2018 Summary of Benefits HAP Senior Plus (HMO) H Option January 1, December 31, 2018

Transcription

1 2018 Summary of Benefits HAP Senior Plus (HMO) H Option H Option H Option January 1, December 31, 2018 H2354_HMO SB 2018 R1 CMS Accepted 10/30/2017

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3 HAP Senior Plus (HMO) Summary of Benefits January 1, December 31, 2018 There is more than one plan listed in this Summary of Benefits booklet. The booklet gives you a summary of what each plan covers 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. You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Medicare health plan (such as HAP Senior Plus (HMO)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what HAP Senior Plus (HMO) covers and what you pay. If you want to compare our plans with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on 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 Sections in this booklet Things to Know About HAP Senior Plus (HMO) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits Optional Benefits (you must pay an extra premium for these benefits) This document is available in other formats such as large print. This document may be available in a non-english language. For additional information, call us at (800) Things to Know About HAP Senior Plus (HMO) Hours of Operation From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. From February 15 to September 30, you can call us Monday from 8:00 a.m. to 8:00 p.m. Eastern time, Tuesday from 8:00 a.m. to 8:00 p.m. Eastern time, Wednesday from 8:00 a.m. to 8:00 p.m. Eastern time, Thursday from 8:00 a.m. to 8:00 p.m. Eastern time, Friday from 8:00 a.m. to 8:00 p.m. Eastern time, Saturday from 8:00 a.m. to 12:00 p.m. Eastern time. 1

4 HAP Senior Plus (HMO) Phone Numbers and Website If you are a member of one of these plans, call toll-free (800) If you are not a member of one of these plans, call toll-free (800) Our website: Who can join? To join HAP Senior Plus (HMO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area for Option 0 (015) and Option 1 (019) includes the following counties in Michigan: Arenac, Bay, Clare, Genesee, Gladwin, Gratiot, Hillsdale, Huron, Ingham, Iosco, Jackson, Lapeer, Livingston, Macomb, Midland, Monroe, Oakland, Saginaw, Sanilac, Shiawassee, St. Clair, Tuscola, Washtenaw and Wayne. Our service area for plan Option 2 (018) includes the following counties in Michigan: Macomb, Oakland and Wayne. Which doctors, hospitals, and pharmacies can I use and how much do I pay? HAP Senior Plus (HMO) plans have a network of doctors, hospitals, pharmacies, and other providers. Our network of HAP-contracted providers practice in the Michigan counties of Arenac, Bay, Clare, Genesee, Gladwin, Gratiot, Hillsdale, Huron, Ingham, Iosco, Jackson, Lapeer, Livingston, Macomb, Midland, Monroe, Oakland, Saginaw, Sanilac, Shiawassee, St. Clair, Tuscola, Washtenaw and Wayne. Providers include the doctors and other health care professionals, hospitals, and other health care facilities who are part of the Henry Ford Health System. Providers also include doctors and other health care professionals, hospitals, and other health care facilities across these 24 counties. With HAP Senior Plus Henry Ford Tiered Access, Plan 018, Option 2, how much you pay for your benefits will be based upon the tier of the provider you choose to see. Tier 1 Providers are the HAP-contracted doctors and other health care professionals, medical groups, hospitals, and other health care facilities who you will access at the highest benefit level or least amount of member cost share. Tier 1 providers are exclusively part of the Henry Ford Health System. Tier 2 Providers are the HAP-contracted doctors and other health care professionals, medical groups, hospitals, and other health care facilities who you will access at the lowest in-network benefit level or highest member cost share. Tier 2 providers are available throughout the 22 county area. See the "Additional Information" section at the back of the book for more information about the HAP Senior Plus Henry Ford Tiered Access plan. If you use providers that are not in our network, the plan may not pay for these services. Plan 015 and Plan 018, include a Part D drug benefit. With these plans, 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 ( You can see our plan's pharmacy directory at our website ( Or, if you prefer a full paper directory, call us at the number listed above, and we will send you a copy. 2

5 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. Two plans in this booklet (Plan 015 and Plan 018), cover Part D drugs. All three plans 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, Or, if you prefer a paper formulary, call us at the number above and we will send you a copy. How will I determine my drug costs? When you choose Plan 015 or Plan 018 with prescription drug coverage, each medication on our drug list is grouped 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 benefit stage you have reached. Later in this document we discuss the benefit stages: Initial Coverage, Coverage Gap, and Catastrophic Coverage. 3

6 Summary of Benefits January 1, December 31, 2018 MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Benefit HAP Senior Plus (HMO) Plan 015 How much is the monthly premium? $0 per month. In addition, you must keep paying your Medicare Part B premium. How much is the deductible? This plan has deductibles for some hospital and medical services and Part D prescription drugs. $145 per year for Medical. $0 per year for Part D prescription drugs. Is there any limit on how much I will pay for my covered services? Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Is there a limit on how much the plan will pay? Our plan has a coverage limit every year for certain benefits. Contact us for the services that apply. 4

7 HAP Senior Plus - Medical Only (HMO) Plan 019 HAP Senior Plus Henry Ford Tiered Access (HMO) Plan 018 $0 per month. In addition, you must keep paying your Medicare Part B premium. $60 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. This plan does not have a deductible. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: $4,500 for services you receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: $4,500 for services you receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Our plan has a coverage limit every year for certain benefits. Contact us for the services that apply. Our plan has a coverage limit every year for certain benefits. Contact us for the services that apply. 5

8 COVERED MEDICAL AND HOSPITAL BENEFIT Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Benefit HAP Senior Plus (HMO) Plan 015 Inpatient Hospital Care 1 Our plan covers an unlimited number of days for an inpatient hospital stay. $230 copay per day for days 1-7 You pay nothing per day for days 8-90 There is no cost to you for additional hospital days not normally covered under Original Medicare. Outpatient Hospital Services We cover medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. $200 copay Covered services include, but are not limited to: Services in an emergency department or outpatient clinic Laboratory and diagnostic tests Mental health care X-rays and other radiology services Medical supplies Certain screenings and preventive services Certain drugs and biological You can also find more information in a Medicare fact sheet called Are You a Hospital Inpatient or Outpatient? If You Have Medicare Ask! This fact sheet is available on the Web at 6

9 HAP Senior Plus - Medical Only (HMO) Plan 019 HAP Senior Plus Henry Ford Tiered Access (HMO) Plan 018 Our plan covers an unlimited number of days for an inpatient hospital stay. $230 copay per day for days 1-7 You pay nothing per day for days 8-90 There is no cost to you for additional hospital days not normally covered under Original Medicare. Our plan covers an unlimited number of days for an inpatient hospital stay. Tier 1: $115 copay per day for days 1-6 You pay nothing for days 7-90 There is no cost to you for additional hospital days not normally covered under Original Medicare. Tier 2: $270 copay per day for days 1-6 You pay nothing for days 7-90 There is no cost to yo for additional hospital days not normally covered under Original Medicare. We cover medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. $200 copay Covered services include, but are not limited to: Services in an emergency department or outpatient clinic Laboratory and diagnostic tests Mental health care X-rays and other radiology services Medical supplies Certain screenings and preventive services Certain drugs and biological You can also find more information in a Medicare fact sheet called Are You a Hospital Inpatient or Outpatient? If You Have Medicare Ask! This fact We cover medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury. Tier 1: $100 copay Tier 2: $200 copay Covered services include, but are not limited to: Services in an emergency department or outpatient clinic Laboratory and diagnostic tests Mental health care X-rays and other radiology services Medical supplies such Certain screenings and preventive services Certain drugs and biological You can also find more information in a Medicare fact sheet called Are You a Hospital Inpatient or Outpatient? If You Have Medicare Ask! This fact 7

10 COVERED MEDICAL AND HOSPITAL BENEFIT Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Benefit HAP Senior Plus (HMO) Plan 015 Outpatient Hospital Services or by calling MEDICARE ( ). (cont'd) TTY users call You can call these numbers for free, 24 hours a day, 7 days a week. Doctor's Office Visits 2 Primary care physician visit: $0 copay Specialist visit: $50 copay Preventive Care There is no cost to you for preventive services also covered at no cost by Medicare. 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) Depression screening Diabetes screenings HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) 8

11 HAP Senior Plus - Medical Only (HMO) Plan 019 sheet is available on the Web at or by calling MEDICARE ( ). TTY users call You can call these numbers for free, 24 hours a day, 7 days a week. HAP Senior Plus Henry Ford Tiered Access (HMO) Plan 018 sheet is available on the Web at or by calling MEDICARE ( ). TTY users call You can call these numbers for free, 24 hours a day, 7 days a week. Primary care physician visit: $0 copay Specialist visit: $50 copay Tier 1: Primary care physician visit: $0 copay Specialist visit: $30 copay Tier 2: Primary care physician visit: $35 copay Specialist visit: $50 copay There is no cost to you for preventive services also covered at no cost by Medicare. 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) Depression screening Diabetes screenings HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) There is no cost to you for preventive services also covered at no cost by Medicare. 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) Depression screening Diabetes screenings HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) 9

12 COVERED MEDICAL AND HOSPITAL BENEFIT Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Benefit HAP Senior Plus (HMO) Plan 015 Preventive Care (cont'd) 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 receive additional services, cost-sharing for those services will apply. Emergency Care $80 copay Worldwide coverage. $80 for each covered emergency room visit outside the United States. Annual limit: $50,000 If you are immediately admitted to the hospital, you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section of this booklet for other costs. Urgently Needed Services $60 copay Worldwide coverage. $60 for each covered urgent care visit outside the United States. 10

13 HAP Senior Plus - Medical Only (HMO) Plan 019 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 receive additional services, cost-sharing for those services will apply. HAP Senior Plus Henry Ford Tiered Access (HMO) Plan 018 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 receive additional services, cost-sharing for those services will apply. $80 copay Worldwide coverage. $80 for each covered emergency room visit outside the United States. Annual limit: $50,000 If you are immediately admitted to the hospital, you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section of this booklet for other costs. $80 copay Worldwide coverage. $80 for each covered emergency room visit outside the United States. If you are immediately admitted to the hospital, you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section of this booklet for other costs. $60 copay Worldwide coverage. $60 for each covered urgent care visit outside the United States. $50 copay Worldwide coverage. $50 for each covered urgent care visit outside the United States. 11

14 COVERED MEDICAL AND HOSPITAL BENEFIT Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Benefit HAP Senior Plus (HMO) Plan 015 Diagnostic Tests, Lab and Radiology Services, and X-Rays (Costs for these services may vary based on place of service.) 1,2 Diagnostic radiology services (hi-tech, e.g., CT, MRI, etc.): $150 copay Diagnostic tests and procedures: $150 copay Lab services: $15 copay (excludes genetic labs) Outpatient x-rays: $35 copay for standard routine x-rays Therapeutic radiology services (such as radiation treatment for cancer): $50 copay A separate physician/professional services cost sharing may apply if other services that have a cost sharing amount are received at the same visit. Hearing Services Exam to diagnose and treat hearing and balance issues: $0-50 copay, depending on the service Routine hearing exam: $0-50 copay, depending on the service 12

15 HAP Senior Plus - Medical Only (HMO) Plan 019 HAP Senior Plus Henry Ford Tiered Access (HMO) Plan 018 Diagnostic radiology services (hi-tech, e.g., CT, MRI, etc.):$150 copay Diagnostic tests and procedures: $150 copay Lab services: $15 copay (excludes genetic labs) Outpatient x-rays: $35 copay for standard routine x-rays Therapeutic radiology services (such as radiation treatment for cancer): $50 copay A separate physician/professional services cost sharing may apply if other services that have a cost sharing amount are received at the same visit. Tier 1: Diagnostic radiology services (hi-tech, e.g., CT, MRI, etc.): $100 copay Diagnostic tests and procedures: $100 copay Lab services: $10 copay (excludes genetic labs) Outpatient x-rays: $0 copay for standard routine x-rays Therapeutic radiology services (such as radiation treatment for cancer): $25 copay Tier 2: Diagnostic radiology services (hi-tech, e.g., CT, MRI, etc.): $200 copay Diagnostic tests and procedures: $200 copay Lab services: $20 copay (excludes genetic labs) Outpatient x-rays: $35 copay for standard routine x-rays Therapeutic radiology services (such as radiation treatment for cancer): $40 copay A separate physician/professional services cost sharing may apply if other services that have a cost sharing amount are received at the same visit. Exam to diagnose and treat hearing and balance issues: $0-50 copay, depending on the service Routine hearing exam: $0-50 copay, depending on the service Exam to diagnose and treat hearing and balance issues: Tier 1: $0-30 copay, depending on the service Tier 2: $35-50 copay, depending on the service Routine hearing exam: 13

16 COVERED MEDICAL AND HOSPITAL BENEFIT Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Benefit HAP Senior Plus (HMO) Plan 015 Hearing Services (cont'd) Dental Services 1,2 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $0-50 copay, depending on the service Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-50 copay, depending on the service Routine eye exam: $0-50 copay, depending on the service Contact lenses (for up to 1 every two years): You pay nothing Eyeglass frames (for up to 1 every two years): You pay nothing Eyeglass lenses (for up to 1 every two years): You pay nothing Eyeglasses or contact lenses after cataract surgery: You pay nothing No prior authorization or referral required. You have full coverage for eyeglass lenses and a benefit of up to $80 toward eyeglass frames every two years. If you prefer to wear contact lenses, you may instead choose to apply your $80 benefit towards the purchase of contact lenses in place of eyeglasses. 14

17 HAP Senior Plus - Medical Only (HMO) Plan 019 HAP Senior Plus Henry Ford Tiered Access (HMO) Plan 018 Tier 1: $0-30 copay, depending on the service Tier 2: $35-50 copay, depending on the service Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $0-50 copay, depending on the service Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): Tier 1: $0-30 copay, depending on the service Tier 2: $35-50 copay, depending on the service Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-50 copay, depending on the service Routine eye exam: $0-50 copay, depending on the service Contact lenses (for up to 1 every two years): You pay nothing Eyeglass frames (for up to 1 every two years): You pay nothing Eyeglass lenses (for up to 1 every two years): You pay nothing Eyeglasses or contact lenses after cataract surgery: You pay nothing No prior authorization or referral required. You have full coverage for eyeglass lenses and a benefit of up to $80 toward eyeglass frames every two years. If you prefer to wear contact lenses, you may instead choose to apply your $80 benefit towards the purchase of contact lenses in place of eyeglasses. Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): Tier 1: $0-30 copay, depending on the service Tier 2: $35-50 copay, depending on the service Routine eye exam: Tier 1: $0-30 copay, depending on the service Tier 2: $35-50 copay, depending on the service Contact lenses (for up to 1 every two years): You pay nothing Eyeglass frames (for up to 1 every two years): You pay nothing Eyeglass lenses (for up to 1 every two years): You pay nothing Eyeglasses or contact lenses after cataract surgery: You pay nothing No prior authorization or referral required. 15

18 COVERED MEDICAL AND HOSPITAL BENEFIT Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Benefit HAP Senior Plus (HMO) Plan 015 Vision Services (cont'd) Mental Health Care 1 Inpatient visit: Our plan covers 90 days for an inpatient hospital stay. The inpatient hospital care limit does not apply to inpatient mental health services provided in a general hospital. Our plan also covers 190 "lifetime reserve" days. These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up the extra "lifetime reserve" days, your inpatient hospital coverage will be limited to 90 days. $230 copay per day for days 1-7 $0 copay for days 8-90 Outpatient group therapy visit: $40 copay Outpatient individual therapy visit: $40 copay You pay the inpatient copay each benefit period. A benefit period begins the day you go into a psychiatric hospital. The benefit period ends when you haven t received any inpatient services in a psychiatric hospital for 60 days in a row. There s no limit to the number of benefit periods. 16 1

19 HAP Senior Plus - Medical Only (HMO) Plan 019 HAP Senior Plus Henry Ford Tiered Access (HMO) Plan 018 You have full coverage for eyeglass lenses and a benefit of up to $80 toward eyeglass frames every two years. If you prefer to wear contact lenses, you may instead choose to apply your $80 benefit towards the purchase of contact lenses in place of eyeglasses. Inpatient visit: Our plan covers 90 days for an inpatient hospital stay. The inpatient hospital care limit does not apply to inpatient mental health services provided in a general hospital. Our plan also covers 190 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up the "lifetime reserve" days, your inpatient hospital coverage will be limited to 90 days. $230 copay per day for days 1-7 $0 copay for days 8-90 Outpatient group therapy visit: $40 copay Outpatient individual therapy visit: $40 copay You pay the inpatient copay each benefit period. A benefit period begins the day you go into a psychiatric hospital. The benefit period ends when you haven t received any inpatient services in a psychiatric hospital for 60 days in a row. There s no limit to the number of benefit periods. Inpatient visit: Our plan covers 90 days for an inpatient hospital stay. The inpatient hospital care limit does not apply to inpatient mental health services provided in a general hospital. Our plan also covers 190 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up the "lifetime reserve" days, your inpatient hospital coverage will be limited to 90 days. Tier 1: $115 copay per day for days 1-6 You pay nothing for days 7-90 Tier 2: $270 copay per day for days 1-6 You pay nothing for days 7-90 Outpatient group therapy visit: Tier 1: $10 copay Tier 2: $40 copay Outpatient individual therapy visit: Tier 1: $10 copay Tier 2: $40 copay 17

20 COVERED MEDICAL AND HOSPITAL BENEFIT Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Benefit HAP Senior Plus (HMO) Plan 015 Mental Health Care 1 (cont'd) Skilled Nursing Facility (SNF) 1 Our plan covers up to 100 days in a SNF. $0 copay per day for days 1 through 20 $ copay per day for days 21 through 100 Each benefit period you pay a daily copay. A benefit period begins the day you go into a skilled nursing facility. The benefit period ends when you haven t received any skilled care in a SNF for 60 days in a row. Outpatient Rehabilitation 1 Cardiac (heart) rehab services: $40 copay Pulmonary rehab services: $40 copay Occupational therapy visit: $40 copay Physical therapy and speech and language therapy visit: $40 copay 18

21 HAP Senior Plus - Medical Only (HMO) Plan 019 HAP Senior Plus Henry Ford Tiered Access (HMO) Plan 018 You pay the inpatient copay each benefit period. A benefit period begins the day you go into a psychiatric hospital. The benefit period ends when you haven t received any inpatient services in a psychiatric hospital for 60 days in a row. There s no limit to the number of benefit periods. Our plan covers up to 100 days in a SNF. $0 copay per day for days 1 through 20 $ copay per day for days 21 through 100 Each benefit period you pay a daily copay. A benefit period begins the day you go into a skilled nursing facility. The benefit period ends when you haven t received any skilled care in a SNF for 60 days in a row. Our plan covers up to 100 days in a SNF. $0 copay per day for days 1 through 20 $ copay per day for days 21 through 100 Each benefit period you pay a daily copay. A benefit period begins the day you go into a skilled nursing facility. The benefit period ends when you haven t received any skilled care in a SNF for 60 days in a row. Cardiac (heart) rehab services: $40 copay Pulmonary services: $40 copay Occupational therapy visit: $40 copay Physical therapy and speech and language therapy visit: $40 copay Cardiac (heart) rehab services: Tier 1: $20 copay Tier 2: $40 copay Pulmonary services: Tier 1: $20 copay Tier 2: $40 copay Occupational therapy visit: Tier 1: $20 copay Tier 2: $40 copay Physical therapy and speech and language therapy visit: 19

22 COVERED MEDICAL AND HOSPITAL BENEFIT Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Benefit HAP Senior Plus (HMO) Plan 015 Outpatient Rehabilitation 1 (cont'd) Ambulance 1 $150 copay Transportation Not covered Foot Care (podiatry services) 2 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $50 copay Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 20% of the cost Prosthetic Devices (braces, artificial limbs, etc.) 1 Prosthetic devices: 20% of the cost Related medical supplies: 20% of the cost Diabetes Supplies and Services 1 Diabetes monitoring supplies: $0 copay Diabetes self-management training: $0 copay 20

23 HAP Senior Plus - Medical Only (HMO) Plan 019 HAP Senior Plus Henry Ford Tiered Access (HMO) Plan 018 Tier 1: $20 copay Tier 2: $40 copay $150 copay $150 copay Not covered Not covered Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $50 copay Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: Tier 1: $30 copay Tier 2: $50 copay 20% of the cost Tier 1: 10% of the cost Tier 2: 20% of the cost Prosthetic devices: 20% of the cost Related medical supplies: 20% of the cost Prosthetic devices: Tier 1: 10% of the cost Tier 2: 20% of the cost Related medical supplies: Tier 1: 10% of the cost Tier 2: 20% of the cost Diabetes monitoring supplies: $0 copay Diabetes self-management training: $0 copay Diabetes monitoring supplies: Tier 1: $0 copay 21

24 COVERED MEDICAL AND HOSPITAL BENEFIT Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Benefit HAP Senior Plus (HMO) Plan 015 Diabetes Supplies and Services 1 (cont'd) Therapeutic shoes or inserts: $0 copay Wellness Programs (e.g., fitness) Silver&Fit Program through American Specialty Health. Choice of fitness activity through fitness centers, home fitness kits, mobile application or fitness devices. $50 per year at first fitness center visit. Nutritional counseling with a registered dietitian. Select doctor-supervised weight loss programs when specific criteria are met. 22

25 HAP Senior Plus - Medical Only (HMO) Plan 019 Therapeutic shoes or inserts: $0 copay HAP Senior Plus Henry Ford Tiered Access (HMO) Tier 2: 20% of the cost Plan 018 Diabetes self-management training: Tier 1: $0 copay Tier 2: 20% of the cost Therapeutic shoes or inserts: Tier 1: $0 copay Tier 2: 20% of the cost Silver&Fit Program through American Specialty Health. Choice of fitness activity through fitness centers, home fitness kits, mobile application or fitness devices. $50 per year at first fitness center visit. Nutritional counseling with register dietitian. Select doctor-supervised weight loss program when specific criteria are met. Silver&Fit Program through American Specialty Health. Choice of fitness activity through fitness centers, home fitness kits, mobile application or fitness devices. $25 per year at first fitness center visit. Nutritional counseling with a registered dietitian. Select doctor-supervised weight loss programs when specific criteria are met. 23

26 PRESCRIPTION DRUG BENEFITS HAP Senior Plus (HMO) Benefit Plan 015 How much do I pay? For Part B drugs such as chemotherapy drugs 1 : 20% of the cost depending on the drug Other Part B drugs 1 : 20% of the cost depending on the drug 1 May require prior authorization. Initial Coverage You pay the following until your total yearly drug costs reach $3,750. 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. Standard Retail Cost-Sharing One-month Two-month Three-month Tier supply supply supply Tier 1 (Preferred $0 copay $0 copay $0 copay Generic) Tier 2 (Generic) $15 copay $30 copay $37.50 copay Tier 3 $ (Preferred $45 copay $90 copay copay Brand) Tier 4 (Non- $ Preferred $95 copay $190 copay copay Brand) Tier 5 (Specialty Tier) 33% of the cost Standard Mail Order Cost-Sharing 33% of the 33% of the cost cost One-month Two-month Three-month Tier supply supply supply Tier 1 (Preferred Generic) $0 copay $0 copay $0 copay 24

27 HAP Senior Plus - Medical Only (HMO) Plan 019 HAP Senior Plus Henry Ford Tiered Access (HMO) Plan 018 For Part B drugs such as chemotherapy drugs 1 : 20% of the cost depending on the drug Other Part B drugs 1 : 20% of the cost depending on the drug Our plan does not cover Part D prescription drugs. For Part B drugs such as chemotherapy drugs 1 : 20% of the cost depending on the drug Other Part B drugs 1 : 20% of the cost depending on the drug 1 May require prior authorization. 1 May require prior authorization. You pay the following until your total yearly drug costs reach $3,750. 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. Standard Retail Cost-Sharing One-month Two-month Three-month Tier supply supply supply Tier 1 (Preferred $2 copay $4 copay $5 copay Generic) Tier 2 (Generic) $15 copay $30 copay $37.50 copay Tier 3 $ (Preferred $45 copay $90 copay copay Brand) Tier 4 (Non- Preferred Brand) Tier 5 (Specialty Tier) $100 copay $200 copay $250 copay 33% of the cost Standard Mail Order Cost-Sharing 33% of the 33% of the cost cost One-month Two-month Three-month Tier supply supply supply Tier 1 (Preferred Generic) $2 copay $4 copay $5 copay 25

28 PRESCRIPTION DRUG BENEFITS HAP Senior Plus (HMO) Benefit Plan 015 Initial Coverage (cont'd) One-month Two-month Three-month Tier supply supply supply Tier 2 $15 copay $30 copay $37.50 copay (Generic) Tier 3 $ (Preferred $45 copay $90 copay copay Brand) Tier 4 (Non- $ Preferred $95 copay $190 copay copay Brand) Tier 5 (Specialty Tier) 33% of the cost 33% of the 33% of the cost cost If you reside in a long-term care facility, you pay the same as at a retail pharmacy. Under limited circumstance, you may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. Coverage Gap The coverage gap begins after the yearly drug cost (including what our plan has paid and what you have paid) reaches $3,750. After you enter the coverage gap, you pay 35% of the plan s cost for covered brand-name drugs and 44% of the plan s cost for covered generic drugs until your costs total $5,000, which is the end of the coverage gap. Not everyone will enter the coverage gap. For more information about your costs in this stage, look at Chapter 6, Section 6, in the Evidence of Coverage online at (hap.org/medicare/member-resources.) Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $5,000, you pay the greater of: 5% of the cost, or 26

29 HAP Senior Plus - Medical Only (HMO) Plan 019 HAP Senior Plus Henry Ford Tiered Access (HMO) Plan 018 One-month Two-month Three-month Tier supply supply supply Tier 2 $15 copay $30 copay $37.50 copay (Generic) Tier 3 $ (Preferred $45 copay $90 copay copay Brand) Tier 4 (Non- Preferred Brand) Tier 5 (Specialty Tier) $100 copay $200 copay $250 copay 33% of the cost 33% of the 33% of the cost cost If you reside in a long-term care facility, you pay the same as at a retail pharmacy. Under limited circumstances, you may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy. The coverage gap begins after the yearly drug cost (including what our plan has paid and what you have paid) reaches $3,750. After you enter the coverage gap, you pay 35% of the plan s cost for covered brand-name drugs and 44% of the plan s cost for covered generic drugs until your costs total $5,000, which is the end of the coverage gap. Not everyone will enter the coverage gap. For more information about your costs in this stage, look at Chapter 6, Section 6, in the Evidence of Coverage online at (hap.org/medicare/member-resources.) 27 After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $5,000, you pay the greater of: 5% of the cost, or

30 PRESCRIPTION DRUG BENEFITS HAP Senior Plus (HMO) Benefit Plan 015 Catastrophic Coverage (cont'd) $3.35 copay for generic (including brand drugs treated as generic) and a $8.35 copay for all other drugs. 28

31 HAP Senior Plus - Medical Only (HMO) Plan 019 HAP Senior Plus Henry Ford Tiered Access (HMO) Plan 018 $3.35 copay for generic (including brand drugs treated as generic) and a $8.35 copayment for all other drugs. 29

32 ADDITIONAL COVERED MEDICAL AND HOSPITAL BENEFITS Benefit HAP Senior Plus (HMO) Plan 015 Acupuncture Not covered Chiropractic Care 2 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 copay Home Health Care You pay nothing Outpatient Substance Abuse 1 Group therapy visit: $40 copay Individual therapy visit: $40 copay Outpatient Surgery 1,2 Ambulatory surgical center: $100 copay, depending on the service Outpatient hospital: $200 copay, depending on the service Over-the-Counter Items Not Covered 30

33 HAP Senior Plus - Medical Only (HMO) Plan 019 HAP Senior Plus Henry Ford Tiered Access (HMO) Plan 018 Not covered Not covered Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 copay Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 copay You pay nothing You pay nothing Group therapy visit: $40 copay Individual therapy visit: $40 copay Group therapy visit: Tier 1: $10 copay Tier 2: $40 copay Individual therapy visit: Tier 1: $10 copay Tier 2: $40 copay Ambulatory surgical center: $100 copay, depending on the service Outpatient hospital: $200 copay, depending on the service Ambulatory surgical center: Tier 1: $50 copay, depending on the service Tier 2: $100 copay, depending on the service Outpatient hospital: Tier 1: $100 copay, depending on the service Tier 2: $200 copay, depending on the service Not Covered Not Covered 31

34 ADDITIONAL COVERED MEDICAL AND HOSPITAL BENEFITS Benefit HAP Senior Plus (HMO) Plan 015 Renal Dialysis 1,2 20% coinsurance 20% coinsurance for Self Dialysis. 20% coinsurance covers dialysis treatment in a facility. Hospice You pay nothing for Hospice care from a Medicare-certified hospice. When enrolled in a Medicare-certified hospice, your hospice services are paid for by Original Medicare. You may have to pay part of the cost for drugs and respite care. Please contact us for more details. Inpatient Mental Health Care For inpatient mental health care, see the "Mental Health Care" section of this booklet. 32

35 HAP Senior Plus - Medical Only (HMO) Plan 019 HAP Senior Plus Henry Ford Tiered Access (HMO) Plan % coinsurance 20% coinsurance for Self Dialysis. 20% coinsurance covers dialysis treatment in a facility. Tier 1: $30 copay Tier 2: 20% coinsurance Tier 1: $0 copay for Self Dialysis. $30 copay covers dialysis treatment in a facility. Tier 2: $0 copay for Self Dialysis. 20% coinsurance covers dialysis treatment in a facility. You pay nothing for Hospice care from a Medicare-certified hospice. When enrolled in a Medicare-certified hospice, your hospice services are paid for by Original Medicare. You may have to pay part of the cost for drugs and respite care. Please contact us for more details. You pay nothing for Hospice care from a Medicare-certified hospice. When enrolled in a Medicare-certified hospice, your hospice services are paid for by Original Medicare. You may have to pay part of the cost for drugs and respite care. Please contact us for more details. For inpatient mental health care, see the "Mental Health Care" section of this booklet. For inpatient mental health care, see the "Mental Health Care" section of this booklet. 33

36 OPTIONAL BENEFITS (you must pay an extra premium each month for these benefits) Benefit HAP Senior Plus (HMO) Plan 015 Package 1: Delta Dental Plan 1 Benefits include: Preventive Dental Comprehensive Dental How much is the monthly premium? Additional $25.70 per month. You must keep paying your Medicare Part B premium. How much is the deductible? This package does not have a deductible. Is there a limit on how much the plan will pay? Our plan pays up to $800 every year. The plan covers the following Services: Diagnostic and Preventive Services: 50% Basic Services: 50% Major Services: 50% You must get services from a Delta Dental Medicare Advantage Premier or Delta Dental Medicare Advantage PPO participating provider located in the states of Michigan, Indiana or Ohio. 34

37 HAP Senior Plus - Medical Only (HMO) Plan 019 HAP Senior Plus Henry Ford Tiered Access (HMO) Plan 018 Benefits include: Preventive Dental Comprehensive Dental Benefits include: Preventive Dental Comprehensive Dental Additional $25.70 per month. You must keep paying your Medicare Part B premium. Additional $25.70 per month. You must keep paying your Medicare Part B premium and your monthly premium. This package does not have a deductible. This package does not have a deductible. Our plan pays up to $800 every year. The plan covers the following Services: Diagnostic and Preventive Services: 50% Basic Services: 50% Major Services: 50% You must get services from a Delta Dental Medicare Advantage Premier or Delta Dental Medicare Advantage PPO participating provider located in the states of Michigan, Indiana or Ohio. Our plan pays up to $800 every year. The plan covers the following Services: Diagnostic and Preventive Services: 50% Basic Services: 50% Major Services: 50% You must get services from a Delta Dental Medicare Advantage Premier or Delta Dental Medicare Advantage PPO participating provider located in the states of Michigan, Indiana or Ohio. 35

38 OPTIONAL BENEFITS (you must pay an extra premium each month for these benefits) HAP Senior Plus (HMO) Benefit Plan 015 Package 2: Delta Dental Plan 2 Benefits include: Preventive Dental Comprehensive Dental How much is the monthly premium? Additional $50.70 per month. You must keep paying your Medicare Part B premium. How much is the deductible? This package does not have a deductible. Is there a limit on how much the plan will pay? Our plan pays up to $1,500 every year. The plan covers the following Services: Diagnostic and Preventive Services: 100% Basic Services: 30% Major Services: 50% You must get services from a Delta Dental Medicare Advantage Premier or Delta Dental Medicare Advantage PPO participating provider located in the states of Michigtan, Indian or Ohio. 36

39 HAP Senior Plus - Medical Only (HMO) Plan 019 HAP Senior Plus Henry Ford Tiered Access (HMO) Plan 018 Benefits include: Preventive Dental Comprehensive Dental Benefits include: Preventive Dental Comprehensive Dental Additional $50.70 per month. You must keep paying your Medicare Part B premium. Additional $50.70 per month. You must keep paying your Medicare Part B premium and your monthly premium. This package does not have a deductible. This package does not have a deductible. Our plan pays up to $1,500 every year. The plan covers the following Services: Diagnostic and Preventive Services: 100% Basic Services: 30% Major Services: 50% You must get services from a Delta Dental Medicare Advantage Premier or Delta Dental Medicare Advantage PPO participating provider located in the states of Michigan, Indiana or Ohio. Our plan pays up to $1,500 every year. The plan covers the following Services: Diagnostic and Preventive Services: 100% Basic Services: 30% Major Services: 50% You must get services from a Delta Dental Medicare Advantage Premier or Delta Dental Medicare Advantage PPO participating provider located in the states of Michigan, Indiana or Ohio. 37

40 ADDITIONAL PLAN INFORMATION In the Henry Ford Tiered Access plan, the physicians and hospitals your PCP will refer you to depends on your choice of PCP. When you select a PCP who belongs to the Henry Ford Medical Group (HFMG), you will also see specialists, when needed, within the HFMG physician group without a referral such as Podiatry. You will need a referral to receive routine and specialty care services from a provider or hospital outside of the HFMG, even if the provider/hospital is part of the Henry Ford Tiered Access. If your Henry Ford Tiered Access PCP is not part of the HFMG, your PCP can refer you to any physician or hospital within the Henry Ford Tiered Access plan network. Pharmacy/Provider Network and Formulary The formulary, pharmacy network and provider network may change at any time. You will receive notice when necessary. Health Education At no cost to you, you have access to many health education programs on the HAP web site at hap.org, including: HAP 5K Challenge Health Risk assessment to build an improvement plan and track progress Health Recipes/Eating healthy HAP Senior Plus (HMO) is a plan with a Medicare contract. Enrollment in the plan depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, and /or copayments/ coinsurance may change January 1 of each year. 38

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44 hap.org/medicare 2850 W. Grand Boulevard Detroit, MI Health Alliane Plan of Michigan. A Nonprofit Company