2019 Allwell Dual Medicare (HMO SNP) H5590: Maricopa, Pima and Yuma counties, AZ

Transcription

1 2019 Allwell Dual Medicare (HMO SNP) H5590: Maricopa, Pima and Yuma counties, AZ H5590_19_7908SB_006_001_M_Accepted

2 This booklet provides you with a summary of what we cover and the cost-sharing responsibilities. It doesn t 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 allwell.azcompletehealth.com. You are eligible to enroll in Allwell Dual Medicare (HMO SNP) 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 Allwell Dual Medicare (HMO SNP) service area counties). Our service area includes the following counties in Arizona: Maricopa, Pima and Yuma. You do not have end-stage renal disease (ESRD). (Exceptions may apply for individuals who develop ESRD while enrolled in an Allwell commercial or group health plan, or a Medicaid plan.) For Allwell Dual Medicare (HMO SNP), you must also be enrolled in the Arizona Medicaid plan. Premiums, copays, coinsurance, and deductibles may vary based on your Medicaid eligibility category and/or the level of Extra Help you receive. Your Part B premium is paid by the State of Arizona for full-dual enrollees. Please contact the plan for further details. The Allwell Dual Medicare (HMO SNP) 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 allwell.azcompletehealth.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 Allwell Dual Medicare (HMO SNP) will be responsible for the costs.) This Allwell Dual Medicare (HMO SNP) plan also includes Part D coverage, which provides you with the ease of having both your medical and prescription drug needs coordinated through a single convenient source.

3 Summary of Benefits JANUARY 1, DECEMBER 31, 2019 Benefits Allwell Dual Medicare (HMO SNP) H Premiums / Copays / Coinsurance With Allwell Dual Medicare, and full Medicaid (AHCCCS) eligibility, you pay With Allwell Dual Medicare and Medicare only, you pay Premiums, copays, coinsurance, and deductibles may vary based on your Medicaid eligibility category and/or the level of Extra Help you receive. Monthly Plan Premium You pay $0 based on your level of Medicaid eligibility You pay up to $32.60 based on your level of Medicaid eligibility (pending) You must continue to pay your Medicare Part B premium. However, for full-dual beneficiaries, the State will cover your Part B premium as long as you retain your Medicaid eligibility. Deductible $ 0 deductible for covered medical services $ 0 deductible for Part D prescription drugs $ 0 deductible for routine dental services $0 days 1 through 60 for Inpatient hospital coverage (which includes Inpatient mental health stays) per benefit period, Depending on the level of Medicaid (AHCCCS) coverage you receive. This plan does not have a medical or Part D prescription deductible. No deductible $183 deductible for covered medical services (pending) $200 deductible for Part D prescription drugs (applies to drugs on Tiers 2, 3, 4 and 5)

4 Benefits Maximum Out-of-Pocket Responsibility (does not include prescription drugs) Allwell Dual Medicare (HMO SNP) H Premiums / Copays / Coinsurance With Allwell Dual Medicare, and full Medicaid (AHCCCS) eligibility, you pay $6700 annually This is the most you will pay in copays and coinsurance for medical services for the year. With Allwell Dual Medicare and Medicare only, you pay $3,400 annually This is the most you will pay in copays and coinsurance for medical services for the year. Inpatient Hospital Coverage* In 2018, the amounts for each benefit period were: $0 In 2018, the amounts for each benefit period were: $0 or $1,340 hospital deductible each admission. $0 copay for days 1 through 60 $335 copay per day for days 61 through 90 $670 copay per day per lifetime reserve day (may change in 2019) Outpatient Hospital* Outpatient Hospital (includes ambulatory surgical center and observation services: $0 copay Observation Services: $0 Ambulatory Surgical Center: $0 copay Outpatient Hospital (includes ambulatory surgical center and observation services): 20% coinsurance per visit Doctor Visits* Preventive Care (e.g. flu vaccine, diabetic screening) Primary Care: $0 per visit Specialist: $0 per visit $0 copay for Medicare-covered preventive services Other preventive services are available. Primary Care: 20% coinsurance per visit Specialist: 20% coinsurance per visit $0 copay for most Medicarecovered preventive services Other preventive services are available. Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

5 Benefits Allwell Dual Medicare (HMO SNP) H Premiums / Copays / Coinsurance With Allwell Dual Medicare, and full Medicaid (AHCCCS) eligibility, you pay With Allwell Dual Medicare and Medicare only, you pay Emergency Care $0 copay for Medicare-covered 20% coinsurance (up to $120) per visit You do not have to pay the coinsurance if admitted to the hospital immediately. Urgently Needed Services $0 copay for Medicare-covered 20% coinsurance (up to a maximum of $65 per visit) Diagnostic Services/Labs/ Imaging* Hearing Services Diagnostic radiology service (i.e., MRI, MRA, CT, PET): $0 copay Lab service: $0 copay Diagnostic tests and/or procedure: $0 EKG: $0 Outpatient x-ray: $0 Therapeutic Radiological services (Radiation therapy): $0 Hearing exam (Medicarecovered): $0 Routine hearing services (non-medicare-covered): $0 copay per visit (1 every year) Hearing aid: $0 copay Lab services: $0 copay Diagnostic tests and procedures:20% coinsurance Outpatient X-ray services: 20% coinsurance Diagnostic Radiological services: 20% coinsurance Hearing exam (Medicarecovered): 20% coinsurance Routine hearing exam: $0 copay (1 every calendar year) Hearing aid: $1,580 copay (2 hearing aids every year) Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

6 Benefits Dental Services Allwell Dual Medicare (HMO SNP) H Premiums / Copays / Coinsurance With Allwell Dual Medicare, and full Medicaid (AHCCCS) eligibility, you pay Dental services (Medicarecovered): $0 Preventive dental services: Oral exam: $0 copay (up to 2 every year) Cleaning: $0 copay (up to 2 every year) Dental x-ray: $0 copay (1 every year) Fluoride treatment : $0 copay (up to 1 every year) With Allwell Dual Medicare and Medicare only, you pay Dental services (Medicarecovered): 20% coinsurance Preventive Dental Services: $0 copay (including oral exams, cleanings, and X-rays) There is a maximum allowance of $3,000 every calendar year; it applies to all preventive dental benefits. Vision Services Comprehensive dental services: Non-routine services: $3,000 Max Diagnostic services Restorative services Endodontics/Periodontics/Extr actions Prosthodontics/Other Oral/Maxillofacial surgery Vision exam to diagnose and treat diseases and conditions of the eye (Medicare covered): Yearly Glaucoma screening (Medicare-covered): $0 copay Eyeglasses or contact lenses after cataract surgery (Medicare-covered): $0 copay $250 toward vision hardware Vision exam (Medicarecovered): 20% coinsurance Routine eye exam: $0 copay per visit (up to 1 every calendar year) Routine eyewear: up to $250 allowance every year Mental Health Services* Outpatient: $0 Copay Individual and group therapy: 20% coinsurance per visit Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

7 Benefits Allwell Dual Medicare (HMO SNP) H Premiums / Copays / Coinsurance With Allwell Dual Medicare, and full Medicaid (AHCCCS) eligibility, you pay Skilled Nursing Facility* $0 copay per day, days 1 through 100 With Allwell Dual Medicare and Medicare only, you pay In 2018, the amounts for each benefit period were $0 or: $0 copay per day, days 1 through 20 $ copay per day, days 21 through 100 (may change for 2019) Physical Therapy* $0 copay 20% coinsurance per visit Ambulance* $0 copay $0 copay for Medicare-covered Air ambulance services 20% coinsurance (per one-way trip) Transportation $0 copay for unlimited trips $0 copay for each one-way trip Up to 10 one-way trips to planapproved locations (up to 50 miles each one way per trip) each calendar year Medicare Part B Drugs* Chemotherapy drugs: 0% coinsurance Other Part B drugs: 0% coinsurance Chemotherapy drugs: 20% coinsurance Other Part B drugs: 20% coinsurance Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

8 Part D Prescription Drugs Deductible Phase This plan does not have a deductible, so this payment phase does not apply to you. Initial Coverage Phase Standard Retail Cost Sharing (after you pay your Part D deductible, if applicable) 30-day supply without LIS 30-day supply with LIS Important Info: $0 copay or $1.20 copay; or up to an $8.25 copay in the Initial Coverage Phase Generic: $0 Brand: $0 Cost-sharing may change depending on the level of help you receive, the pharmacy you choose (such as Standard Retail, Mail- Order, Long-Term Care or Home Infusion) and when you enter another of the four phases of the Part D benefit. For more information about the costs for Long-Term Supply, Home Infusion, or additional pharmacy-specific cost-sharing and the phases of the benefit, please call us or access our EOC online. Low income subsidy (LIS) is extra help you receive from Medicare. To find out if you qualify, visit Medicare.gov or call Member Services at (TTY: 711).

9 Benefits Additional Covered Benefits Allwell Dual Medicare (HMO SNP) H Premiums / Copays / Coinsurance Over-the-Counter (OTC) Items Meals* Chiropractic Care* Medical Equipment/ Supplies* Foot Care* (Podiatry Services) With Allwell Dual Medicare, and full Medicaid (AHCCCS) eligibility, you pay $0 copay ($60 allowance per month for items available via mail order) Please visit the plan s website to see the list of covered overthe-counter items. $0 copay Plan covers home-delivered meals (up to 2 meals per day for 14 days) following discharge from an inpatient facility or skilled nursing facility provided the meals are medically necessary and ordered by a physician or practitioner. Chiropractic services (Medicare-covered): $0 copay per visit Durable Medical Equipment (i.e., Wheelchairs, oxygen): $0 copay Prosthetics (i.e., braces, artificial limbs): $0 copay Diabetic supplies: $0 copay Foot exams and treatment (Medicare-covered): $0 copay per visit With Allwell Dual Medicare (HMO SNP) and Medicare only, you pay $0 copay ($60 allowance per month for items available via mail order) Please visit the plan s website to see the list of covered overthe-counter items. $0 copay Plan covers home-delivered meals (up to 2 meals per day for 14 days) following discharge from an inpatient facility or skilled nursing facility provided the meals are medically necessary and ordered by a physician or practitioner. Chiropractic services (Medicare-covered): 20% coinsurance per visit Durable Medical Equipment (e.g., wheelchairs, oxygen): 20% coinsurance Prosthetics (e.g., braces, artificial limbs): 20% coinsurance Diabetic supplies: 20% coinsurance Foot exams and treatment (Medicare-covered): 20% coinsurance Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

10 Benefits Additional Covered Benefits Allwell Dual Medicare (HMO SNP) H Premiums / Copays / Coinsurance Virtual Visit Wellness Programs With Allwell Dual Medicare, and full Medicaid (AHCCCS) eligibility, you pay Teladoc plan offers 24 hours a day/7days a week/365 days a year virtual visit access to board certified doctors to help address a wide variety of health concerns/questions. Supplemental smoking and tobacco use cessation (counseling to stop smoking or tobacco use): $0 copay For a detailed list of wellness program benefits offered, please refer to the EOC. Coverage for one Personal Emergency Medical Response Device per lifetime. $0 copay Basic Fitness Membership With Allwell Dual Medicare (HMO SNP) and Medicare only, you pay Teladoc offers 24 hours a day/7days a week/365 days a year virtual visit access to board certified doctors to help address a wide variety of health concerns/questions. Fitness program: $0 copay 24-hour nurse advice line: $0 copay Supplemental smoking and tobacco use cessation (counseling to stop smoking or tobacco use): $0 copay Coverage for one Personal Emergency Medical Response Device per lifetime. $0 copay For a detailed list of wellness program benefits offered, please refer to the EOC. AZ Emergency Care Annual Routine Physical Exam $50,000 plan coverage limit for supplemental urgent/emergent services outside the U.S. and its territories every year. $50,000 plan coverage limit for supplemental urgent/emergent services outside the U.S. and its territories every year. $0 copay (one per year) $0 copay (one per year)

11 Comprehensive Written Statement for Prospective Enrollees The benefits described in the Premium and Benefit section of the Summary of Benefits are covered by our Medicare Advantage plan. For each benefit listed, you can see what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. Coverage of the benefits described in this Summary of Benefits depends upon your level of Medicaid eligibility. No matter what your level of Medicaid eligibility is, Allwell Dual Medicare (HMO SNP) will cover the benefits described in the Premium and Benefit section of the Summary of Benefits. If you have questions about your Medicaid eligibility and what benefits you are entitled to, call Arizona Health Care Cost Containment System (AHCCCS) toll-free at Our source of information for Medicaid benefits is AHCCCS. All Medicaid covered services are subject to change at any time. For the most current Arizona Medicaid coverage information, please visit or call Member Services for assistance. A detailed explanation of Arizona Medicaid benefits can be found in the Arizona Summary of Services online at

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16 For more information, please contact: Allwell Dual Medicare (HMO SNP) 1870 W. Rio Salado Parkway Tempe, AZ allwell.azcompletehealth.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 plan is available to anyone who has both Medical Assistance from the State and Medicare. You must continue to pay your Medicare Part B premium. However, for full-dual beneficiaries, the State will cover your Part B premium as long as you retain your Medicaid eligibility. 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 services. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. This document is available in other formats such as Braille, large print or audio. Allwell is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Allwell depends on contract renewal. Contract services are funded in part under contract with the State of Arizona. SBS020965EK00 (8/18)

17 2019 Part D Model LIS Premium Summary Table for Those Receiving Extra Help BRIDGEWAY HEALTH SOLUTIONS/Allwell Dual Medicare (HMO SNP) Monthly Plan Premium for People who get Extra Help from Medicare to Help Pay for their Prescription Drug Costs If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan. This table shows you what your monthly plan premium will be if you get extra help. Your level of extra help Monthly Premium for Allwell Dual Medicare (HMO SNP)* 100% $0 75% $ % $ % $24.40 *This does not include any Medicare Part B premium you may have to pay. Allwell Dual Medicare s premium includes coverage for both medical services and prescription drug coverage. If you aren t getting extra help, you can see if you qualify by calling: Medicare of TTY users call (24 hours a day/7 days a week), Your State Medicaid Office, or The Social Security Administration at TTY users should call between 7 a.m. and 7 p.m., Monday through Friday. If you have any questions, please call Member/Customer Services at , TTY: 711 from 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. Allwell Dual Medicare is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Allwell Dual Medicare depends on contract renewal. You must continue to pay your Medicare Part B premium. However, for full-dual beneficiaries, the State will cover your Part B premium as long as you retain your Medicaid eligibility. 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 on January 1 of each year. ALL_19_8963LTR_C_ H5590_