HMO Summary of Benefits Memorial Hermann Advantage HMO H

Transcription

1 2017 HMO Summary of Benefits HMO H This Summary of Benefits document provides an outline of health and drug services covered by HMO plan January 1, 2017 December 31, HMO is provided by Memorial Hermann Health Plan, Inc., a Medicare Advantage organization with a Medicare contract. Enrollment in this plan depends on contract renewal. 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." To join HMO, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. Our service area includes the following counties in Texas: Fort Bend, Harris, and Montgomery. 1 Page Y0110_FL_POST_SBCAHMO17 CMS Accepted 09/20/ E1-AHMO-SBC

2 Who can join? To join HMO, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our services areas are listed on the front cover of this Summary of Benefits. 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, healthplan.memorialhermann.org/medicare. Or, call us and we will send you a copy of the formulary. Which doctors, hospitals, and pharmacies can I use? HMO 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. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan's provider directory at our website (healthplan.memorialhermann.org/ medicare). You can see our plan's pharmacy directory at our website (healthplan.memorialhermann.org/ medicare). Or, call us and we will send you a copy of the provider and pharmacy directories. How will I determine my drug costs? Our plan groups each medication into one of five "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. Things to Know About HMO HMO Phone Numbers, Days and Hours of Operations and Website information 2 Page

3 If you have question regarding becoming a member of HMO call us toll-free at (888) , TTY/TDD 711. We are open from October 1 to February 14, 7 days a week from 8:00 a.m. to 8:00 p.m. Central time. During February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Central time. A licensed agent may answer your call. If you are a member of this plan, and would like an explanation of your requested Summary of Benefits call Customer Service toll-free at (844) , TTY/TDD 711. We are open from October 1 to February 14, 7 days a week from 8:00 a.m. to 8:00 p.m. Central time. During February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Central time. Or, you may visit our website at healthplan.memorialhermann.org/medicare 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 (844) 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 Page

4 Sections in this booklet Monthly Premium/Deductible And Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Optional Benefits (you must pay an extra premium for these benefits) Prescription Drug Benefits 4 Page

5 Monthly Plan Premium Deductible Maximum Out-of-Pocket Responsibility (does not include prescription drugs) Inpatient Hospital coverage HMO $0.00 per month. $ per year for Tier 4 and Tier 5 Part D prescription drugs. $ for services you receive from In-Network providers. $ copay per stay. In addition, you must keep paying your Medicare Part B premium. This plan does not have a medical deductible. The most you pay for copays, coinsurance, and other costs for medical services for the year. Our plan covers an unlimited number of days for an inpatient hospital stay. Doctors Visits (Primary and Specialists) Primary Care Physician Visit: Cost share may apply for Part B $5.00 injectables. For detailed information Specialist Visit: regarding additional cost shares for the other covered in office $40.00 copay procedures/services provided by the Physician/Specialist, see the Medical Benefits Chart in Chapter 4 of the Evidence of Coverage. Preventive Care You pay for this preventive service. 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) 5 Page

6 Emergency Care Urgently Needed Services Diagnostic Services/Labs/ Imaging HMO $75.00 copay $40.00 copay Blood Services: Non-Radiologic Diagnostic Procedures/Tests $10.00 copay 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 "Welcome to Medicare" preventive visit (one-time) Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. Costs for these services may be different if received in an outpatient surgery setting. Diagnostic Radiology Services (such as MRIs, CT Scans): 6 Page

7 HMO $ copay Lab Services: Therapeutic radiology services (such as radiation treatment for cancer): $25.00 copay Hearing Services Outpatient X-rays: $15.00 copay Basic hearing and balance exam performed by a primary care doctor: Hearing to diagnose and treat hearing and balance issues: $40.00 copay Routine Hearing Exam: Annual Hearing Exam: $40.00 copay for annual hearing exam performed by specialist. for annual hearing exam performed by primary care provider. Hearing Aids: 7 Page

8 HMO $250 every year max plan allowance for hearing aids, both ears combined. Dental Services Limited dental services (this does In general, preventive dental not include services in connection services (such as cleaning, routine with care, treatment, filling, dental exams, and dental x-rays) removal, or replacement of teeth): are not covered by Original Comprehensive Services: Medicare. We cover: $75.00 copay Medicare-covered dental services Preventive Services: limited to surgery of the jaw or facial bones, extraction of teeth Preventive Services are not to prepare the jaw for radiation covered under Memorial treatments of neoplastic cancer Hermann Advantage (HMO). disease, or services that would be covered when provided by a physician. Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-40 copay Eye Exams: No copay for routine eye exam if using specialty vendor/provider. Copay applies if done by MD. Routine Eye Exam: Performed by Optician/ Optometrist: Performed by Ophthalmologist: $40.00 copay Contact Lenses: Eyeglasses (frames and lenses) 8 Page

9 HMO Eyeglass Frames: Eyeglass Lenses: Eyeglasses or Contact Lenses After Cataract Surgery: Mental Health Services (including Inpatient) Skilled Nursing Facility Rehabilitation Services $50 every year maximum plan allowance for eye-wear and contacts. Inpatient Services: $ copay per stay. Outpatient Services: Outpatient group therapy visit: $40.00 copay Outpatient individual therapy visit: $40.00 copay You pay nothing per day for days 1 through 20 $ copay per day for days 21 through 100 Cardiac (heart) Rehab Services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $25.00 copay Inpatient visit: Our plan covers an unlimited number of days for an inpatient hospital stay. Our plan covers up to 100 days in a skilled nursing facility. Pulmonary Services: $25.00 copay 9 Page

10 HMO Occupational Therapy Visit: $35.00 copay Physical Therapy and Speech and Language Therapy Visit: $35.00 copay (continued) Ambulance Transportation Foot Care (podiatry services) HMO $ copay per one-way trip. HMO does not offer transportation services. $40.00 copay Non-emergent transportation prior authorization required. Foot exams and treatment Routine Foot Care Limitations may apply. Medical Equipment/Supplies Wellness Programs (e.g. fitness) Durable Medical Equipment (DME: wheelchairs, oxygen, etc.): 20% of the cost Prosthetics (e.g., braces, artificial limbs) 20% of the cost Medical Supplies: 20% of the cost Fitness: 24 Hour Nurse Line In-Network: Readmission Prevention Care Readmission Prevention Care is provided to members upon discharge from a facility or skilled nursing facility. 10 Page

11 (continued) HMO for 24/7 nurse line services performed by the contracted vendor as a part of the wellness benefit. Authorization Required: Services cannot exceed 4 weeks per authorization period. Readmission Prevention Care: In-Network: $10.00 copay per visit Medicare Part B Drugs For Part B drugs such as chemotherapy drugs: 20% of the cost Other Part B Drugs: 20% of the cost 11 Page

12 Prescription Drug Cost-Sharing may change depending on the pharmacy you choose and when you enter another phase of the Part D benefit. For more information on the additional pharmacy-specific cost-sharing and the phases of the benefit, please call us at for TTY users, 711, 24 hours a day, seven (7) days a week. Initial Coverage: Standard Retail Cost-Sharing After you pay your yearly deductible, 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. Initial Coverage Tier One-Month Two-Month Standard Retail Supply Supply Cost-Sharing (After you pay your deductible, if applicable) Three-Month Supply Preferred Retail Tier 1 (Preferred Generic) $5.00 $10.00 $12.50 Non-Preferred Retail Tier 2 (Generic) $15.00 $30.00 $37.50 Preferred Retail Tier 3 (Preferred Brand) $45.00 $90.00 $ Non-Preferred Retail Tier 4 (Non-Preferred) $99.00 $ $ Specialty Tier 5 (Specialty) 27% Not Available Not Available Initial Coverage: Standard Mail Order Cost-Sharing (After you pay your deductible, if applicable) Tier One-Month Supply Three-Month Supply Tier 1 (Preferred Generic) Not Available $10.00 Tier 2 (Generic) Not Available $ Page

13 Initial Coverage: Standard Mail Order Cost-Sharing (After you pay your deductible, if applicable) Tier One-Month Supply Three-Month Supply Tier 3 (Preferred Brand) Not Available $90.00 Tier 4 (Non-Preferred) Not Available $ Tier 5 (Specialty) 27% Not Available 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, After you enter the coverage gap, you pay 40% of the price for brand name drugs plus a portion of the dispensing fee and 51% of the price for generic drugs. Not everyone will enter the coverage gap. Catastrophic Coverage 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 or a preferred multi-source drug (including brand drugs treated as generic) and a $8.25 copay for all other drugs. 13 Page

14 Pack HMO - Optional Supplemental Benefits Our plan offers some extra benefits that are not covered by Original Medicare and not included in your benefits package as a plan member. If you want these optional supplemental benefits, you must sign up for them and you may have to pay an additional premium for them. At the time of your enrollment, you will be given the opportunity to choose the Optional Supplemental benefits in addition to the basic plan benefits, by indicating your preference on the enrollment form. The Pack HMO Optional Supplemental benefits include: Chiropractic Services Hearing Aids Comprehensive-Preventive Dental Worldwide Emergency/Urgent Coverage Eyewear Pack HMO Premium Chiropractic Services Comprehensive Dental Services Copayment/Coinsurance under the Optional Supplemental Plan $49.00 monthly $20.00 copay per visit for Routine Care Comprehensive Dental Services: You pay 25% for minor services You pay 70% for major services Authorization: No Limitations : Yes, $1500 plan maximum benefit per year combined with Preventive Dental Services. Limited to 15 visits per year. Covered services include: Optional Routine Care Minor Restorative dental services: Periodontal Scaling and Root Planning (Deep Cleaning) - Up to one per quadrant every 36 months Amalgam Restoration (fillings) Up to two fillings per year 14 Page

15 Eyewear Hearing Aids Preventive Dental Services Copayment/Coinsurance under the Optional Supplemental Plan $ plan benefit maximum per year. Eyeglasses (frames & lenses) Up to one pair per year - $ benefit and vendor discount or Contact lenses and fitting Up to one pair per year - $ benefit and vendor discount $ plan benefit maximum per year. Preventive Dental Services: You pay a for preventive services Authorization: No Limitations : Yes, $1500 plan maximum benefit per year combined with Comprehensive Dental Services. Simple Extractions Up to two extractions per year Major Dental Services: Crowns Up to one crown per year Root Canal Treatment Up to one root canal per year Complete or Partial Dentures Up to one complete and one partial denture every 36 months. Limitations and Exclusions: Orthoptics or vision training and any associated supplemental training Recreational eyewear (e.g., non-prescription sunglasses) is excluded from coverage. The $ plan benefit is in addition to the base $50.00 plan benefit per year. Applied to both ears combined. $ plan benefit per year in addition to the base $ benefit per year. Preventive dental services: includes cleaning, routine dental exams, and dental x-rays. Oral Exams Up to two oral exams per year Prophylaxis (cleanings) Fluoride Treatment Dental X-rays Bitewing x-rays (2 films) Up to one Bitewing x-ray per year 15 Page

16 Worldwide Emergency/Urgent Coverage Copayment/Coinsurance under the Optional Supplemental Plan for worldwide emergent/urgent coverage. Full mouth or Panoramic x-ray Up to one Full Mouth or Panoramic x-ray every 36 months. Applies to services outside of the US and its territories. 16 Page