutritional education classes and/or individual sessions for all enrollees by certified practitioners. Immediately following discharge from a hospital or SNF inpatient stay, we offer the services of a qualified health care provider who, in cooperation with the enrollee s physician, will review the enrollee s complete medication regimen that was in place prior to admission and compare and reconcile with the regimen prescribed for the enrollee at discharge to ensure new prescriptions are obtained and discontinued medications are discarded. This reconciliation of the enrollee s medications will be provided in the home and is designed to
13 identify and eliminate medication side effects and interactions that could result in illness or injury. Re-admissions Prevention Immediately following an enrollee s discharge from a hospital or skilled nursing facility (SNF) inpatient stay we may combine the benefits below as a complete Readmission Prevention benefit or offer the benefits separately: In-Home Safety Assessment as described earlier in this section; Post discharge In-home Medication Reconciliation, as described earlier in this section Health Education Group sessions in which the educator provides information or skills instruction; One-on-one instructional sessions; and/or; Interactive web and/or telephone-based coaching to reinforce what you have learned in a group or individual session. Prescription Drug Benefits Initial Coverage You pay the following until your total yearly drug costs reach $3,700. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail Cost-Sharing
14 Tier 1 (Generic) Tier Tier 2 (Preferred Brand) Tier 3 (Non-Preferred Brand) One-month Supply Two-month supply Three-month supply $0.25 $0.50 $0.75 $1 $2 $3 $1 $2 $3 Tier 4 (Specialty Tier) $3 $6 $9 Standard Mail Order Cost-Sharing Tier 1 (Generic) Tier 2 (Preferred Brand) Tier Three-month supply $0.75 $3 Tier 3 (Non-Preferred Brand) $3 Tier 4 (Specialty Tier) $9 If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. Coverage Gap Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,700. After you enter the coverage gap, you pay 40% of the plan's cost for covered brand name drugs
15 and 51% of the plan's cost for covered generic drugs until your costs total $4,950 which is the end of the coverage gap. Not everyone will enter the coverage gap. Under this plan, you may pay even less for the brand and generic drugs on the formulary. Your cost varies by tier. You will need to use your formulary to locate your drug's tier. See the chart that follows to find out how much it will cost you. Standard Retail Cost-Sharing Tier Drugs Covered One-month Supply Two-month supply Three-month supply Tier 1 (Generic) All $0.25 copay $0.50 copay $0.75 copay Standard Mail Order Cost-Sharing Tier Tier 1 (Generic) Drugs Covered All Three-month supply $0.75 copay Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,950, you pay the greater of: 5% of the cost, or $3.30 copay for generic (including brand drugs treated as generic) and a $8.25 copayment for all other drugs.
16 Summary of Medicaid-Covered Benefits for Contract H3054, 004 The benefits described below are covered by Medicaid. The benefits described in the Covered Medical and Hospital Benefits section of the Summary of Benefits are covered by Medicare. For each benefit listed below, you can see what Puerto Rico Government Health Plan (PRGHP) covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. Service Medicaid Genesis @ Home Constellation Health (HMO SNP) Hospital Coverage Code 100 110 H3054-004 Admission $0 $3 $0 Nursery $0 $0 $0 EMERGENCY ROOM (ER) Emergency Room (ER) Visit* $0 $0 $0 Non-emergency visit to a hospital $3.80 $3.80 $0 emergency room* Trauma $0 $0 $0 AMBULATORY VISITS TO Primary Care Physician (PCP) $0 $1 $0 Specialist $0 $1 $0 Sub-Specialist $0 $1 $0 Pre-natal Services $0 $0 $0 OTHER SERVICES High-Tech Laboratories** $0 50 $0 Clinical Laboratories** $0 50 $0 X-Rays** $0 50 $0 Special Diagnostic Tests** $0 $1 $0 Therapy - Physical $0 $1 $0 Therapy - Respiratory $0 $1 $0 Therapy - Occupational $0 $1 $0 Vaccines $0 $0 $0 Healthy Child Care $0 $0 $0
17 DENTAL Preventive (Child) $0 $0 $0 Preventive (Adult) $0 $1 $0 Restorative $0 $1 $0 PHARMACY*** Generic (Children 0-20) $0 $0 $0 Generic (Adult)**** $1 $1 $0.25 Brand (Children 0-20) $0 $0 $0 Brand (Adult)**** $3 $3 $1 Preferred brand; $1 Non-preferred brand; $3 for Specialized Other Outpatient Substance Abuse $0 $1 $0 Outpatient Mental Health $0 $1 $0 Eye Exams $0 $1 $0 Hearing Exams $0 $1 $0 Physical Exam $0 $1 $0 Ambulatory Surgery $0 $1 $0 Special Coverage $0 $1 $0 *Copays for emergency and non-emergency visits are under consideration of the Center for Medicare and Medicaid Services (CMS). **Applies only to diagnostic tests. Copays do not apply to a test required as part of a preventive treatment. ***Copays are apply to each drug included in the same prescription. If the MAO has the drugs section divided by tiers copays for each tier must be presented. ****The copays do not apply to pregnant women enrolled in Medicaid (100-110), kids 0-20 years old enrolled in Medicaid and the CHIP Program.