2011 ADDITIONAL INFORMATION

Transcription

1 Cochise, Pima and Santa Cruz counties, Arizona 2011 ADDITIONAL INFORMATION about covered benefits available under the Health Net Ruby 1 (HMO), Ruby 4 (HMO) and Green (HMO) plans Material ID # H0351_2011_0043 CMS Approved

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3 THE HEALTH NET RUBY 1 (HMO), RUBY 4 (HMO) and GREEN (HMO) PLANS THE SIMPLE TRUTH Health care is complicated. Choosing a company. Selecting a plan. Understanding your coverage. It can be difficult. But it doesn t have to be. You simply have to know what choices you have so you can make the best decision possible. Tens of thousands of people have chosen Health Net. Why? Because we ve built our business around the specific needs of the individuals we serve. We have a variety of color-coded easy-to-use plans to meet as many situations as possible. Our vast network of participating physicians, hospitals, pharmacies and medical professionals has been carefully built over a decade. Another great reason to choose Health Net is because we have made it easier to understand both your benefits and your costs. The next several pages outline products and services available to you from Health Net, and we also clarify some of the benefits and services that may be a challenge to understand. We encourage you to review this information so you can take advantage of the many Health Net products, services and resources designed to help keep you healthy. UNDERSTANDING YOUR BENEFITS IS KEY TO GETTING THE MOST FROM YOUR HEALTH CARE COVERAGE It s important that you understand your benefits so you can get the health care services you need. At Health Net, we re here to make sure that each benefit is easy to understand and simple for you to use. This section will help explain some of your benefits in more detail. Annual Out-of-Pocket limit The Health Net Ruby 1 HMO, Ruby 4 HMO and Green HMO plans have an annual out-ofpocket limit of $3,400. (An out-of-pocket limit is the maximum you will spend for plan-covered services during the year. After you meet the annual out-of-pocket limit, Health Net will pay 100% of out-of-pocket limit covered services). All copayments and coinsurance for Medicare Part A and B covered services, including the annual deductible applicable to the Ruby 4 plan (see below), count towards the annual out-ofpocket limit. Optional Supplemental Benefits and Part D copayments and coinsurance do not count towards the annual out-of-pocket limit. Annual Deductible The Ruby 4 plan has an annual deductible of $120. (A deductible is the amount a member pays before selected services are covered by the plan.) The annual deductible does not apply to the following benefit categories: Primary Care Physician (PCP) office s Preventive care (for example, mammograms, immunizations, routine physical exams) Emergency room care Urgent care Diabetes monitoring and nutrition therapy Comprehensive outpatient rehabilitation facility s Chiropractic services (Medicare covered) Specialist physician office

4 Podiatry services (Medicare covered) Psychiatric services Physical and speech/language therapy Occupational therapy Outpatient diagnostic procedures/tests/lab Cardiac rehabilitation services Hearing exam (Medicare-covered) Vision exam (Medicare-covered) Medicare Part D prescription drugs Optional Supplemental benefits The annual medical plan deductible does apply to the following Medicare Part A and B benefit categories: Inpatient acute hospital Inpatient psychiatric hospital Skilled Nursing Facility Partial hospitalization (mental health) Home health services Mental health specialty services Outpatient substance abuse s Outpatient diagnostic/therapeutic radiology services Outpatient hospital/ambulatory surgical center services Ambulance services Durable medical equipment Prosthetics/medical supplies Dialysis Medicare Part B Prescription Drugs Primary Care Physician (PCP) and Specialist Office Visits You pay a different copayment per depending on the type of provider from whom you receive care: Primary Care Physician (PCP) Office Visit Specialist Office Visit Ruby 1 (HMO) $5 $35 Ruby 4 (HMO) $10 $45 Green (HMO) $5 $30 Outpatient Services/Surgery At an ambulatory surgical center or outpatient hospital facility, for all plans you pay: Non-surgical procedures (when no Medicare-covered drugs/ biologicals are provided) Ruby 1 Ruby 4 Green $0 Surgery $150 $0 $250 $0 $150 Ruby 1 Ruby 4 Green Standard X-rays $35 per $35 per $25 per CT Scan MRA/MRI PET scan and nuclear medicine $125 per $150 per $200 per

5 OPTIONAL SUPPLEMENTAL BENEFITS GOLD BENEFITS Dental, Vision, Chiropractic and Acupuncture Health Net offers you the choice of two optional supplemental benefit packages available for an additional monthly premium. Quality, affordable benefits such as acupuncture, chiropractic, dental and vision natural complements to traditional medical coverage. Both of these options are a great way to round out your health coverage while enjoying the convenience of one-stop shopping with Health Net. Please see the 2011 Optional Supplemental Benefits Gold Benefits brochure for details and rates. HEALTH CLUB MEMBERSHIP/ FITNESS CLASSES Get fit, have fun and make new friends! With Health Net, you can enjoy the SilverSneakers Fitness Program at no additional cost. The SilverSneakers Fitness Program includes: A basic membership at a safe and friendly participating location in your area, with access to more than 10,000 participating locations throughout the country, including several women-only sites. All of the benefits a regular membership provides, with access to amenities such as treadmills, free weights and other fitness equipment. Fun group exercise classes, where available, designed exclusively for older adults such as SilverSneakers Muscular Strength and Range of Movement, YogaStretch and SilverSplash. Work at the pace you prefer to improve your strength, flexibility, balance, agility and coordination. Health education seminars and fun social activities. You ll have access to information that will help you manage your health. There will also be social events where you can join others who share your interest in a healthy lifestyle and meet new friends. A staff member designated to work specifically with SilverSneakers members to provide the personal assistance you expect with a quality membership. SilverSneakers Steps If you reside 15 miles or more from a SilverSneakers participating fitness location, you can register for SilverSneakers Steps. After registering online, members receive a kit with the wellness tools they need to achieve a healthier lifestyle. With Steps, you can take good health with you wherever you go. Registering for Steps doesn t preclude you from joining a participating fitness center. SilverSneakers is a registered mark of Healthways, Inc. Decision Power : Health in Balance. Information, resources and support for every person, every stage of health. When you choose Health Net, you get more than health care coverage. You get Decision Power. Decision Power brings together under one roof the information, resources and personal support that fit you, your health and your life. Whether you re focused on staying fit, dealing with back pain or facing a serious diagnosis, we re here to help you work with your doctor and make informed decisions. Staying healthy is just as important as getting well. Making the most of your health is what Decision Power is all about. We re focused on your whole health, not just one concern or disease. So we work with you to identify potential health risks, and help prevent minor concerns from becoming big problems. And we re here should you face serious medical concerns. Your health, your time, your choice. Whether you have a question want help with a specific health goal

6 need treatment but want to understand all your options are living with illness you choose how and when to use the information, resources and support available. You can use Decision Power online, or by calling a Health Coach. Try multiple resources at once, or one at a time 24 hours a day, seven days a week, Decision Power is here for you. You have access to Decision Power through your current enrollment with Health Net of Arizona, Inc. Decision Power is part of Health Net s Medicare Advantage benefit plans but is not affiliated with Health Net s provider network. Decision Power services, including Health Coaches, are additional resources that Health Net makes available to enrollees of the above listed Health Net company. PERSONAL CUSTOMER SERVICE: TAKE CARE PROGRAM SM The information you need when you need it is just a phone call away with Health Net s personal customer service program, Take Care. SM Our friendly, knowledgeable staff can provide education and information that will help you make the most of your health, tell you about network medical and support services, provide support for pharmacy questions, and more. From answers to simple questions about your coverage, to coordinated care for a complicated condition, Take Care takes care of you every step of the way TTY for the hearing impaired 8:00 a.m. to 8:00 p.m., 7 days a week Health Net and Decision Power are registered service marks of Health Net, Inc. All rights reserved.

7 A Medicare Advantage organization with a Medicare contract. This contract is renewed annually and availability of coverage beyond the end of the contract year is not guaranteed. Individuals must have both Part A and Part B to enroll. You must reside in the plan service area in order to apply for Health Net s MA plans. Medicare beneficiaries can only enroll in these plans during certain times of the year and must continue to pay their Medicare Part B premiums. Limitations, copayments/coinsurance, and restrictions may apply. Plan benefits and cost-sharing may vary by plan, county and region. In-network providers are those providers who contract with Health Net. Out-of-network providers are those who do not have a contract with Health Net and who accept Medicare. You must use plan providers except in emergency or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-ofnetwork providers, neither Medicare nor Health Net will be responsible for the costs. With few exceptions, you will need to get referrals (approval in advance) from your primary care physician. If you don t have a referral before you receive services from a specialist, you may have to pay for these services yourself. The Medicare Prescription Drug Benefit is only available to members who have enrolled in a Health Net Medicare Advantage with Part D (MA-PD) plan or Prescription Drug Plan (PDP). Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances, and quantity limitations and restrictions may apply. Beneficiaries that are already enrolled in a Health Net MA-PD or PDP plan must receive their Medicare Prescription Drug Benefit through that Plan and may be enrolled in only one MA-PD or PDP Plan at a time. Beneficiaries enrolled in an MA Plan may not enroll in a PDP, unless they are a member of a Private Fee-for-Service MA Plan (PFFS) that does not provide Medicare prescription drug coverage, a Medical Savings Account MA Plan (MSA), or an 1876 Cost Plan. People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for up to 100% of drug costs including monthly prescription drug premiums, annual deductibles and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don t even know it. For more information about this Extra Help, contact your local Social Security office or call MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call If you qualify for extra help with your Medicare Prescription Drug Plan costs, your premium and drug costs will be lower. When you join a Health Net MA-PD plan, Medicare will tell us how much extra help you are getting. Then, we will let you know the amount you will pay. If you aren t getting any extra help, you can see if you qualify by calling MEDICARE ( ) (TTY users should call ), 24 hours a day, 7 days a week; your State Medicaid Office; or the Social Security administration at (TTY users should call ) between 7:00 a.m. and 7:00 p.m., Monday through Friday. This document is only a summary for informational purposes. It is not a contract. The benefit information provided herein is a brief summary, not a comprehensive description of benefits. For more information, contact the plan. The actual complete terms and conditions of the health plan are set forth in the applicable Evidence of Coverage (EOC) or Vendor Benefits Rider (VBR) document. Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1, Medicare beneficiaries may enroll in Health Net MA plans through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at For full information on this plan s benefits, including information on premium withhold or direct bill options, and other exclusions, limitations or restrictions to services not already identified in this document, please contact Health Net at , TTY (for the hearing and speech impaired), 8:00 a.m. to 8:00 p.m., 7 days a week.

8 This document is available in alternate formats or languages. To obtain this information in an alternate format or language, call Health Net at (TTY ), 8:00 a.m. to 8:00 p.m., 7 days a week. Este documento se encuentra disponible en diferentes formatos o idiomas. Para obtener esta información en un formato o idioma diferente, llame a Health Net al (TTY ), de 8:00 a.m. a 8:00 p.m., los 7 días de la semana. Health Net of Arizona, Inc. is a subsidiary of Health Net, Inc. Health Net is a registered service mark of Health Net, Inc. All rights reserved. AZ70076 (8/10)