2018 Summary. Effective January 1, December 31, 2018

Transcription

1 2018 Summary of Benefits Effective January 1, December 31, 2018 This is a summary of drug and health services covered by The Health Plan SecureCare - Option I, MA Only (HMO) (H3672, Plan 014); The Health Plan SecureCare - Option II (HMO) (H3672, Plan 013); and The Health Plan SecureCare - Option IV (HMO) (H3672, Plan 018) The Health Plan SecureCare (HMO) is a Medicare Advantage HMO Plan with a Medicare contract. Enrollment in the plan depends on contract renewal. H3672_013_014_018_HMO18_004 ACCEPTED

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3 The benefit information provided is a summary of what we cover and what you pay. 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 request the Evidence of Coverage or access it online at healthplan.org/medicare. To join The Health Plan SecureCare - Option I, MA Only (HMO); The Health Plan SecureCare - Option II (HMO); or The Health Plan SecureCare - Option IV (HMO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in Ohio: Ashland, Carroll, Columbiana, Coshocton, Gallia, Hocking, Holmes, Jackson, Mahoning, Medina, Meigs, Morgan, Perry, Portage, Stark, Summit, Trumbull, Tuscarawas, Vinton and Wayne. The Health Plan SecureCare (HMO) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. 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 medicare.gov or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call This document is available in other formats such as Braille, large print or audio. For additional information, call us at For more information, please visit us at healthplan.org/medicare, or call us toll-free at (TTY users should call 711). 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. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern. You can see our plan s provider directory at our website at findadoc.healthplan.org. You can see our plan s pharmacy directory at our website at healthplan.org/medicare. SecureCare - Option II (HMO) and SecureCare - Option IV (HMO) cover Part D drugs. SecureCare - Option I, MA Only (HMO); SecureCare - Option II (HMO); and SecureCare - Option IV (HMO) 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 at healthplan.org/medicare. This information is not a complete description of benefits. Contact the plan for more information. Limitations, ments and restrictions may apply. Benefits, premiums and/or ments/ co-insurance may change on January 1 of each year. The formulary, pharmacy and/or provider network(s) may change at any time. You will receive notice when necessary.

4 PREMIUMS & BENEFITS Monthly Plan Premium OPTION I, MA ONLY (HMO) SHOULD KNOW You pay nothing You pay $46 You pay nothing You must continue to pay your Medicare Part B premium. Deductible You pay nothing You pay nothing You pay nothing This plan does not have a deductible for medical services. Maximum Out-of-Pocket Responsibility (does not include Part D prescription drugs) $4,500 annually $4,500 annually $3,750 annually The most you pay for s, co-insurance, and other costs for medical services for the year. Inpatient Hospital Coverage (per admission) Days 1-5: You pay $250 per day Days 6-90: Days 1-5: You pay $250 per day Days 6-90: Days 1-5: You pay $325 per day Days 6-90: Our plan covers an unlimited number of days for an inpatient hospital stay. You pay nothing You pay nothing You pay nothing Outpatient Hospital Coverage You pay $0-$250 You pay $0-$250 You pay $0-$275 $0 for observation visits; $0 for colonoscopy. Doctor Visits Primary Care Visit You pay nothing You pay nothing You pay $15 per visit Specialist Visit per visit per visit You pay $45 per visit Prior authorization is required for certain specialist visits. $0 for Medicare covered vision exam. 2 SUMMARY OF BENEFITS

5 SECURECARE OPTION I, II & IV HMO JANUARY 1, 2018 DECEMBER 31, 2018 PREMIUMS & BENEFITS Preventive Care (Medicarecovered) OPTION I, MA ONLY (HMO) SHOULD KNOW You pay nothing You pay nothing You pay nothing Any additional preventive services approved by Medicare during the contract year will be covered. Emergency Care (worldwide) You pay $80 per visit You pay $80 per visit You pay $80 per visit If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care. Covered emergency services outside of U.S. have a $25,000 annual plan max. Urgently Needed Services You pay $65 per visit You pay $65 per visit You pay $65 per visit If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for urgently needed services. SUMMARY OF BENEFITS 3

6 PREMIUMS & BENEFITS OPTION I, MA ONLY (HMO) SHOULD KNOW Diagnostic Services/Labs/ Imaging Prior authorization is required for some services by your doctor or other network provider. Please contact the plan for more information. Diagnostic Radiology Service (such as MRIs, CT scans) You pay $0-$200 You pay $0-$200 You pay $0-$200 Lab Services You pay nothing You pay nothing You pay nothing $200 for CT scans, MRI, MRA, PET and SPECT scans; $0 for all diagnostic mammograms and diagnostic bone density exams. Diagnostic Tests and Procedures Outpatient X-rays Therapeutic Radiology Services (such as radiation treatment for cancer) You pay nothing You pay nothing You pay nothing You pay $0-$50, depending on the service You pay $0-$50, depending on the service You pay $0-$75, depending on the service You pay 20% You pay 20% You pay 20% A $0 will apply to X-ray services that are part of a scheduled outpatient surgery, ER visit, or inpatient hospital stay. One per date of service. 4 SUMMARY OF BENEFITS

7 PREMIUMS & BENEFITS Hearing Services SECURECARE OPTION I, II & IV HMO JANUARY 1, 2018 DECEMBER 31, 2018 OPTION I, MA ONLY (HMO) SHOULD KNOW Medicare covered Exam You pay $45 Dental Services Medicarecovered Services You pay $35 This does not include services in connection with care, treatment, filling, removal, or replacement of teeth. Routine Dental Services You pay $0 for preventive: 2 exams, 2 cleanings, one set of bitewing X-rays You pay $0 for preventive: 2 exams, 2 cleanings, one set of bitewing X-rays You pay $20 for preventive: 2 exams, 2 cleanings, one set of bitewing X-rays Non-Medicare covered routine dental is provided through the plan s dental administrator. Please contact the plan for more details. Vision Services Medicarecovered exam to diagnose and treat conditions of the eye (including yearly glaucoma screening) You pay nothing You pay nothing You pay nothing SUMMARY OF BENEFITS 5

8 PREMIUMS & BENEFITS Vision Services (continued) OPTION I, MA ONLY (HMO) SHOULD KNOW Medicarecovered Eyewear You pay nothing You pay nothing You pay nothing Routine Eye Exam (for up to 1 every year) This is not a covered benefit for this plan Non-Medicare covered routine vision is provided through the plan s vision administrator. Please contact the plan for more details. Routine Eyewear You pay $15 You pay $15 This is not a covered benefit for this plan For plans with routine eyewear coverage, the plan coverage limit for non- Medicare covered/routine eyewear: $65 towards one pair of frames every two years. One pair of basic eye glass lenses covered every two years. $100 towards one pair of contacts and contact lens fitting exam every two years. 6 SUMMARY OF BENEFITS

9 SECURECARE OPTION I, II & IV HMO JANUARY 1, 2018 DECEMBER 31, 2018 PREMIUMS & BENEFITS OPTION I, MA ONLY (HMO) SHOULD KNOW Mental Health Services Inpatient Services (per admission) Days 1-5: You pay $250 per day Days 1-5: You pay $250 per day Days 1-5: You pay $320 per day Days 6-90: Days 6-90: Days 6-90: You pay nothing per day You pay nothing per day You pay nothing per day Outpatient Individual Therapy Visit Outpatient Group Therapy Visit per outpatient/ individual or group therapy visit per outpatient/ individual or group therapy visit You pay $40 per outpatient/ individual or group therapy visit Skilled Nursing Facility Days 1-20: You pay nothing Days 1-20: You pay nothing Days 1-20: You pay nothing Our plan covers up to 100 days in a skilled nursing facility. Days : Days : Days : You pay $150 per day You pay $150 per day You pay $160 per day Physical Therapy per visit per visit You pay $40 per visit Ambulance (worldwide) You pay $200 Air ambulance: 20% co-insurance You pay $200 Air ambulance: 20% co-insurance You pay $250 Air ambulance: 20% co-insurance Covered emergency services outside of U.S. have a $25,000 annual plan max. Transportation (routine) Medicare Part B Drugs Not covered Not covered Not covered You pay 20% You pay 20% You pay 20% SUMMARY OF BENEFITS 7

10 PREMIUMS & BENEFITS Foot Care (podiatry services) Medicarecovered Foot Exams and Treatment OPTION I, MA ONLY (HMO) You pay $45 SHOULD KNOW Foot exams and treatments if you have diabetesrelated nerve damage and/ or meet certain conditions. Routine Foot Care You pay $45 Routine foot care covered for up to 2 visits every year. Medical Equipment Supplies Supplies are covered when they are ordered as part of your care. Durable Medical Equipment (e.g., wheelchairs, oxygen) You pay 20% You pay 20% You pay 20% Durable medical equipment must meet certain criteria to be covered. Please contact the plan for more details. Prosthetics (e.g., braces, artificial limbs) You pay 20% You pay 20% You pay 20% 8 SUMMARY OF BENEFITS

11 PREMIUMS & BENEFITS Diabetes Supplies Diabetes Monitoring Supplies Diabetes Self- Management Therapeutic Shoes or Inserts SECURECARE OPTION I, II & IV HMO JANUARY 1, 2018 DECEMBER 31, 2018 OPTION I, MA ONLY (HMO) You pay $7.50 You pay $7.50 You pay $7.50 You pay nothing You pay nothing You pay nothing You pay 20% You pay 20% You pay 20% SHOULD KNOW For monitoring supplies, coverage is limited to LifeScan preferred monitoring devices and test strips. Coverage is limited to 100 test strips for a 30-day. Additional quantity requires coverage review. Wellness Programs (e.g., fitness, tobacco cessation, etc.) You pay nothing You pay nothing You pay nothing SilverSneakers is the fitness program covered by this plan. SUMMARY OF BENEFITS 9

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13 Outpatient Prescription Drugs Cost Sharing Deductible Initial Coverage SECURECARE OPTION I, II & IV HMO JANUARY 1, 2018 DECEMBER 31, 2018 Prescription Coverage SECURECARE - OPTION I, MA ONLY (HMO) This plan does not provide Part D Rx coverage N/A SECURECARE - This plan provides Part D Rx coverage SECURECARE - OPTION IV (HMO) This plan provides Part D Rx coverage N/A $100 $200 $3,750 $3,750 SHOULD KNOW Cost-sharing may change depending on the pharmacy you choose and when you enter another phase of the Part D benefit. For more information on a pharmacyspecific costsharing and the phases of the benefit, please call us or access our Evidence of Coverage or formulary online at healthplan. org/medicare. Deductible applies to drugs in Tier 3, Tier 4, and Tier 5 only. In the initial coverage phase, you pay the cost share amount indicated 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. SUMMARY OF BENEFITS 11

14 Tier 1: Preferred Generic Tier 2: Generic OPTION I, MA ONLY (HMO) SHOULD KNOW N/A You pay: You pay: Cost-sharing may differ Preferred Retail Preferred Retail relative to the pharmacy s status as $3 $5 preferred or nonpreferred, $9 $15 mail-order, Other Network Retail Other Network Retail Long Term Care (LTC) or home infusion, and $13 $15 if a 30- or 90- day of $39 $45 prescription medication is Mail Order Mail Order ordered. For more information please call $0 $0 us or access our Evidence N/A You pay: You pay: of Coverage or formulary Preferred Retail Preferred Retail online at healthplan. org/ $10 $10 medicare. $30 $30 Other Network Retail Mail Order $20 $60 Other Network Retail Mail Order $20 $60 $20 $20 12 SUMMARY OF BENEFITS

15 SECURECARE OPTION I, II & IV HMO JANUARY 1, 2018 DECEMBER 31, 2018 Tier 3: Preferred Brand OPTION I, MA ONLY (HMO) N/A You pay: You pay: Preferred Retail Preferred Retail SHOULD KNOW $35 $35 $105 $105 Other Network Retail Other Network Retail $45 $45 $135 $135 Mail Order Mail Order $70 $70 Tier 4: Non- Preferred Drug N/A You pay: You pay: Preferred Retail $85 Preferred Retail $85 $255 $255 Other Network Retail Other Network Retail $95 $95 $285 $285 Mail Order Mail Order $170 $170 SUMMARY OF BENEFITS 13

16 OPTION I, MA ONLY (HMO) SHOULD KNOW Tier 5: Specialty (Extended day not available in this Tier) Coverage Gap N/A You pay: You pay: N/A Preferred Retail 31% of the cost N/A Other Network Retail 31% of the cost N/A Mail Order 31% of the cost Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug 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 price for brand name drugs plus a portion of the drug dispensing fee, and 44% of the price for generic drugs until your costs total $5,000. Preferred Retail 29% of the cost N/A Other Network Retail Mail Order 29% of the cost N/A 29% of the cost Most Medicare drug plans have a coverage gap (also called the donut hole ). This means that there s a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug 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 price for brand name drugs plus a portion of the drug dispensing fee, and 44% of the price for generic drugs until your costs total $5, SUMMARY OF BENEFITS

17 SECURECARE OPTION I, II & IV HMO JANUARY 1, 2018 DECEMBER 31, 2018 OPTION I, MA ONLY (HMO) SHOULD KNOW Catastrophic Coverage N/A 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 $3.35 for generic (or a preferred multisource drug) and a $8.35 ment for all other drugs. 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 $3.35 for generic (or a preferred multisource drug) and a $8.35 ment for all other drugs. SUMMARY OF BENEFITS 15

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19 Discrimination is Against the Law The Health Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. The Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. The Plan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact The Health Plan Customer Service Department. If you believe that The Plan 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 with: The Health Plan Appeals Coordinator, 1110 Main Street, Wheeling, WV 26003, Phone: , TTY: 711, Fax , info@healthplan.org. You can file a grievance in person or by mail, fax, or . If you need help filing a grievance The Health Plan Customer Service Department 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, D.C , (TDD). Complaint forms are available at ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY:711)

20 ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS: 711). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711). 번으로전화해주십시오. ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم: 711).!य न द': य(द आप!ह द% ब लत ह1 त आपक लए म 7त म' भ ष सह यत स व ए उपल>ध ह (TTY: 711) पर क ल कर' ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (TTY: 711). ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele (TTY: 711). UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer (TTY: 711). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけます (TTY: 711) まで お電話にてご連絡ください Wann du Deitsch (Pennsylvania German / Dutch) schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call (TTY: 711). AANDACHT: Als u nederlands spreekt, kunt u gratis gebruikmaken van de taalkundige diensten. Bel (TTY: 711). ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la (TTY: 711). УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером (телетайп: 711). XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (TTY: 711).

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22 1110 Main Street, Wheeling, WV