Y0097_1303_M Accepted Summary of Benefits

Transcription

1 Y0097_1303_M Accepted 2019 Summary of Benefits

2 How to Contact Gateway Health GATEWAY ( ) (TTY 711) How to Find a Provider or Pharmacy GatewayHealthPlan.com Hours of Operation From October 1 to March 31, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. From April 1 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time.

3 Dual Eligible (D-SNP) Plans Highlights Medicare Assured Diamond SM (HMO SNP) Medicare Assured Ruby SM (HMO SNP) Monthly Plan Premium $0 * Primary Care Visits as low as $0 Deductible $0 Preventive Care Urgent & Emergency Care In and out-of-network Diagnostic Services/ Labs/Imaging Generic prescriptions as low as $0 Monthly Plan Premium $37 Primary Care Visits as low as $0 Deductible as low as $0 Preventive Care Urgent & Emergency Care In and out-of-network Diagnostic Services/ Labs/Imaging Generic prescriptions as low as $0 To be eligible for the Diamond plan, you must have Medicare Parts A and B and Medical Assistance (Full or QMB). Also, you must live in our service area and with limited exceptions you must not have End-Stage Renal Disease. To be eligible for the Ruby plan, you must have Medicare Parts A and B and Medical Assistance (SLMB, QI or QDWI). Also, you must live in our service area and with limited exceptions you must not have End-Stage Renal Disease. Have Questions? Gateway ( ) (TTY 711) 8 a.m. 8 p.m. 7 days a week

4 2019 Summary of Benefits Assured Diamond (HMO SNP) Assured Ruby (HMO SNP) This is a summary of drug and health benefits for January 1, 2019 December 31, 2019 The benefit information provided is a summary of what we cover and what you pay. It does not list every benefit that we cover or list every limit or exclusion. To get a complete list of benefits we cover, please request the Evidence of Coverage by calling Gateway (TTY users call 711). From October 1 to March 31, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. From April 1 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time. You can also view or download the Evidence of Coverage at

5 To join Assured Diamond (HMO SNP) or Assured Ruby (HMO SNP), 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: Pennsylvania County Service Area Adams Allegheny Armstrong Beaver Bedford Berks Blair Bucks Butler Cambria Chester Clarion Crawford Cumberland Dauphin Delaware Erie Fayette Forest Greene Huntingdon Indiana Lancaster Lawrence Lebanon Lehigh Mercer Montgomery Northampton Perry Philadelphia Schuylkill Somerset Venango Washington Westmoreland York Assured Diamond and Ruby plans are Medicare Advantage HMO Special Needs Plans with a Medicare contract. These plans are designed specifically for people who have Medicare and who are also entitled to assistance from Medicaid. More About Original Medicare If you want to know more about the cost and coverage of Original Medicare, look in your current "Medicare & You" handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Have Questions? Gateway ( ) (TTY 711) 8 a.m. 8 p.m. 7 days a week

6 Plan Benefits Assured Diamond SM (HMO SNP) Assured Ruby SM (HMO SNP) Monthly Plan Premium $0 Monthly Plan Premium * $37 Monthly Plan Premium * Deductible $0 Maximum Out-of-Pocket Responsibility (does not include prescription drugs) $3,400 Out-of-Pocket Limit for In-Network Medicare-covered Services Inpatient Hospital Coverage^ $0 Copay per day for days 1-90 Outpatient Hospital Coverage^ $0 and Authorization required $0 or $85 per year for Part D for co-pay level 4, based on level of extra help $6,700 Out-of-Pocket Limit for In-Network Medicare-covered Services $275 Copay Days 1 to 5 and $0 Copay Days 6 to 90 $200 Copay for Hospital $275 Copay for Observation Services Doctor Visits $0 * for PCP and Specialist visits $0 PCP visits and $35 * Specialist visits Preventive Care $0 $0 Emergency Care $0 * to Hospital and cannot be applied towards $90 * Copay will not be waived if admitted Deductible Urgently Needed Services $0 * to Hospital and cannot be applied towards $45 * Copay will not be waived if admitted Deductible Lab Services & Diagnostic Tests^ $0 * and Authorization required $0 * and Authorization required X-rays / Complex Imaging^ (e.g., CT scan/mri) $0 * and Authorization required $35 * Copay and Authorization required Hearing Exam $0 * for routine exams $0 * for routine exams Hearing Aid Preventive Dental Services (every six months) Vision Services (Davis Vision Network) $1500 Maximum Every two years Both ears combined One cleaning & oral exam. One dental x-ray/ one panoramic x-ray every 5 years. Filings, simple extractions and two crowns per year. 1 Exam Every year Supplemental Eyewear: Limited to one (1) pair of glasses or Contact Lenses each year. Vendor frames and standard lenses or standard contact lenses at no cost per calendar year when purchased from Davis vision collection. $200 toward non-vendor frames or $200 toward non vendor contact lenses per calendar year. $750 Maximum Every two years Both ears combined One dental x-ray every six months One panoramic x-ray every 5 years 1 Exam Every year $35 Copay Supplemental Eyewear: Limited to one (1) pair of glasses or Contact Lenses each year. Vendor frames and standard lenses or standard contact lenses at no cost per calendar year when purchased from Davis vision collection. $175 toward non-vendor frames or $175 toward non vendor contact lenses per calendar year. Mental Health Services $0 * for Individual and Group Sessions $35 * Copay for Individual and Group Sessions

7 Plan Benefits Assured Diamond SM (HMO SNP) Assured Ruby SM (HMO SNP) Skilled Nursing Facility^ $0 $0 Copay Days 1 to 20 and $172 * Copay Days 21 to 100 Physical Therapy^ $0 * and Authorization required $35 * Copay and Authorization required Ambulance^ Transportation^ Medicare Part B Drugs^ $0 $0 * for Ground and Air. Authorization required for Non-Emergency Medicare Services 50 trips, one way, Every year in Planapproved Location. Requires 72 hour notice Transportation services are for medical related reasons only as defined by the plan. Mode of transportation also includes car. Authorization (based on criteria established by Gateway Health) and scheduling rules apply. Beneficiary must call noted transportation vendor to receive service. $200 * Copay for Ground and Air. Authorization required for Non-Emergency Medicare Services 24 trips, one way, Every year in Planapproved Location. Requires 72 hour notice Transportation services are for medical related reasons only as defined by the plan. Mode of transportation also includes car. Authorization (based on criteria established by Gateway Health) and scheduling rules apply. Beneficiary must call noted transportation vendor to receive service. 20% * Coinsurance and Prior authorization required for certain Part B/Chemo drugs Foot Care^ (podiatry services) $0 and Authorization required $35 and Authorization required Medical Equipment/Supplies & Prosthetics^ $0 * and Authorization required 20% * Coinsurance and Authorization required Diabetic Testing Supplies $0 and Authorization required 20% * Coinsurance and Authorization required Lab/Diagnostic Tests (Phys Office or Freestanding Lab) Lab/Diagnostic Tests (Outpatient Facility) Therapeutic and Radiology Services $0 Covered in Full $0 and Authorization required $0 and Authorization required $0 and Authorization required X-Rays $0 $35 Copay Cardiac and Pulmonary Rehabilitation Services Nursing Hotline $0 Toll-free telephonic coaching and nurse advice from trained clinicians, 24 hours a day, 7 days a week regarding a recent diagnosis, treatment options or surgery, current symptoms, self-care home treatments, when to go to the doctor, when to go to the Urgent Care Center or Emergency Room, preventive care and lab tests. $175 Copay for Diagnostic $60 for Therapeutic $35 for X-Ray $35 Copay for Cardiac rehab, $30 Copay for Pulmonary rehab Toll-free telephonic coaching and nurse advice from trained clinicians, 24 hours a day, 7 days a week regarding a recent diagnosis, treatment options or surgery, current symptoms, self-care home treatments, when to go to the doctor, when to go to the Urgent Care Center or Emergency Room, preventive care and lab tests. Benefits continued on next page * Depending on your level of Medicaid eligibility and/or level of Extra Help # Once you pay $5,100 out-of-pocket, the plan will pay all or most of the drug costs for the remainder of the calendar year. ^Prior authorization may be required Have Questions? Gateway ( ) (TTY 711) 8 a.m. 8 p.m. 7 days a week

8 Plan Benefits Personal Emergency Response System (PERS) Assured Diamond SM (HMO SNP) Benefit coordinated through Gateway Health Case Management Department. Limited to one PERS device per member per lifetime. Assured Ruby SM (HMO SNP) Not Covered Inpatient Mental Health Care Days 1-150: $0 copay Days 1-5: $275 copay per day Chiropractic Services $0 and Authorization required $35 Copay and Authorization required Diabetes Programs and Supplies $0 and Authorization required for diabetes self-management training, monitoring supplies, therapeutic shoes or inserts Outpatient Prescription Drugs Part D Deductible: $0 to $85* Initial Coverage Limit: $3,820 Out-of-Pocket: $5,100 # 30-Day Supply Tier 1 Preferred Generic Drugs All drugs $0.00 $0 and Authorization required for diabetes self-management training, 20% monitoring supplies, therapeutic shoes or inserts Part D Deductible: $0 to $85* Initial Coverage Limit: $3,820 Out-of-Pocket: $5,100 # 30-Day Supply Tier 1 Preferred Generic Drugs All drugs $0.00 Part D Prescription Drugs Initial Coverage Period^ (Amounts also apply to 60 and 90-day supplies) Tier 2 Generic Drugs All drugs $0.00, $1.25, or $3.40, Tier 3 Preferred Brand Drugs Generic drugs $0.00, $1.25, or $3.40, Brand drugs $0.00, $3.80, or $8.50, Tier 4 Non-Preferred Drugs Generic drugs $0.00, $1.25, or $3.40, Brand drugs $0.00, $3.80, or $8.50, Tier 5 Specialty Tier Drugs Generic drugs $0.00, $1.25, or $3.40, Brand drugs $0.00, $3.80, or $8.50, Tier 2 Generic Drugs All drugs $0.00, $1.25, or $3.40, Tier 3 Preferred Brand Drugs Generic drugs $0.00, $1.25, or $3.40, Brand drugs $0.00, $3.80, or $8.50, Tier 4 Non-Preferred Drugs Generic drugs $0.00, $1.25, or $3.40, Brand drugs $0.00, $3.80, or $8.50, Tier 5 Specialty Tier Drugs Generic drugs $0.00, $1.25, or $3.40, Brand drugs $0.00, $3.80, or $8.50,

9 Plan Benefits Assured Diamond SM (HMO SNP) Assured Ruby SM (HMO SNP) Optional Supplemental Benefits Health Education SilverSneakers Fitness Program Preventive Services, Wellness/Education and other Supplemental Benefit Programs Over-the-Counter Items (no cough/cold) Tobacco Cessation Bathroom/Home Safety Devices Disease Management Program featuring: Health education materials, and Telephonic outreach for education and support from Plan Care Managers Provides membership at participating network fitness centers at no cost, including: Basic fitness membership to Plan approved fitness facility Orientation to the fitness center and instructions about how to use equipment and services Pak per year for those members with limited access to a network fitness center. $0 Copay for all preventive services covered under Original Medicare at $0 sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. $300 Every three months Members will receive OTC catalog with a quarterly limit for purchasing CMSapproved non-prescription over-the-counter medication and health-related items through catalog purchasing.(limits and shipping restrictions may apply) Maximum Plan Benefit Coverage carried forward expires at the end of the calendar year Plan provides two additional counseling visits per attempt, in addition to the Medicare-covered benefit. Benefit coordinated through Gateway Health Case Management Department. Limited to 5 in home safety devices per year. Items limited to: toilet seat riser, toilet safety arm support, tub grab bars, tub and shower anti slip treads, wall mount grab bars, reaching aid and rug anchors Not Covered Provides membership at participating network fitness centers at no cost, including: Basic fitness membership to Plan approved fitness facility Orientation to the fitness center and instructions about how to use equipment and services Pak per year for those members with limited access to a network fitness center. $0 Copay for all preventive services covered under Original Medicare at $0 sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. $40 Every three months Members will receive OTC catalog with a quarterly limit for purchasing CMSapproved non-prescription over-the-counter medication and health-related items through catalog purchasing.(limits and shipping restrictions may apply) Maximum Plan Benefit Coverage carried forward expires at the end of the calendar year Not Covered Not Covered * Depending on your level of Medicaid eligibility and/or level of Extra Help # Once you pay $5,100 out-of-pocket, the plan will pay all or most of the drug costs for the remainder of the calendar year. ^Prior authorization may be required Have Questions? Gateway ( ) (TTY 711) 8 a.m. 8 p.m. 7 days a week

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11 Important Information for Those Receiving Extra Help Assured Diamond SM and Assured Ruby SM Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for their Prescription Drug Costs If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan. This table shows you what your monthly plan premium will be if you get extra help. Your level of extra help Gateway Health Medicare Assured Diamond SM * Gateway Health Medicare Assured Ruby SM * 100% $0 $0 75% N/A $ % N/A $ % N/A $27.70 *This does not include any Medicare Part B premium you may have to pay. If you aren t getting extra help, you can see if you qualify by calling: Medicare of TTY users call (24 hours a day/7 days a week), Your State Medicaid Office, or The Social Security Administration at TTY users should call between 7 a.m. and 7 p.m., Monday through Friday. If you have any questions, please call Customer Service at GATEWAY ( ), (TTY: 711) from 8 a.m. 8 p.m. Eastern Time, 7 days a week. Have Questions? Gateway ( ) (TTY 711) 8 a.m. 8 p.m. 7 days a week

12 Pre-Enrollment Checklist Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a customer service representative at (PA), (OH) or (NC). TTY users should call 711. Understanding the Benefits Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services that you routinely see a doctor. Visit GatewayHealthPlan.com or call (PA), (OH) or (NC). TTY users should call 711 to view a copy of the EOC. Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select a new doctor. Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions. Understanding Important Rules In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. Depending on your level of extra help, part or all of this premium could be paid by Medicare. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn t cover. For more information about this extra help, contact your local Social Security office, or call Social Security at TTY users should call You can also apply for extra help online at Benefits, premiums and/or copayments/co-insurance may change on January 1, Except in emergency or urgent situations, we do not cover services by out-of-network providers (doctors who are not listed in the provider directory). This plan is a dual eligible special needs plan (D-SNP). Your ability to enroll will be based on verification that you are entitled to both Medicare and medical assistance from a state plan under Medicaid. Other restrictions may apply. Gateway Health SM is an HMO plan with a Medicare contract. Enrollment in Gateway Health s Diamond or Ruby plans depend on contract renewal. This information is not a complete description of benefits. Call Member Service at (PA), (OH) or (NC). TTY users should call 711 for more information. Have Questions? Gateway ( ) (TTY 711) 8 a.m. 8 p.m. 7 days a week