2018 Summary of Benefits

Transcription

1 2018 Summary of Benefits PruittHeath Premier D-SNP (HMO SNP) H3291, Pan 002 This is a summary of drug and heath services covered by PruittHeath Premier D-SNP (HMO SNP) January 1, December 31, 2018 PruittHeath Premier D-SNP (HMO SNP) is Medicare Advantage HMO pan with a Medicare contract. Enroment in the Pan depends on contract renewa. This information is not a compete description of benefits. Contact the pan for more information. The benefit information provided is a summary of what we cover and what you pay. It does not ist every service that we cover or ist every imitation or excusion. To get a compete ist of services we cover, pease ca Member Services and request the Evidence of Coverage. To Reach our Member Services Representatives: To-free , TTY/TDD users shoud ca 711. Hours of operation: 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14, and Monday to Friday (except hoidays) from February 15 through September 30. To join PruittHeath Premier D-SNP (HMO SNP), you must: be entited to Medicare Part A, -- and -- be enroed in Medicare Part B, -- and -- ive in our service area, -- and -- you are a United States citizen or are awfuy present in the United States, -- and -- you do not have End-Stage Rena Disease (ESRD), with imited exceptions, such as if you deveop ESRD when you are aready a member of a pan that we offer, or you were a member of a different pan that was terminated, -- and -- you meet the eigibiity requirements described beow. Specia eigibiity requirements for our pan Our pan is designed to meet the needs of peope who receive certain Medicaid benefits. (Medicaid is a joint Federa and state government program that heps with medica costs for certain peope with imited incomes and resources.) To be eigibe for our pan you must be eigibe for both Medicare and Medicaid. H3291_2018_SB002 Fie & Use 10/03/2017 1

2 Our service area incudes this county in Georgia: Carke. PruittHeath Premier D-SNP (HMO SNP) has a network of doctors, hospitas, pharmacies, and other providers that can be found on our website at If you use providers that are not in our network, the pan may not pay for these services. The formuary, pharmacy network, and/or provider network may change at any time. You wi receive notice when necessary. This document is aso avaiabe in Braie and in arge print. Benefits, premium, deductibe, and/or copayments/coinsurance may change on January 1, Premium, copayments, coinsurance, and deductibes may vary based on the eve of Extra Hep you receive. Pease contact the pan for further detais. Limitations, copayments, and restrictions may appy. This information is avaiabe for free in Spanish. Pease ca our customer service number at (TTY: 711). Hours of operation: 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 through February 14, and Monday to Friday (except hoidays) from February 15 through September 30.. Esta información está disponibe en otros idiomas de manera gratuita. Comuníquese con Servicios a Ciente a (TTY: 711). Horario de Atención a Ciente: De 1 de Octubre hasta e 14 de Febrero, de 8 a.m. a 8 p.m. os siete días de a semana (excepto Día de Acción de Gracias y Navidad), y de 15 de Febrero a 30 de Septiembre, de Lunes a Viernes (excepto feriados). ATTENTION: If you speak Spanish or Vietnamese, anguage assistance services, free of charge, are avaiabe to you. Ca TTY/TTD (711). PruittHeath Premier D-SNP (HMO SNP) compies with appicabe Federa civi rights aws and does not discriminate on the basis of race, coor, nationa origin, age, disabiity, or sex. PruittHeath Premier D-SNP (HMO SNP) cumpe con as eyes federaes de derechos civies apicabes y no discrimina por motivos de raza, coor, nacionaidad, edad, discapacidad o sexo. PruittHeath Premier D-SNP (HMO SNP) tuân thủ uật dân quyền hiện hành của Liên bang và không phân biệt đối xử dựa trên chủng tộc, màu da, nguồn gốc quốc gia, độ tuổi, khuyết tật, hoặc giới tính. If you want to know more about the coverage and costs of Origina Medicare, ook in your current Medicare & You handbook. View it onine at or get a copy by caing MEDICARE ( ), 24 hours a day, 7 days a week. TTY users shoud ca H3291_2018_SB002 Fie & Use 10/03/2017 2

3 Premiums and Benefits PruittHeath Premier D-SNP (HMO SNP) Monthy Pan Premium You pay $ You must continue to pay your Medicare Part B premium. Note: the Part B premium is covered for fu-dua members. Deductibe Maximum Out-of-Pocket Responsibiity (does not incude prescription drugs) Inpatient Hospita Coverage <$183> per year Our pan charges the standard Medicare deductibe. This cost may change in aignment with Origina Medicare cost-sharing for $6,700 annuay You pay: <$1,316> deductibe for each benefit period Days 1-60: <$0> copay for each benefit period Days 61-90: <$329> copay per day of each benefit period Days 91 and beyond: <$658> copay per each "ifetime reserve day" after day 90 for each benefit period (up to 60 days over your ifetime) The above costs may change in aignment with Origina Medicare cost-sharing for Outpatient Hospita Coverage Doctor Visits Primary Care Providers You pay $0 copay per visit. Speciaists (referras may be required) You pay 20% coinsurance per visit. Sef referra: You have the right to go to a women s heath speciaist (such as a gynecoogist) without a referra. Preventive Care You pay nothing. Any additiona preventive services approved by Medicare during the contract year wi be covered. There are some items not covered at $0 cost. 3 H3291_2018_SB002 Fie & Use 10/03/2017

4 Premiums and Benefits PruittHeath Premier D-SNP (HMO SNP) Emergency Care You pay $80 copay per visit. If you are admitted to the hospita within 3 days, you do not have to pay your share of the cost for emergency care. Urgenty Needed Services You pay 20% coinsurance up to a maximum of $65. If you are admitted to the hospita within 3 days, you do not have to pay your share of the cost for urgent care. Diagnostic Services/Labs/Imaging Diagnostic radioogy services (e.g., MRI) Therapeutic radioogy services Lab services You pay $0 copay. Diagnostic procedures and tests Outpatient x-rays Pease contact the pan for more information. Hearing Services Hearing exam You pay 20% of the cost for traditiona Medicare-covered hearing services. Suppementa Benefit Routine hearing exam, fitting and evauation for hearing aids You pay $0 copay for one routine hearing exam, and fitting/evautation for hearing aids per year. Hearing aids Aowance up to $1250 for hearing aids every two years. Denta Service You pay 20% coinsurance for Medicare-covered services; deductibe appies; 4 H3291_2018_SB002 Fie & Use 10/03/2017

5 Premiums and Benefits PruittHeath Premier D-SNP (HMO SNP) Vision Services Yeary eye exam for diabetic retinopathy Suppementa Benefit Routine eye exam Gaucoma screening You pay 20% coinsurance for Medicare-covered services. Deductibe appies. You pay $0 copay for one routine eye exam visit and one gaucoma screening per year. Eyegasses, enses,frames, contacts Aowance of up to $225 per year. Menta Heath Services Inpatient visit You pay: <$1,316> deductibe for each benefit period Days 1-60: <$0> copay for each benefit period Days 61-90: <$329> copay per day of each benefit period Days 91 and beyond: <$658> copay per each "ifetime reserve day" after day 90 for each benefit period (up to 60 days over your ifetime) The above costs may change in aignment with Origina Medicare cost-sharing for Outpatient group therapy visit Outpatient individua therapy visit You pay 20% of the cost group/individua therapy visit. Skied Nursing Faciity You pay: Days 1-100: $0 copay. Days 101 and beyond: You pay a costs. No prior hospita stay required. Rehabiitation Services Occupationa therapy visit Physica therapy and speech and anguage therapy visit Ambuance Non-Emergency Transportation You pay 20% of the cost one way.prior authorization may be required for non-emergency services. You pay 0% of the tota cost for transportation services to a medica appointment for up to 30 one-way trips per year. 5 H3291_2018_SB002 Fie & Use 10/03/2017

6 Premiums and Benefits PruittHeath Premier D-SNP (HMO SNP) Medicare Part B Drugs 20% of the cost for chemotherapy and other Part B drugs. Foot Care (podiatry services) Foot exams and treatment Suppementa Benefit Routine foot care You pay $0 for 6 routine foot care visits per year. Medica Equipment/Suppies Durabe Medica Equipment (e.g., wheechairs, oxygen) Prosthetics (e.g., braces, artificia imbs) Diabetic suppies Diabetic Therapeutic Shoes and Inserts 6 H3291_2018_SB002 Fie & Use 10/03/2017

7 Outpatient Prescription Drugs Retai Pharmacy (in network) (up to a 30-day suppy) Long-term care (LTC) cost-sharing (up to a 31-day suppy) Initia Coverage Stage (After you pay your $405 deductibe, if appicabe) Cost-Sharing (A formuary Drugs) 25% $0/$1.25/$3.35/15%* for generics $0/$3.70/$8.35/15%* for a other drugs 25% $0/$1.25/$3.35/15%* for generics $0/$3.70/$8.35/15%* for a other drugs *Cost-sharing is based on your eve of Extra Hep. Cost-Sharing may change depending on the pharmacy you choose and when you enter another stage of the Part D benefit. For more information on the additiona pharmacy-specific cost-sharing and the stages of the benefit, pease ca us or access our Evidence of Coverage onine. 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 Pharmacy Directory and compete pan formuary (ist of Part D prescription drugs) and any restrictions on our website at There are four phases to prescription drug coverage under Part D. Deductibe Stage: If you receive Extra Hep to pay your prescription drugs, this payment stage does not appy to you. If you do not receive Extra Hep, you begin in this payment stage when you fi your first prescription of the year. During this stage, you pay the fu cost of your drugs. You stay in this stage unti you have paid $405 for your drugs. ($405 is the amount of your deductibe.) Initia Coverage Stage: During this stage, the pan pays its share of the cost of your drugs and you pay your share of the cost. You stay in this stage unti your year-to-date tota drug costs (your payments pus any Part D pan s payments) tota $3,750. Gap Coverage Stage: During this stage, you pay 35% of the price for brand name drugs pus a portion of the dispensing fee) and 44% of the price for generic drugs. You stay in this stage unti your year-to-date out-of-pocket costs (your payments) reach a tota of $5, H3291_2018_SB002 Fie & Use 10/03/2017

8 Catastrophic Coverage Stage: During this stage, the pan wi pay most of the cost for your drugs. You pay the greater of: --either-- coinsurance of 5% of the cost of the drug, --or-- $3.35 for a generic drug or a drug that is treated ike a generic and $8.35 for a other drugs. Georgia Medicaid and PruittHeath Premier The benefits that the individua is entited to under Tite XIX (Medicaid); PruittHeath Premier enros individuas with different eves of Medicaid benefits. This means that, depending on your eve of Medicaid benefits, some or none of the out of pocket costs for PruittHeath Premier coud be covered by Medicaid. For more information on your eve of Medicaid and the benefits you are entited to contact: Georgia Medicaid It s aways a good idea to ask your doctor or pharmacist whether the specific service or item you need is covered under Medica Assistance. There are some imits to these services and some may require you or your doctor to get permission from Medica Assistance first; this is caed prior approva. Generay, Medica Assistance covers the foowing services: Doctor and nurse office visits (when you visit a doctor nurse for checkups, ab tests, exams or treatment). Prescription drugs. Inpatient hospita services (room and board, drugs, ab tests and other services when you must stay in the hospita). Outpatient hospita services you receive in a hospita even though you do not stay in the hospita overnight. Nursing faciities (nursing homes). Emergency ambuance services. Preventive denta care, fiings and ora surgery for chidren. Certain emergency denta care for aduts. Non-emergency transportation (to get to and from medica appointments, for Medicaid members ony). Medica equipment and suppies prescribed by a doctor for use in your home (such as wheechairs, crutches or wakers). Exams, immunizations (shots) and treatments for chidren (see box beow). Famiy panning services (such as exams, drugs, treatment and counseing). 8 H3291_2018_SB002 Fie & Use 10/03/2017

9 Home heath services ordered by a doctor and received in your home (such as part- time nursing, physica therapy or home heath aides). Hospice care services provided by a Medicaid hospice provider. Vision care for chidren (imited services for aduts). Hearing services for chidren The foowing is a ist of waiverbenefits provided under Georgia Medicaid. Whether you receive them is based upon your eve of Medicaid: Medicare premiums, deductibes and coinsurance Non-emergency transportation (to get to and from medica appointments) 24 hour medica access Skied nursing services Adut day heath/adut day care Aternative iving services/assisted iving services (does not incude room and board costs) Emergency response system Home deivered meas Home deivered services Persona support services houseceaning, shopping, aundry, assistance with activities of daiy iving, such as eating, dressing, moving about, etc. Respite care- both in-home and out-of-home The cost-sharing protections that the individua is entited to under Tite XIX (Medicaid). PruittHeath Premier is prohibited from imposing cost-sharing requirements on Dua Eigibe enroees that woud exceed the amounts permitted under the State Medicaid pan if the enroee were not enroed in PruittHeath Premier DSNP. PruittHeath Premier s contracts with network providers incude anguage that ensures providers accept the Medicare fee schedue pus enroee cost sharing as payment in fu. Under PruittHeath Premier providers may ony coect enroee cost sharing as specified by the Heath Pan and in aignment with Medicare and Georgia Medicaid guideines. Cost sharing by Medicaid Category QMB Medicaid pays Medicare Part A premiums, if any, Medicare Part B premiums, and Medicare deductibes and coinsurance for Medicare services provided by Medicare providers to the extent consistent with the Medicaid State Pan. QMB Pus Medicaid pays Medicare Part A premiums, if any, Medicare Part B premiums, Medicare deductibes and coinsurance, and provides fu Medicaid benefits. SLMB Medicaid pays for the Medicare Part B premium ony. H3291_2018_SB002 Fie & Use 10/03/2017 9

10 SLMB Pus Medicaid pays for Medicare Part B premium and receive fu State Medicaid benefits. QI -Medicaid pays for the Medicare Part B premium ony. The description of the benefits and cost-sharing protections that are covered under the D-SNP. Benefits provided by PruittHeath Premier are summarized in see this document. For a fu isting of the benefits see the Evidence of Coverage at PruittHeath Premier has a contract with Georgia Medicaid to coordinate your Medicare and Medicaid services. Your Medicaid services are sti provided through Georgia Medicaid but PruittHeath Premier wi hep in ensuring a of your heathcare services work together. PruittHeath Premier ensures that members continue to have a of the cost sharing protections under both Medicare and Medicaid. H3291_2018_SB002 Fie & Use 10/03/