2018 MEDICARE. summary of benefits. advantage plan. Serving Members in Josephine & Jackson Counties

Transcription

1 2018 MEDICARE advantage plan summary of benefits Serving Members in Josephine & Jackson Counties

2 Table of Contents About the Summary of Benefits... 1 Who Can Join?... 1 Which doctors, hospitals and pharmacies can I use?... 1 Tips for comparing your Medicare choices... 1 About ATRIO Health Plans... 1 Monthly Premium, Deductibles, and Limits on How Much You Pay for Covered... 2 Plan Premium... 2 Plan Deductible... 2 Out-of-Pocket Limits... 2 Covered Medical and Hospital Benefits... 2 Inpatient Hospital Care... 2 Outpatient Surgery... 2 Doctor s Office Visits... 2 Preventive Care... 2 Emergency Care... 3 Urgently Needed... 3 Diagnostic Tests, Lab and Radiology, and X-rays... 3 Hearing... 3 Dental... 3 Vision... 4 Mental Health... 4 Skilled Nursing Facility (SNF)... 4 Rehabilitation... 4 Ambulance... 5 Transportation... 5 Medicare Part B Drugs... 5 Foot Care... 5 Medical Equipment and Supplies... 5 Wellness Programs... 5 Chiropractic... 5 Prescription Drug Benefits... 6 Deductible Stage... 6 Initial Coverage Stage... 6 Coverage Gap Stage... 6 Catastrophic Coverage Stage... 6

3 2018 Summary of Benefits January 1, 2018 December 31, 2018 About the Summary of Benefits This is a summary of drug and health services covered by and ATRIO Silver Rx (Rogue) (PPO). 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 an ATRIO Health Plans Medicare Advantage Plan, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area for and includes the following counties in Oregon: Josephine and Jackson Counties. Which doctors, hospitals and pharmacies can I use? ATRIO Health Plans has a network of doctors, hospitals, pharmacies, 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. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan s Formulary (Part D prescription drug list), Provider Directory and Pharmacy Directory at our website, atriohp.com. Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what and covers and what you pay. 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 About ATRIO Health Plans Our Customer Service Department can be reached at , daily from 8 a.m. to 8 p.m. Pacific. TTY users should call Our website can be viewed online at atriohp.com. ATRIO Health Plans has PPO and HMO-SNP plans with a Medicare contract. Enrollment in ATRIO Health Plans 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 copayments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. Out-of-network/non-contracted providers are under no obligation to treat ATRIO Health Plan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services. H6743_SB_JJ_2018 Accepted 014, 016 1

4 Monthly Premium, Deductibles, and Limits on How Much You Pay for Covered Plan Premium Plan Deductible Out-of-Pocket Limits $9 per month. In addition, you must keep paying your Medicare Part B premium. $250 per year for some in-network and out-ofnetwork services. $3,400 for services you receive from innetwork providers. $5,100 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit. $112 per month. In addition, you must keep paying your Medicare Part B premium. $50 per year for some in-network and out-ofnetwork services. $3,200 for services you receive from innetwork providers. $4,700 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit. Covered Medical and Hospital Benefits Note: marked with * may require prior authorization. Inpatient Hospital Care * Our plan covers an unlimited number of days for an inpatient hospital stay. Outpatient Surgery * Doctor s Office Visits Preventive Care In-network: $275 copay per day for days 1-7 You pay nothing per day for days 8-90 You pay nothing per day for days 91 and beyond $375 copay per day for days 1-7 You pay nothing per day for days 8-90 There is a $1,925 out-of-pocket maximum for Inpatient Hospital Care every benefit period. Ambulatory surgical center: In-network: $225 copay $325 copay Outpatient hospital: In-network: 20% of the cost 30% of the cost Primary care physician: In-network: $35 copay Specialist: In-network: $45 copay $50 copay In-network: $200 copay per day for days 1-8 You pay nothing per day for days 9-90 You pay nothing per day for days 91 and beyond $325 copay per day for days 1-8 You pay nothing per day for days 9-90 There is a $1,600 out-of-pocket maximum for Inpatient Hospital Care every benefit period. Ambulatory surgical center: In-network: $225 copay $325 copay Outpatient hospital: In-network: 20% of the cost 30% of the cost Primary care physician: $30 copay Specialist: You pay nothing for Medicare covered preventive services. Any additional preventive services approved by Medicare during the contract year will be covered. Our plan also covers an Annual Physical Exam at no cost 2

5 Emergency Care Worldwide emergency/ urgent coverage Urgently Needed Worldwide emergency/ urgent coverage, see Emergency Care Diagnostic Tests, Lab and Radiology, and X-rays * Hearing Dental * $100 copay $100 copay $35 copay $15 copay Diagnostic radiology services (such as MRIs, CT scans): Therapeutic radiology services (such as radiation treatment for cancer): Diagnostic tests and procedures: Lab 25% coinsurance Outpatient x-rays: Exam to diagnose and treat hearing and balance issues: In-network: $45 copay $50 copay Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): In-network: $45 copay $50 copay Diagnostic radiology services (such as MRIs, CT scans): Therapeutic radiology services (such as radiation treatment for cancer): Diagnostic tests and procedures: Lab In-network: You pay nothing You pay nothing Outpatient x-rays: Exam to diagnose and treat hearing and balance issues: Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): 3

6 Vision Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): In-network: $45 copay $50 copay Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): Routine eye exam: 1 routine vision exam every calendar year Mental Health * Inpatient mental health care: In-network: $250 copay per day for days 1-7 You pay nothing per day for days 8-90 $375 copay per day for days 1-7 You pay nothing per day for days 8-90 There is a $1,925 out-of-pocket maximum for Inpatient Hospital Care every benefit period Inpatient mental health care: In-network: $200 copay per day for days 1-8 You pay nothing per day for days 9-90 $325 copay per day for days 1-8 You pay nothing per day for days 9-90 There is a $1,600 out-of-pocket maximum for Inpatient Hospital Care every benefit period. Skilled Nursing Facility (SNF) * Rehabilitation * Outpatient group therapy visit: Outpatient individual therapy visit: In-Network: $20 copay per day for days 1-20 $65 copay per day for days $100 copay per day for days Cardiac (heart) rebab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): Pulmonary rehab services: Occupational therapy visit: Outpatient group therapy visit: Outpatient individual therapy visit: In-Network: $20 copay per day for days 1-20 $65 copay per day for days $75 copay per day for days Cardiac (heart) rebab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): Pulmonary rehab services: Occupational therapy visit: 4

7 Rehabilitation Continued Ambulance * Physical therapy and speech and language therapy visit: 20% coinsurance Physical therapy and speech and language therapy visit: In-network: $200 copay $200 copay Transportation Not Covered Not Covered Medicare Part B Drugs * Foot Care Medical Equipment and Supplies * Wellness Programs * Chiropractic For Part B drugs such as chemotherapy drugs: Other Part B drugs: Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: Durable medical equipment: Prosthetic devices: Diabetes monitoring supplies: You pay nothing Health Education: The plan will cover attendance to a plan sponsored evidence based health promotion program for members with chronic conditions. For example, programs such as the Chronic Disease Self- Management Program licensed through Stanford University and other similar evidence-based programs would be covered. Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): In-network: 50% coinsurance 50% coinsurance For Part B drugs such as chemotherapy drugs: Other Part B drugs: Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: Durable medical equipment: Prosthetic devices: Diabetes monitoring supplies: You pay nothing Health Education: The plan will cover attendance to a plan sponsored evidence based health promotion program for members with chronic conditions. For example, programs such as the Chronic Disease Self- Management Program licensed through Stanford University and other similar evidence-based programs would be covered. Fitness Benefit: $500 maximum plan benefit coverage every calendar year. Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): 50% coinsurance 5

8 Prescription Drug Benefits Deductible Stage The Part D Deductible applies only to drugs in tiers 3, 4 and 5. The Part D Deductible is $150 There is no Part D Deductible Initial Coverage Stage You pay the following 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. Tier Tier 1 (Preferred Generic) Standard Retail Cost Sharing One-month (up to a 30-day supply) Three-month (up to a 90-day supply) $10 copay $20 copay Tier Tier 1 (Preferred Generic) Standard Retail Cost Sharing One-month (up to a 30-day supply) Three-month (up to a 90-day supply) $6 copay $12 copay Tier 2 (Generic) $20 copay $40 copay Tier 2 (Generic) $15 copay $30 copay Tier 3 (Preferred Brand) Tier 4 (Non- Preferred Brand) Tier 5 (Specialty Tier) Tier 6 (Select Care Drugs) $45 copay $90 copay $95 copay $190 copay 29% Not Available $0 $0 Tier 3 (Preferred Brand) Tier 4 (Non- Preferred Brand) Tier 5 (Specialty Tier) Tier 6 (Select Care Drugs) $40 copay $80 copay $85 copay $170 copay 33% Not Available $0 $0 Coverage Gap Stage 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 plan's cost for covered brand name drugs and 44% of the plan's cost for covered generic drugs until your costs total $5,000, which is the end of the coverage gap. Not everyone will enter the coverage gap. Catastrophic Coverage Stage 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 copay for generic (including brand drugs treated as generic) and an $8.35 copayment for all other drugs. 6

9 josephine & jackson county office 1867 Williams Hwy, Suite 110 Grants Pass, OR (877) TTY/TDD: 1(800) office hours Daily, 8 a.m. - 5 p.m. Pacific customer service hours Daily, 8 a.m. - 8 p.m. Pacific You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, Call: 1(800)MEDICARE TTY/TDD users should call 1(877) , 24 hours a day/7 days a week. The Social Security Office at 1(800) between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1(800) , or your Medicaid Office. ATRIO Health Plans has PPO and HMO D-SNP plans with a Medicare contract. Enrollment in ATRIO Health Plans depends on contract renewal. H6743_SB_JJ_2018 Accepted atriohp.com