PPO Summary of Benefits Memorial Hermann Advantage PPO H

Transcription

1 2017 Summary of Benefits H This Summary of Benefits document provides an outline of health and drug services covered by plan January 1, 2017 December 31, is provided by Memorial Hermann Health Insurance Company, 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, 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. Page 1 Y0110_FL_POST_SBCA17 CMS Accepted 09/20/ E1-A-SBC

2 Who can join? To join, 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? has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers in our network, you may pay less for your covered services. But if you want to, you can also use providers that are not in our network. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Out-of-network/non-contracted providers are under no obligation to treat Memorial Hermann Advantage members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the -sharing that applies to out-of-network services. 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 s? 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 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. Page 2

3 Things to Know About Phone Numbers, Days and Hours of Operations and Website information If you have question regarding becoming a member of 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 s 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 3

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 Page 4

5 Monthly Plan Premium Deductible Maximum Out-of-Pocket Responsibility (does not include prescription drugs) Inpatient Hospital coverage $0.00 per month. $ per year for Tier 4 and Tier 5 Part D prescription drugs. $ for services you receive from In-Network providers. $ for services you receive from any provider. Your limit for services received from In-Network providers will count toward this limit. In-Network: $300 copay per day for days 1 through 5. You pay nothing per day for days 6 through 90. You pay nothing per day for days 91 and beyond. 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 s for medical services for the year. Our plan covers an unlimited number of days for an inpatient hospital stay. Doctors Visits (Primary and Specialists) Preventive Care Out-of-Network: 40% of the Primary Care Physician Visit: In-Network: $5.00 Specialist Visit: In-Network: $40.00 copay In-Network: You pay $0.00 copay for this preventive service. Cost share may apply for Part B injectables. For detailed information regarding additional shares for the other covered in office procedures/services provided by the Physician/ Specialist, see the Medical Benefits Chart in Chapter 4 of the Evidence of Coverage. Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Page 5

6 Emergency Care Urgently Needed Services Out-of-Network: 40% of the In-Network/Out- of- Network $75.00 copay In-Network/Out- of -Network 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 "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 for emergency care. Page 6

7 Diagnostic Services/Labs/ Imaging $40.00 copay Blood Services: Costs for these services may be different if received in an outpatient surgery setting. Non-Radiologic Diagnostic Procedures/Tests In-Network: $10.00 copay Diagnostic Radiology Services (such as MRIs, CT Scans): In-Network: $ copay Lab Services: Therapeutic radiology services (such as radiation treatment for cancer): In-Network: $25.00 copay Hearing Services Outpatient X-rays: In-Network: $15.00 copay Basic hearing and balance exam performed by a primary care doctor: No copay for routine hearing exam if using In-network specialty Page 7

8 Out-of-Network: 40% of the vendor/provider. $40 copay applies if done by In-network MD. Hearing exam to diagnose and treat hearing and balance issues: In-Network: $40.00 copay Out-of Network: 40% of the Routine Hearing Exam: Annual Hearing Exam: In-Network: $0.00 copay for annual hearing exam performed by primary care provider. $40.00 copay for annual hearing exam performed by specialist. Out-of-Network: 40% of the for annual hearing exam. Hearing Aids: In-Network: $0.00 copay $250 every year max plan allowance for hearing aids, both ears combined. Page 8

9 Out-of-Network: $0.00 copay $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 (). 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): In-Network: $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: In-Network: $40.00 copay Page 9

10 Contact Lenses: Out-of-Network: $0.00 copay Eyeglasses (frames and lenses) Out-of-Network: $0.00 copay Eyeglasses Frames: Out-of-Network: $0.00 copay Eyeglass Lenses: Out-of-Network: $0.00 copay Eyeglasses or Contact Lenses After Cataract Surgery: for one pair Mental Health Services (including Inpatient) $50 every year maximum plan allowance for eye-wear and contacts for both In-Network and Out-of-Network. Inpatient Services: In-Network: $ copay per day for day 1 through 5. You pay nothing per day for days 6 though 90. You pay nothing per day for days 91 through beyond. Inpatient visit: Our plan covers an unlimited number of days for an inpatient hospital stay. Page 10

11 Outpatient Services: Outpatient group therapy visit: In-Network: $40.00 copay Skilled Nursing Facility Outpatient individual therapy visit: In-Network: $40.00 copay In-Network: You pay nothing per day for days 1 through 20. $ copay per day for days 21 through 100. Our plan covers up to 100 days in a skilled nursing facility. Rehabilitation Services Out-of-Network: 40% of the per stay Cardiac (heart) Rehab Services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): In-Network: $25.00 copay Pulmonary Services: In-Network: $25.00 copay Occupational Therapy Visit: Page 11

12 In-Network: $35.00 copay Physical Therapy and Speech and Language Therapy Visit: In-Network: $35.00 copay (continued) Ambulance In-Network: $ copay per one-way trip. Non-emergent transportation prior authorization required. Transportation Foot Care (podiatry services) Medical Equipment/Supplies Out-of-Network: $ copay per one-way trip. does not offer transportation services. In-Network: $40.00 copay Out-of-Network: 40% of the Durable Medical Equipment (DME: wheelchairs, oxygen, etc.): In-Network: 20% of the Foot exams and treatment Routine Foot Care Limitations may apply. Prosthetics (e.g., braces, artificial limbs) Page 12

13 (continued) In-Network: 20% of the Wellness Programs (e.g. fitness) Medical Supplies: In-Network: 20% of the Fitness: In-Network/ Out-of-Network: $0.00 copay 24 Hour Nurse Line In-Network/Out-of-Network: $0.00 copay for 24/7 nurse line services performed by the contracted vendor as a part of the wellness benefit. Readmission Prevention Care Readmission Prevention Care is provided to members upon discharge from a facility or skilled nursing facility. Authorization Required: Services cannot exceed 4 weeks per authorization period. Readmission Prevention Care: In-Network/Out-of-Network: $10.00 copay per visit Medicare Part B Drugs For Part B drugs such as chemotherapy drugs: In-Network: 20% of the Page 13

14 (continued) Other Part B Drugs: In-Network: 20% of the Page 14

15 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 -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 s reach $3,700. Total yearly drug s are the total drug s paid by both you and our Part D plan. You may get your drugs at network retail pharmacies and mail order pharmacies. Initial Coverage Standard Retail Cost-Sharing (After you pay your deductible, if applicable) Tier One-Month Supply Two-Month Supply 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 $30.00 Page 15

16 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 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 (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 After your yearly out-of-pocket drug s (including drugs purchased through your Coverage retail pharmacy and through mail order) reach $4,950, you pay the greater of: 5% of the, 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. Page 16

17 Pack - 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 Optional Supplemental benefits include: Chiropractic Services Hearing Aids Comprehensive-Preventive Dental Worldwide Emergency/Urgent Coverage Eyewear Pack Premium Copayment/Coinsurance under the Optional Supplemental Plan $49.00 monthly Chiropractic Services Comprehensive Dental Services In-Network/Out-of-Network $20.00 copay per visit for Routine Care In-Network/Out-of-Network 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 Simple Extractions Up to two extractions per year Major Dental Services: Page 17

18 Copayment/Coinsurance under the Optional Supplemental Plan 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. Eyewear Hearing Aids In-Network/Out-of-Network $ plan benefit maximum per year Eyeglasses (frames & lenses) Up to one pair per year - $275 benefit and vendor discount or Contact lenses and fitting Up to one pair per year - $275 benefit and vendor discount In-Network/Out-of-Network $ plan benefit maximum per year Limitations and Exclusions: Orthoptics or vision training and any associated supplemental training Recreational eyewear (e.g., non-prescription sunglasses) is excluded from coverage. The $275 plan benefit is in addition to the base $50.00 plan benefit per year. Applies to both ears combined. $ plan benefit per year in addition to the base $ benefit per year. Preventive Dental Services In-Network/Out-of-Network Preventive Dental Services: You pay a $0.00 copay for preventive services Preventive dental services: includes cleaning, routine dental exams, and dental x-rays. Oral Exams Up to two oral Authorization: No exams per year Prophylaxis (cleanings) Limitations : Yes, $1500 plan Fluoride Treatment maximum benefit per Dental X-rays year combined Bitewing x-rays (2 films) with Comprehensive Dental Up to one Bitewing x-ray Services. per year Page 18

19 Worldwide Emergency/Urgent Coverage Copayment/Coinsurance under the Optional Supplemental Plan $0.00 copay 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. Page 19