2017 Summary of Benefits

Transcription

1 2017 INFORMATION 2017 Summary of Benefits Prominence Plus (HMO) & Prominence Prime (HMO) for Brooks, Hidalgo, and Starr Counties To learn more about our plans or to enroll, call TOLL FREE: TTY/TDD: 711 HOURS: October 1 to February 14, 7 days a week, 8 am 8 pm February 15 to September 30, Monday through Friday, 8 am 8 pm Prominence Health Plan is an HMO plan with a Medicare contract. Enrollment depends on contract renewal. Y0109_STX002003SB17_CMS Acccepted

2 2017 SUMMARY of BENEFITS Prominence Plus & Prominence Prime Health Plans (HMO) H7680, PLANS 002 & 003 THIS IS A SUMMARY OF DRUG AND HEALTH SERVICES COVERED BY PROMINENCE PLUS AND PROMINENCE PRIME HEALTH PLANS (HMO) JANUARY 1, DECEMBER 31, 2017 Prominence Plus and Prominence Prime are Medicare Advantage HMO plans with a Medicare contract. Enrollment in the Plans depends on contract renewal. 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. To join Prominence Plus (HMO) or Prominence Prime (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 Texas: Brooks, Hidalgo and Starr. Prominence Plus (HMO) and Prominence Prime (HMO) have 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. Prominence 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. Prominence Health Plan cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Prominence Health Plan tuân thủ luật 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. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY/TDD: 711). CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY/TDD: 711). 1

3 Premiums and Benefits Prominence Plus (HMO) * H Medical + Rx Prominence Prime (HMO) * H Medical Coverage Only Monthly Plan Premium You pay $0 You pay $0 You must continue to pay your Medicare Part B premium. Medicare Part B Premium Buy Down Not Applicable The Plan will pay $25 toward your 2017 monthly Part B premium Deductible You pay nothing You pay nothing These plans do not have a deductible. Maximum Out-of- Pocket Responsibility (does not include prescription drugs) $4,000 annually $3,400 annually The most you pay for copays, coinsurance and other costs for medical services for the year. Inpatient Hospital Coverage $200 copay per day for days 1 through 7 for days 8 through 90. for days 91 and beyond. $100 copay per day for days 1 through 5 for days 6 through 90. for days 91 and beyond. Our plans cover an unlimited number of days for an inpatient hospital stay. Prior authorization is required. Please contact the plan for more information. Doctor Visits Primary Care Specialists $0 copay per visit $0 copay per visit Preventive Care You pay nothing You pay nothing Any additional Abdominal aortic aneurysm screening; Alcohol misuse counseling; Annual Wellness Physical Exam; 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; Lung cancer screening; Medical nutrition therapy services; Obesity screening and counseling; Prostate cancer screenings (PSA); Sexually transmitted infections screening and counseling; Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease); Vaccines, including Flu, Hepatitis B, & Pneumococcal shots; Welcome to Medicare preventive visit (one-time); Yearly Wellness visit. preventive services approved by Medicare during the contract year will be covered. There are some items not covered at $0 cost. 2

4 Premiums and Benefits Prominence Plus (HMO) * H Medical + Rx Prominence Prime (HMO) * H Medical Coverage Only Emergency Care Worldwide Emergency Care $75 copay per visit $75 copay per visit $75 copay per visit $75 copay per visit The emergency care copay is waived if you are admitted to the hospital for the same diagnosis within 3 days of the emergency care visit. Urgently Needed Services The urgent care copay is waived if you are admitted to the hospital for the same diagnosis within 3 days of the urgent care visit. Diagnostic Services/ Labs/Imaging Diagnostic radiology service (e.g., CT, MRI) Lab services Diagnostic tests and procedures Outpatient x-rays $150 copay per visit $10 copay per visit $10 copay per visit $0 copay per visit $75 copay per visit $0 copay per visit $0 copay per visit $5 copay per visit Prior authorization is required for some services. Please contact the plan for more information. Hearing Services Routine hearing exam Medicare-covered hearing exam Hearing aid $380 annual allowance $380 annual allowance One routine hearing exam allowed annually. Hearing aid allowance is a combined annual allowance, not per ear. Dental Services Preventive dental (Oral exam, cleaning, x-rays & fluoride treatment) Medicare-covered dental Two preventive dental visits allowed annually. Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth). required for Medicarecovered dental services. Please contact the plan for more information. Vision Services Routine eye exam Medicare-covered eye exam Eyewear $200 annual allowance $200 annual allowance One routine eye exam allowed annually. Our plan pays up to $200 for supplemental prescription eyewear every year, which can apply towards lenses, frames or contact lenses. 3

5 Premiums and Benefits Prominence Plus (HMO) * H Medical + Rx Prominence Prime (HMO) * H Medical Coverage Only Mental Health Services Inpatient visit Outpatient therapy visit Partial Hospitalization $200 copay per day for days 1 through 7. for days 8 through 90. $55 copay per day $100 copay per day for days 1 through 5. for days 6 through 90. $55 copay per day required for Inpatient Hospital stays and Partial Hospitalization. Please contact the plan for more information. Skilled Nursing Facility (SNF) Per benefit period $0 per day/days 1-20 $150 per day/days $0 per day/days 1-20 $150 per day/days Our plan covers up to 100 days in a SNF. required. Please contact the plan for more information. Rehabilitation Services Occupational therapy visit Physical therapy & speech language pathology visits $40 copay per visit $40 copay per visit 10 occupational, 10 physical and 10 speechlanguage therapy visits are allowed annually without prior authorization. Prior authorization is required for all visits over 10. Please contact the plan for more information. Ambulance $250 copay per segment $250 copay per segment Non-emergency transport requires prior authorization. Please contact the plan for more information. Transportation Not covered Not covered Foot Care (podiatry services) Foot exams and treatment Routine foot care Not covered Not covered 4

6 Premiums and Benefits Prominence Plus (HMO) * H Medical + Rx Prominence Prime (HMO) * H Medical Coverage Only Medical Equipment/ Supplies Durable Medical Equipment (DME) (e.g., wheelchairs, oxygen) Prosthetics (e.g., braces, artificial limbs) Diabetes supplies Diabetic therapeutic shoes or inserts 20% coinsurance 10% coinsurance 10% coinsurance 20% coinsurance 20% coinsurance 10% coinsurance 10% coinsurance 20% coinsurance required for all DME, Prosthetics and Medical Supply items with a purchase price greater than $500 or $38.50 per month if rented. Please contact the plan for more information. Abbott Laboratories is a preferred vendor for diabetic testing supplies. If Abbott products are utilized your cost share will be 10% of the discounted rate. Wellness Programs (e.g., fitness) You pay nothing for Silver & Fit membership You pay nothing for Silver & Fit membership Silver & Fit Fitness Benefit provides access to fitness facilities, classes, and in-home exercise kits Medicare Part B Drugs 20% of the cost for chemotherapy and other Part B drugs 20% of the cost for chemotherapy and other Part B drugs required for all Part B drugs with a cost greater than $100. Please contact the plan for more information. Outpatient Prescription Drugs See Table Below Not covered Premiums and Benefits OUTPATIENT PRESCRIPTION DRUGS Prominence Plus (HMO) H Medical + Rx Prescription Drug Deductible $0 Retail Rx 30-day supply Mail Order 90-day supply Phase 1: Initial Coverage Tier 1: Preferred Generic Tier 2: Generic Tier 3: Preferred Brand Tier 4: Non-Preferred Brand Tier 5: Specialty Tier You pay $2 You pay $8 You pay $30 You pay $60 You pay 33% You pay $4 You pay $16 You pay $60 You pay $120 Not available 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 the phases of the benefit, please call us or access our Evidence of Coverage online at Coverage Gap Tier 1 & Tier 2 drugs are covered in the gap. 5

7 ADDITIONAL BENEFITS Premiums and Benefits Prominence Plus (HMO) * H Medical + Rx Prominence Prime (HMO) * H Medical Coverage Only Annual Physical Exam $0 copay $0 copay You pay the plan costsharing amount for screening exams and/ or diagnostic tests received in preparation for this visit or ordered as a result of this visit. Chiropractic Care Medicare-covered chiropractic visit (Manipulation of the spine to correct a subluxation) Outpatient Surgery Outpatient hospital or Ambulatory Surgery Center (ASC) $20 copay per visit $20 copay per visit $150 copay $50 copay Prior Authorization is required for all visits over 10 annually. Please contact the plan for more information. required for Outpatient Surgery. Please contact the plan for more information. Over-the-Counter Items (Please visit our website to see our list of covered over-the-counter items.) $0 copay $30 monthly allowance $0 copay $30 monthly allowance Any unused portion of the $30 monthly allowance may not be carried over from one month to the next. Items ordered through this program are delivered to you for free. 6

8 DISCRIMINATION IS AGAINST THE LAW Prominence 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. Prominence Health Plan does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Prominence Health Plan: Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters 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: Qualified interpreters Information written in other languages If you need these services, contact Scott Heinze. If you believe that Prominence Health 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: Scott Heinze, 1510 Meadow Wood Lane, Reno, NV 89502, , TTY/TDD: 711, or Fax You can file a grievance in person or by mail or fax. If you need help filing a grievance, Scott Heinze 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 7

9 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/TDD users should call 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 co-payments/co-insurance may change on January 1 of each year. This document is available in other formats such as large print. This information is available for free in other languages. Please contact our Member Services number at for additional information. (TTY/TDD users should call 711). Hours are 8 a.m. to 8 p.m. seven days a week from October 1 to February 14. From February 15 through September 30, hours are 8 a.m. to 8 p.m. Monday through Friday. Esta información está disponible de forma gratuita en otros idiomas. Por favor, póngase en contacto con nuestro número de Servicio al Cliente al para obtener información adicional. (Los usuarios de TTY/TDD deben llamar al 711). Horario es de 8 am a 8 p.m. los siete días de la semana del 1 de octubre al 14 de febrero. Del 15 de febrero al 30 de septiembre, las horas son 08 a.m.-8 p.m. de lunes a viernes. For more information, please call us at the phone number below or visit us at Toll-free , 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. Central. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Central. You can see our plan s Provider and Pharmacy Directory on our website at: We cover Part D drugs on the Prominence Value Plan. The Prominence Prime Plan does not include Part D coverage. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider on both Plans. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website at 8

10 To learn more about our plans or to enroll, call TOLL FREE TTY/TDD 711 Hours: October 1 to February 14 7 days a week, 8 am 8 pm February 15 to September 30 Monday through Friday 8 am 8 pm Prominence Health Plan is an HMO plan with a Medicare contract. Enrollment depends on contract renewal _STX 9/16