2019 Health Net Seniority Plus Green (HMO) H0562:045 Alameda, Placer, Sacramento and Stanislaus Counties, CA

Transcription

1 2019 Health Net Seniority Plus Green (HMO) H0562:045 Alameda, Placer, Sacramento and Stanislaus Counties, CA H0562_19_7815SB_045_M_Accepted

2 This booklet provides you with a summary of what we cover and your cost-sharing responsibilities. It does not 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 ca.healthnetadvantage.com. You are eligible to enroll in Health Net Seniority Plus Green (HMO) 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 Health Net Seniority Plus Green (HMO) service area county). Our service area includes the following counties in California: Alameda, Placer, Sacramento and Stanislaus. You do not have end-stage renal disease (ESRD). (Exceptions may apply for individuals who develop ESRD while enrolled in a Health Net commercial or group health plan, or a Medicaid plan.) The Health Net Seniority Plus Green (HMO) 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 ca.healthnetadvantage.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 Health Net Seniority Green (HMO) will be responsible for the costs.) 2

3 Summary of Benefits JANUARY 1, 2019 DECEMBER 31, 2019 Benefits Health Net Seniority Plus Green (HMO) H0562: 045 Premiums / Copays / Coinsurance Monthly Plan Premium $139 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 You must continue to pay your Medicare Part B premium. $0 deductible for medical services $3,400 annually This is the most you will pay in copays and coinsurance for covered medical services for the year. $275 copay per day, days 1 through 7 $0 copay per day, days 8 and beyond Outpatient Hospital: $275 copay per visit Observation Services: $120-$275 copay per visit Ambulatory Surgical Center: $125 copay per visit Primary Care: $10 copay per visit Specialist: $10 copay per visit $0 copay Other preventive services are available. $120 copay per visit Urgently Needed Services $10 copay You do not have to pay the copay if admitted to the hospital immediately. Diagnostic Services/Labs/ Imaging* Hearing Services* Dental Services Lab services: $0 copay Diagnostic tests and procedures: $0 copay X-ray services: $0 copay Hearing exam (Medicare-covered): $10 copay per visit Routine hearing exam: $10 copay (every 1 calendar year) Dental services (Medicare-covered): $0 copay per visit Additional preventive and comprehensive dental benefits are available for an extra premium. See optional supplemental benefits section. Vision Services* Mental Health Services* Vision exam (Medicare-covered): $10 copay per visit Routine eye exam: $10 copay Individual and group therapy: $25 copay per visit 3

4 Benefits Health Net Seniority Plus Green (HMO) H0562: 045 Premiums / Copays / Coinsurance Skilled Nursing Facility * $0 copay per stay, per benefit period. Physical Therapy* $0 copay per visit Ambulance* Transportation Ground ambulance services: $125 copay per one-way trip Air ambulance services: 5% coinsurance per one-way trip Not Covered Medicare Part B Drugs* Chemotherapy drugs: 20% coinsurance Other Part B drugs: 20% coinsurance 4

5 Additional Covered Benefits Benefits Health Net Seniority Green Plus (HMO): H Premiums / Copays / Coinsurance Chiropractic Care* Medical Equipment/ Supplies* Foot Care * (Podiatry Services) Wellness Programs Chiropractic services (Medicare-covered): $10 copay per visit Durable Medical Equipment (e.g., wheelchairs, oxygen): 20% coinsurance Prosthetics (e.g., braces, artificial limbs): 20% coinsurance Diabetic supplies: $0 copay Foot exams and treatment (Medicare-covered): $10 copay per visit Routine foot care: $10 copay (12 visits per year.) 24-hour nurse advice line: $0 copay For a detailed list of wellness program benefits offered, please refer to the EOC. 5

6 Monthly Premium Optional Supplemental Benefits (you must pay an extra premium each month for these benefits) This additional monthly premium is in addition to your monthly plan premium and the monthly Medicare Part B premium. Dental Care Benefits Preventive/Comprehensive Dental Care Optional Supplemental Benefits Package 1 $20.00 per month Dental HMO You must select a dentist from our list of network providers to use the benefits of the Dental HMO plan. Additional service limits apply. What you pay an in-network provider Non-routine services Preventive services Diagnostic services Restorative services Endodontic services Periodontics Extractions Prosthodontics (dentures, oral/maxillofacial surgery and other services) $0 copay $0 copay $0 - $15 copay $0 -$300 copay $5 - $275 copay $0 - $375 copay $15 - $150 copay $0 -$2,250 copay Vision Eyewear Benefits Additional benefits and limits apply. Charges from an out-of-network provider are not covered. What you pay an in-network provider Vision hardware benefit maximum Chiropractic and Acupuncture Services $250 for 1 pair of eyeglasses (frames and lenses) or contact lenses every 2 calendar years. What you pay an in-network provider Chiropractic Acupuncture $10 copay per visit $10 copay per visit Limited to 30 visits per year (acupuncture and chiropractic visits combined) Fitness Benefits The Silver&Fit program is an Exercise and Healthy Aging Program which provides a no-cost membership at a participating Silver&Fit fitness center or membership in the Silver&Fit Home Fitness Program for members who are unable to visit a fitness center or prefer to work out at home. There is no copayment or coinsurance for the fitness benefit services. 6

7 Optional Supplemental Benefits (you must pay an extra premium each month for these benefits) Optional Supplemental Benefits Package 2 Monthly Premium $30.00 per month This additional monthly premium is in addition to your monthly plan premium and the monthly Medicare Part B premium. Dental Care Benefits Dental PPO Preventive/Comprehensive dental care You can see any licensed dentist to receive covered dental services. You may pay more to see an out-ofnetwork provider. Additional limits apply. In-network Out-of-network Annual deductible (applies to all covered services) $35 $35 Annual benefit maximum $1,000 in- and out-of-network combined Preventive services and diagnostic services Covered at 100% You pay 20% Restorative services You pay 20% You pay 40% Periodontic services You pay 20% You pay 40% Extractions You pay 20% You pay 40% Preventive services and diagnostic services Covered at 100% You pay 20% Restorative services You pay 20% You pay 40% Periodontic services You pay 20% You pay 40% Extractions You pay 20% You pay 40% Chiropractic and Acupuncture Services Chiropractic $10 copay per visit Acupuncture $10 copay per visit Limited to 30 visits per year (acupuncture and chiropractic visits combined) Vision Eyewear Benefits What you pay an in-network provider Additional benefits and limits apply. Charges from an out-of-network provider are not covered. In-network Vision hardware benefit maximum $250 for 1 pair of eyeglasses (frames and lenses) or contact lenses every 2 calendar years. Fitness Benefits The Silver&Fit program is an Exercise and Healthy Aging Program which provides a no-cost membership at a participating Silver&Fit fitness center or membership in the Silver&Fit Home Fitness Program for members who are unable to visit a fitness center or prefer to work out at home. There is no copayment or coinsurance for the fitness benefit services. 7

8 Section 1557 Non-Discrimination Language Notice of Non-Discrimination Health Net complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Net does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Health Net: 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 Health Net s Customer Contact Center at California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO); Oregon: (HMO and PPO) (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 believe that Health Net 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 above and telling them you need help filing a grievance; Health Net s Customer Contact Center is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office 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, (TDD: ). Complaint forms are available at Health Net is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Health Net depends on contract renewal. 8

9 Section 1557 Non-Discrimination Language Multi-Language Interpreter Services ARABIC California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO); Oregon: (HMO and PPO) ARMENIAN California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO) (TTY: 711). CHINESE California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO); Oregon: (HMO and PPO) (TTY: 711) CUSHITE (TTY: 711). Oregon: (HMO and PPO) FRENCH (TTY: 711). Oregon: (HMO and PPO) GERMAN Oregon: (HMO and PPO) (TTY: 711). HINDI California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO) (TTY: 711). HMONG California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO) (TTY: 711). JAPANESE KOREAN California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO); Oregon: (HMO and PPO) (TTY: 711) 9

10 MON-KHMER CAMBODIAN California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO); Oregon: (HMO and PPO) (TTY: 711) PERSIAN PUNJABI California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO) (TTY: 711) ROMANIAN Oregon: (HMO and PPO) (TTY: 711). RUSSIAN California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO); Oregon: (HMO and PPO) (TTY: 711). SPANISH California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO); Oregon: (HMO and PPO) (TTY: 711). TAGALOG THAI California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO) (TTY: 711). California: (Jade, Sapphire, Amber, and HMO SNP), (all other HMO); Oregon: (HMO and PPO) (TTY: 711). UKRAINIAN Oregon: (HMO and PPO) (TTY: 711). VIETNAMESE 10

11 For more information, please contact: Health Net Seniority Plus Green (HMO) PO Box Van Nuys, CA ca.healthnetadvantage.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 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 and prescription drug services. This document is available in other formats such as Braille, large print or audio. The provider network may change at any time. You will receive notice when necessary. Health Net is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Health Net depends on contract renewal. SBS020819EK00_A (07/18) 11