Secure Blue. no Rx (PPO) Care Plus Medicare Advantage Plans Secure Blue no Rx PPO SUMMARY OF BENEFITS. Serving Select Counties in Idaho

Transcription

1 Care Plus Medicare Advantage Plans Secure Blue no Rx PPO Secure Blue no Rx (PPO) 2017 SUMMARY OF BENEFITS Serving Select Counties in Idaho H1302_004_MK17005 ACCEPTED Form No. 16- (09-16)

2 For more information: Call us at (TTY ) We are available seven days a week from 8 a.m. to 8 p.m., from October 1 to February 14. Our hours of operation for the rest of the year are Monday through Friday from 8 a.m. to 8 p.m. Visit us online at us at sales@bcidaho.com Send correspondence to P.O. Box 8406, Boise, ID This document is available in other formats such as Braille, large print or audio. Blue Cross of Idaho Care Plus is a PPO health plan with a Medicare contract. Enrollment in Blue Cross of Idaho Care Plus 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 co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. The provider network may change at any time. You will receive notice when necessary. Blue Cross of Idaho Care Plus complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ) (TTY: )

3 Secure Blue no Rx (PPO) SUMMARY OF BENEFITS This is a summary of drug and health services covered by Secure Blue no Rx (PPO), from January 1, 2017 to December 31, 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. Who can join? To join Secure Blue no Rx (PPO), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area, which includes the following counties in Idaho: Ada, Bannock, Bingham, Boise, Bonner, Bonneville, Boundary, Canyon, Cassia, Clark, Elmore, Fremont, Gem, Jefferson, Kootenai, Madison, Minidoka, Nez Perce, Owyhee, Payette, Power, and Twin Falls. Which doctors and hospitals can I use? Secure Blue no Rx (PPO) has a network of doctors, hospitals and other providers. If you use the providers in our network, you may pay less for your covered services. But if you want to, you can also use providers that are not in our network. As a member of Secure Blue no Rx (PPO), you are not required to select a Primary Care Provider (PCP), however, we encourage all members to select a PCP so he or she can help you navigate your access to health services. Secure Blue no Rx (PPO) does not require referrals from a PCP for you to access and visit specialists in-network or out-of-network. You can see our plan s provider directory by visiting How do I determine my drug costs? Secure Blue no Rx (PPO) covers Part B drugs including chemotherapy and some drugs administered by your provider. However, this plan does not cover Part D prescription drugs. If you buy a Medicare Advantage plan that does not include Part D drug coverage, like Secure Blue no Rx (PPO), you cannot purchase a stand-alone Part D drug plan from another company during the plan year. If you have creditable prescription drug coverage (as least as good as Part D coverage) through an employer plan, or another program, you can continue to use that prescription drug coverage while a member of Secure Blue no Rx (PPO). How do I use the Summary of Benefits? Confirm your eligibility by reviewing the 2017 Secure Blue no Rx (PPO) Service Area Map on page 2. Compare premiums, deductibles and benefits in the benefits grid that starts on page 3. Review Optional Supplemental Benefits on page 7. Or call us and we will help you locate a provider, or send you a provider directory. 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 SECURE BLUE NO RX PPO SUMMARY OF BENEFITS 1

4 2017 Secure Blue no Rx (PPO) Service Area Boundary Bonner Kootenai Benewah Latah Shoshone Clearwater Secure Blue no Rx (PPO) Nez Perce Lewis Idaho Adams Valley Lemhi Washington Payette Gem Canyon Ada Owyhee Boise Elmore Camas Gooding Custer Blaine Lincoln Minidoka Butte Clark Fremont Jefferson Madison Bingham Bonneville Jerome Power Bannock Twin Falls Cassia Oneida Franklin Teton Caribou Bear Lake 2 SECURE BLUE NO RX PPO SUMMARY OF BENEFITS

5 Secure Blue no Rx (PPO) Summary of Benefits Secure Blue no Rx (PPO) January 1, 2017 December 31, 2017 PREMIUMS AND BENEFITS IN-NETWORK OUT-OF-NETWORK Monthly Plan Premium You must continue to pay your Medicare Part B premium. (Blue area of service map) You pay $42.00 Medical Deductible This plan does not have a medical deductible. You pay nothing Part D Prescription Drug Deductible Maximum Out-of-Pocket Responsibility (does not include prescription drugs) This plan does not have Part D prescription drug coverage. No coverage The most you pay for copays, coinsurance and other costs for medical services for the year. $3,400 In-Network and Out-of-Network combined Inpatient Hospital Coverage Our plans cover an unlimited number of days for an inpatient hospital stay. You pay nothing per day for days 6 through 90. You pay nothing per day for days 91 and beyond Our plans cover an unlimited number of days for an inpatient hospital stay. You pay nothing per day for days 11 through 90. You pay nothing per day for days 91 and beyond $175 copay per day for days 1-5 $200 copay per day for days 1-10 Doctor Visits No referral required for specialist visits. Primary Care $15 copay $30 copay Specialists $25 copay $30 copay Preventive Care Any additional preventive services approved by Medicare during the contract year will be covered. There are some items not covered at $0 cost. You pay nothing You pay nothing SECURE BLUE NO RX PPO SUMMARY OF BENEFITS 3

6 Secure Blue no Rx (PPO) January 1, 2017 December 31, 2017 PREMIUMS AND BENEFITS IN-NETWORK OUT-OF-NETWORK Emergency Care Urgently Needed Services Diagnostic Services/Labs/ Imaging Diagnostic Radiology Service (like CT, MRI) If you are admitted to the hospital within 3 days for the same condition, you do not have to pay your share of the cost for emergency care. $65 copay $65 copay Cost sharing for necessary urgently needed services furnished out-of-network is the same as for such services furnished in-network. $25 copay $25 copay Prior authorization is required for some services by your doctor or other network provider. Please contact the plan for more information. 10% of the cost 25% of the cost Lab Services 10% of the cost 25% of the cost Diagnostic Tests and Procedures Hearing Services Dental Services Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) Routine Eye Exam (One Annually) 10% of the cost 25% of the cost Exam to diagnose and treat hearing and balance issues. 10% of the cost $30 copay Limited Medicare covered dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth). Routine dental coverage is available with additional premium. 10% of the cost 25% of the cost Our plan pays up to $100 every year for eyewear, including contact lenses, eyeglasses, frames and lenses. $25 copay $30 copay $25 copay $30 copay 4 SECURE BLUE NO RX PPO SUMMARY OF BENEFITS

7 Secure Blue no Rx (PPO) January 1, 2017 December 31, 2017 PREMIUMS AND BENEFITS IN-NETWORK OUT-OF-NETWORK Mental Health Services You pay nothing per day for days 6 through 90 of an inpatient visit. You pay nothing per day for days 11 through 90 of an inpatient visit. Inpatient Visit $175 copay per day for days 1-5 $200 copay per day for days 1-10 Outpatient group therapy visit Outpatient individual therapy visit Skilled Nursing Facility (SNF) $25 copay 25% of the cost $25 copay 25% of the cost Our plan covers up to 100 days per benefit period in a SNF. $20 copay per day for days 1-20 You pay nothing per day for days $100 copay per day for days 1-12 You pay nothing per day for days Rehabilitation Services Occupational therapy visit $25 copay $30 copay Physical therapy and speech and language therapy visit Ambulance $25 copay $30 copay Includes ground or air transport. $175 copay $175 copay Transportation Foot Care (podiatry services) Not covered. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions. Foot exams and treatment $25 copay $30 copay SECURE BLUE NO RX PPO SUMMARY OF BENEFITS 5

8 Secure Blue no Rx (PPO) January 1, 2017 December 31, 2017 PREMIUMS AND BENEFITS IN-NETWORK OUT-OF-NETWORK Medical Equipment/ Supplies Durable Medical Equipment (like wheelchairs, oxygen) Prosthetics (e.g. braces, artificial limbs) 10% of the cost 20% of the cost 10% of the cost 20% of the cost Diabetes Supplies You pay nothing 20% of the cost Diabetes Shoes and Inserts 10% of the cost 20% of the cost Wellness Programs (e.g., fitness) You have the option of choosing between the Silver&Fit Gym Membership, which gives you access to network of fitness clubs for $50 annually, or you can participate in the home exercise program and receive up to two home exercise kits for $10 annually. Silver&Fit Gym Membership $50 annually Not covered Silver&Fit Home Exercise kits $10 annually $10 annually Medicare Part B Drugs Part B drugs are drugs usually administered in a inpatient hospital setting, like chemotherapy drugs. These are not the same as outpatient Part D prescription drugs. 20% for chemotherapy drugs 20% for other Part B drugs 30% for chemotherapy drugs 30% for other Part B drugs Outpatient Surgery Ambulatory Surgical Center $175 copay 20% of the cost Outpatient Hospital $175 copay 20% of the cost Outpatient Part D Prescription Drugs Part D Prescription Drugs This plan does not cover Part D prescription drugs. 6 SECURE BLUE NO RX PPO SUMMARY OF BENEFITS

9 Optional Supplemental Dental Coverage healthy smiles Healthy Smiles Plus For only $28.70 more per month, Healthy Smiles Plus covers preventive dental services with no maximum limits, no in-network deductibles and no waiting periods. Because Blue Cross of Idaho covers 100 percent of in-network preventive services after a $20 copayment, this plan is the best option if you re looking for a low premium dental plan that encourages good oral habits that help maintain a healthy smile. Healthy Smiles Plus preventive benefits include: Oral examinations once in a six-month period Emergency oral examination Panoramic X-ray or full mouth series X-ray one time in any five consecutive years Bitewing X-rays once per benefit period Periapical X-rays Additional Basic Dental Services Healthy Smiles Plus offers the following basic dental services after satisfying a six-month waiting period and $50 deductible (in-network preventive services don t apply to deductible). Fillings same tooth surface restoration covered once in a two-year period Extractions Cleanings regular cleaning or periodontal maintenance once in a six-month period Preventive In-Network Out-of-Network Deductible $0 $50 per member, per benefit period Benefit Period Maximum None Preventive Dental Services (oral exams, cleanings, x-rays) 100% of maximum allowance after $20 copayment per visit 50% of maximum allowance after deductible Basic In-Network Out-of-Network Deductible $50 per member, per benefit period Benefit Period Maximum $1,000 per member, per benefit period Basic Dental Services (fillings, extractions) 80% of the maximum allowance after deductible 50% of maximum allowance after deductible SECURE BLUE NO RX PPO SUMMARY OF BENEFITS 7

10 Nondiscrimination Statement: Discrimination is Against the Law. Blue Cross of Idaho Care Plus complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Blue Cross of Idaho Care Plus does not exclude people or treat them differently because of race, color, national origin, age, disability or sex. Blue Cross of Idaho Care Plus: 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 contact Blue Cross of Idaho s Customer Service Department. Call (TTY: ), or call the customer service phone number on the back of your card. If you believe that Blue Cross of Idaho 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: Manager, Grievances and Appeals 3000 East Pine Avenue, Meridian, Idaho Telephone: (800) ext.3838 Fax: TYY: You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, our Grievances and Appeals Coordinator 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, DC (TYY ) Complaint forms are available at: Reference: 8 SECURE BLUE NO RX PPO SUMMARY OF BENEFITS

11 Arabic ملحوظة: إذا كنت تتحدث اذكر اللغة فا ن خدمات المساعدة اللغویة تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبكم: ). Chinese 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: ) French ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS : ). German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: ). Japanese 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: ) まで お電話にてご連絡ください Korean :, (TTY: ). Persian-Farsi توجھ: اگر بھ زبان فارسی گفتگو می کنید تسھیلات زبانی بصورت رایگان برای شما فرا ھم می باشد. با ( (TTY: تماس بگیرید. Romanian ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la (TTY: ). Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: ). Serbo-Croation OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: ). Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: ). Sudanic Fulfulde MAANDO: To a waawi [Adamawa], e woodi ballooji-ma to ekkitaaki wolde caahu. Noddu (TTY: ). Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: ). Ukrainian УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером (телетайп: ). Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: ). Y0010_MK17030 Accepted 08/14/2016 SECURE BLUE NO RX PPO SUMMARY OF BENEFITS 9

12 Medicare Advantage Plans Secure Blue no Rx PPO 3000 East Pine Avenue Meridian, Idaho Mailing Address: P.O. Box 8406 Boise, Idaho TTY Please recycle H1302_004_MK17005 ACCEPTED Form No. 16- (09-16) 2016 by Blue Cross of Idaho Care Plus, an independent licensee of the Blue Cross and Blue Shield Association, with services provided by Blue Cross of Idaho