2019 Allwell Dual Medicare (HMO SNP) H1436: 005 Abbeville, Allendale, Anderson, Bamberg, Barnwell, Beaufort, Berkeley, Calhoun, Charleston, Chester,

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1 2019 Allwell Dual Medicare (HMO SNP) H1436: 005 Abbeville, Allendale, Anderson, Bamberg, Barnwell, Beaufort, Berkeley, Calhoun, Charleston, Chester, Chesterfield, Clarendon, Colleton, Dillon, Edgefield, Fairfield, Florence, Georgetown, Greenville, Greenwood, Hampton, Jasper, Kershaw, Laurens, Lee, Marion, Marlboro, McCormick, Newberry, Orangeburg, Pickens, Richland, Saluda, Spartanburg, Union, and Williamsburg Counties, SC H1436_19_7872SB_005_M_Accepted

2 This booklet provides you with a summary of what we cover and your cost-sharing responsibilities. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please call us at the number listed on the last page, and ask for the Evidence of Coverage (EOC), or you may access the EOC on our website at allwell.absolutetotalcare.com. You are eligible to enroll in Allwell Dual Medicare (HMO SNP) if: You are entitled to Medicare Part A and enrolled in Medicare Part B. Members must continue to pay their Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. You must be a United States citizen, or are lawfully present in the United States and permanently reside in the service area of the plan (in other words, your permanent residence is within the Allwell Dual Medicare (HMO SNP) service area counties). Our service area includes the following counties in South Carolina: Abbeville, Allendale, Anderson, Bamberg, Barnwell, Beaufort, Berkeley, Calhoun, Charleston, Chester, Chesterfield, Clarendon, Colleton, Dillon, Edgefield, Fairfield, Florence, Georgetown, Greenville, Greenwood, Hampton, Jasper, Kershaw, Laurens, Lee, Marion, Marlboro, McCormick, Newberry, Orangeburg, Pickens, Richland, Saluda, Spartanburg, Union, and Williamsburg You do not have end-stage renal disease (ESRD). (Exceptions may apply for individuals who develop ESRD while enrolled in an Allwell commercial or group health plan, or a Medicaid plan.) For Allwell Dual Medicare (HMO SNP), you must also be enrolled in South Carolina Medicaid. Premiums, copays, coinsurance, and deductibles may vary based on your Medicaid eligibility category and/or the level of Extra Help you receive. Your Part B premium is paid by the State of South Carolina for full-dual enrollees. Please contact the plan for further details. The Allwell Dual Medicare (HMO SNP) plan gives you access to our network of highly skilled medical providers in your area. You can look forward to choosing a primary care provider (PCP) to work with you and coordinate your care. You can ask for a current provider directory or, for an up-to-date list of network providers, visit allwell.absolutetotalcare.com. (Please note that, except for emergency care, urgently needed care when you are out of the network, out-of-area dialysis services, and cases in which our plan authorizes use of out-of-network providers, if you obtain medical care from out-of-plan providers, neither Medicare nor Allwell Dual Medicare (HMO SNP) will be responsible for the costs.) This Allwell Dual Medicare (HMO SNP) plan also includes Part D coverage, which provides you with the ease of having both your medical and prescription drug needs coordinated through a single convenient source.

3 Summary of Benefits JANUARY 1, DECEMBER 31, 2019 Benefits Allwell Dual Medicare (HMO SNP) H Premiums / Copays / Coinsurance Premiums, copays, coinsurance, and deductibles may vary based on your Medicaid eligibility category and/or the level of Extra Help you receive. Monthly Plan Premium $0 Deductible Maximum Out-of-Pocket Responsibility (does not include prescription drugs) Inpatient Hospital Coverage* Outpatient Hospital* Doctor Visits* Preventive Care* (e.g. flu vaccine, diabetic screening) Emergency Care Urgently Needed Services Diagnostic Services/Labs/ Imaging* Hearing Services (You must continue to pay your Medicare Part B premium, if not otherwise paid for by Medicaid or another third party.) $0 deductible for covered medical services $415 deductible for Part D prescription drugs $6,700 annually This is the most you will pay in copays and coinsurance for medical covered services for the year. $0 copay per stay Outpatient Hospital (includes ambulatory surgical center and observation services): $0 copay per visit Primary Care: $0 copay per visit Specialist: $0 copay per visit $0 copay for most preventive services Other preventive services are available. $0 copay per visit You do not have to pay the copay if admitted to the hospital immediately. $0 copay per visit Lab services: $0 copay Diagnostic tests and procedures: $0 copay Outpatient X-ray services: $0 copay Diagnostic Radiological services: $0 copay Hearing exam (Medicare-covered): $0 copay Routine hearing exam: $0 copay (1 every calendar year) Hearing aid: $0 copay (2 hearing aids every year) Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

4 Benefits Allwell Dual Medicare (HMO SNP) H Premiums / Copays / Coinsurance Dental Services Vision Services Mental Health Services* Dental services (Medicare-covered): $0 copay per visit Preventive Dental Services: $0 copay (including oral exams, cleanings, fluoride treatment, and X-rays) Comprehensive dental services: $0 copay (including restorative services, endodontics, periodontics, extractions, prosthodontics, and other oral and maxillofacial surgery) There is a maximum allowance of $1,500 every calendar year; it applies to all comprehensive dental benefits. Vision exam (Medicare-covered): $0 copay per visit Routine eye exam: $0 copay per visit (1 every calendar year) Routine eyewear: up to $300 allowance for every calendar year Individual and group therapy: $0 copay per visit Skilled Nursing Facility* $0 copay per stay Physical Therapy* $0 copay per visit Ambulance* $0 copay (per one-way trip) Transportation* Not covered Medicare Part B Drugs* Chemotherapy drugs: $0 copay Other Part B drugs: $0 copay Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

5 Deductible Phase Initial Coverage Phase (after you pay your Part D deductible, if applicable) Important Info: Part D Prescription Drugs $415 deductible 30-day supply without LIS Standard Retail Cost Sharing 30-day supply with LIS 25% coinsurance Generic: $0, $1.25 or $3.40 Brand: $0, $3.80, or $8.50 Cost-sharing may change depending on the level of help you receive, the pharmacy you choose (such as Standard Retail, Mail- Order, Long-Term Care or Home Infusion) and when you enter another of the four phases of the Part D benefit. For more information about the costs for Long-Term Supply, Home Infusion, or additional pharmacy-specific cost-sharing and the phases of the benefit, please call us or access our EOC online. Low income subsidy (LIS) is extra help you receive from Medicare. To find out if you qualify, visit Medicare.gov or call Member Services at (TTY: 711). Additional Covered Benefits Benefits Allwell Dual Medicare (HMO SNP) H Premiums / Copays / Coinsurance Over-the-Counter (OTC) Items $0 copay ($250 allowance per quarter for items available via mail order) Please visit the plan s website to see the list of covered over-thecounter items. Chiropractic Care* Medical Equipment/ Supplies* Foot Care* (Podiatry Services) Virtual Visits Chiropractic services (Medicare-covered): $0 copay per visit Routine chiropractic services: $0 copay per visit (12 visits per year) Durable Medical Equipment (e.g., wheelchairs, oxygen): $0 copay Prosthetics (e.g., braces, artificial limbs): $0 copay Diabetic supplies: $0 copay Foot exams and treatment (Medicare-covered): $0 copay per visit Routine foot care: $0 copay per visit (6 visits per year.) Teladoc offers 24 hours a day/7days a week/365 days a year virtual visit access to board certified doctors to help address a wide variety of health concerns/questions Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

6 Additional Covered Benefits Benefits Allwell Dual Medicare (HMO SNP) H Premiums / Copays / Coinsurance Wellness Programs Fitness program: $0 copay 24-hour nurse advice line: $0 copay Supplemental smoking and tobacco use cessation (counseling to stop smoking or tobacco use): $0 copay Coverage for one Personal Emergency Medical Response Device per lifetime. For a detailed list of wellness program benefits offered, please refer to the EOC. South Carolina Medicaid Program Covered Benefits for Dual Eligible (Medicare and Medicaid) Beneficiaries The benefits described below are available on a fee for service basis by South Carolina Medicaid for dual eligible beneficiaries who meet the eligibility requirements for Medicaid benefits. 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 South Carolina Medicaid covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. The Medicaid information included in this section is current as of 8/1/2018. All Medicaid covered services are subject to change at any time. For the most current South Carolina Medicaid coverage information, please visit the South Carolina Medicaid website at or call the Medicaid Hotline at (TTY: ), Monday - Friday, 8:00 a.m. - 6:00 p.m. Medicaid Covered Services Within limits, Medicaid will pay for services that are medically necessary. For Medicaid payment purposes, the following definitions apply: Children - birth through 20 years of age Adults - 21 years of age and older Co-payments - The South Carolina Medicaid program requires many beneficiaries to pay a small part of their medical bill for some services called a co-payment. Certain groups do not pay co-payments for the medical services they receive: children, pregnant women, people in a nursing home, people receiving home and community based waiver services, and people receiving family planning. Co-payments enable beneficiaries to assume some responsibility for their medical care. Co- payments are paid to the provider when services are rendered. The provider will tell the beneficiary when a co-payment is applicable.

7 Medicaid can pay for the following healthcare services: Hospital inpatient, outpatient, emergency room Lab and X-ray Doctor office visits (physician, nurse practitioner, midwife, podiatrist, chiropractor) Well child care - EPSDT Well adult care Vision Dental Prescription drug (not all drugs are covered) Family Panning Medical equipment Hospice Ambulance Transportation to medical appointments Nursing facility ICF for mentally retarded Inpatient psychiatric care Home Health Physical therapy Speech/language therapy Mental health services Alcohol and drug abuse services Family support services Targeted case management Behavioral Health Services for emotionally disturbed children Home and Community based long-term care services

8 Section 1557 Non-Discrimination Language Notice of Non-Discrimination Allwell complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Allwell does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Allwell: Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Allwell s Member Services telephone number listed for your state on the Member Services Telephone Numbers by State Chart. From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. If you believe that Allwell has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by calling the number in the chart below and telling them you need help filing a grievance; Allwell s Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Offce for Civil Rights, electronically through the Offce for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, (TTY: ). Complaint forms are available at Member Services Telephone Numbers by State Chart State Telephone Number and Plan Type Arizona / (HMO and HMO SNP) (TTY: 711) Arkansas (HMO) (TTY: 711) Florida (HMO); (HMO SNP) (TTY: 711) Georgia (HMO); (HMO SNP) (TTY: 711) Illinois (HMO) (TTY: 711) Indiana (HMO and PPO); (HMO SNP) (TTY: 711) Kansas (HMO); (HMO SNP) (TTY: 711) Louisiana (HMO) (TTY: 711) Mississippi (HMO); (HMO SNP) (TTY: 711) Missouri (HMO); (HMO SNP) (TTY: 711) New Mexico (HMO SNP) (TTY: 711) Ohio (HMO); (HMO SNP) (TTY: 711) Pennsylvania (HMO); (HMO SNP) (TTY: 711) South Carolina (HMO and HMO SNP) (TTY: 711) Texas (HMO); (HMO SNP) (TTY: 711) Wisconsin (HMO SNP) (TTY: 711) ALL_19_8450FLY_C_ACCEPTED_

9 Section 1557 Non-Discrimination Language Multi-Language Interpreter Services

10

11 Allwell is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Allwell depends on contract renewal. FLY020520ZK00 (8/18)

12 For more information, please contact: Allwell Dual Medicare (HMO SNP) 1441 Main Street, Suite 900 Columbia, SC allwell.absolutetotalcare.com Current members should call: (TTY: 711) Prospective members should call: (TTY: 711) From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. 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 or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call This plan is available to anyone who has both Medical Assistance from the State and Medicare. You must continue to pay your Medicare Part B premium. However, for full-dual beneficiaries, the State will cover your Part B premium as long as you retain your Medicaid eligibility. This information is not a complete description of benefits. Call (TTY: 711) for more information. Coinsurance is the percentage you pay of the total cost of certain medical services and prescription drug services. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. This document is available in other formats such as Braille, large print or audio. Allwell is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Allwell depends on contract renewal. SBS026181ED00_A (7/18)

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