Errata Sheet to the Imperial Health Plan of California (HMO) Traditional LA (006) & Traditional SFO (007) 2018 Evidence of Coverage

Transcription

1 Errata Sheet to the Imperial Health Plan of California (HMO) Traditional LA (006) & Traditional SFO (007) 2018 Evidence of Coverage [Insert date] This is important information on changes in your Imperial Health Plan coverage. We previously sent you the Evidence of Coverage (EOC) documents which provide information about your coverage as an enrollee in our plan. This notice is to let you know there are errors in your EOC document. Below you will find information describing and correcting the errors. Please keep this information for your reference. Changes to your EOC Where you can find Original Page 62, Chapter 4 plan - Acupuncture (006) Up to 18 treatments per year: You pay $5 copayment per treatment for a total maximum benefit of $90 per calendar year (006): Up to 18 treatments per year: You pay $5 copayment per treatment. No maximum benefit coverage amount (006) does not have a maximum benefit coverage amount for Acupuncture Page 62, Chapter 4 plan - Acupuncture (007) Up to 18 treatments per year: You pay $15 copayment per treatment for a total maximum benefit of $270 per calendar year. Up to 18 treatments per year: You pay $15 copayment per treatment. There is not a maximum benefit coverage amount (007) does not have a maximum benefit coverage amount for Acupuncture Page 64, Chapter 4 (006) may require prior for Cardiac

2 Original plan Cardiac Page 64, Chapter 4 plan Cardiac There is $0 coinsurance, copayment, or deductible for these services coinsurance for Cardiac Rehabilitation (007) may require prior for Cardiac and you will pay 20% coinsurance Page 64, Chapter 4 plan - Cardiovascular disease risk reduction visit (therapy for cardiovascular disease) Requires prior (HMO) (007) do not require a prior for Cardiovascular disease risk reduction visit (therapy for cardiovascular disease) Page 67, Chapter 4 plan - Dental 20% Co-insurance for up to on full set of dental x- rays every three months unless medically necessary (006) and Traditional SFO (HMO) 20% Coinsurance for up to on full set of dental x- rays every year unless medically necessary (HMO) (007) dental x-ray benefit is every year Page 78, Chapter 4 plan Inpatient stay: Covered services received in a hospital or SNF during a noncovered inpatient stay (006) you pay $0 (006): Inpatient Hospital Stay You pay $0 Skilled Nursing Facility (SNF) Care Covers up to 100 days in a SNF per benefit period. You pay $0 for days 1-20 (006) you pay $ of hospital stay and $0 for days 1-20 and $135 co-payment per day for for SNF

3 Original You pay $135 copayment per day for Page 78, Chapter 4 plan Inpatient stay: Covered services received in a hospital or SNF during a noncovered inpatient stay (007) you pay $100 for days 1 through 5 and $ for days 6 through 90 Inpatient Hospital Stay You pay $100 for days 1-5 and $0 for days 6-90 Skilled Nursing Facility (SNF) Care Covers up to 100 days in SNF per benefit period You pay $0 for days 1-20 You pay $ copayment per day for days (007) for hospital stay, you pay $100 for days 1 5 and $0 for days 6 90 for. For SNF you pay $0 for days 1-20 an $ co-payment per day for days Page 80, Chapter 4 plan Medicare Part B Prescription Drugs You pay no for Part B covered chemotherapy drugs and other Part B covered drugs. (006) and Traditional SFO (HMO) Prior required You pay $0 co-payment for Part B covered chemotherapy drugs and other Part B covered drugs. prior and You pay $0 co-payment for Medicare Part B Prescription Drugs Page 83, Chapter 4 plan Outpatient Mental Health Care For Traditional LA (HMO) (006) and You pay $0 for outpatient group therapy visit with a psychiatrist. You pay $0 for outpatient individual therapy visit with a psychiatrist coinsurance for outpatient group therapy visit with a psychiatrist. coinsurance for outpatient individual (007) you pay 20% coinsurance for outpatient group therapy visit with a psychiatrist and you pay 20% coinsurance for outpatient individual therapy visit with a psychiatrist

4 Page 84, Chapter 4 plan Outpatient Page 85, Chapter 4 plan Partial Hospitalization Services Page 86, Chapter 4 plan Physician/Practitioner Services, including doctor s office visits Page 87, Chapter 4 plan Prosthetic Devices and Related Supplies Page 88, Chapter 4 Original You pay $0 for occupational therapy visit(s). therapy visit with a psychiatrist You pay $10 co-payment for occupational therapy visit(s). $0 co-pay (006) and Traditional SFO (HMO) Prior required coinsurance for Medicare covered partial hospitalization services for specialist visits (007) you pay $10 copayment for occupational therapy visit(s). prior and you pay 20% coinsurance for Medicare covered partial hospitalization services prior for specialist visits not PCP visits prior for prosthetic devices and related supplies (HMO) (007) do not

5 plan - Screening and Counseling to reduce alcohol misuse Page 90, Chapter 4 plan Services to treat kidney disease and conditions Page 94, Chapter 4 plan Urgently needed services Page, Chapter 4 Section 2.1 Your medical benefits and costs as a member of the plan Original (006) you pay $65 copayment for each visit to an urgent care facility or outside of the service area. (006) and Traditional LA - (HMO) You pay $0 co-payment for each visit to an urgent care facility. You pay $65 co-payment for worldwide emergency care. Worldwide coverage up to $50,000 per year. require a prior for Screening and counseling to reduce alcohol misuse prior for Services to treat kidney disease and conditions (006) and Traditional LA - (HMO) (007) you pay $0 co-payment for each visit to an urgent care facility and $65 co-payment for worldwide emergency care. You are not required to take any action in response to this document, but we recommend you keep this information for future reference. If you have any questions please call us at , (TTY/TDD: 711), [Monday through Sunday, 8:00 am to 8:00 pm except holidays during October 1 through February 14 and] Monday through Friday 8:00 am to 5:00 pm [February 15 through September 30] except holidays. Imperial Health Plan is an (HMO) (HMO SNP) with a Medicare Contract. Enrollment in Imperial Health Plan depends on contract renewal.

6 Imperial Health Plan of California (HMO) (HMO SNP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. 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).