2017 Summary of Benefits: Presbyterian Senior Care (HMO) Plan 1, Plan 2 with Rx, Plan 3 with Rx

Transcription

1 2017 Summary of Benefits: Presbyterian Senior Care (HMO) Plan 1, Plan 2 with Rx, Plan 3 with Rx This is a summary of health and drug services covered by Presbyterian Senior Care (HMO) January 1, 2017 to December 31, Presbyterian Senior Care (HMO) is a Medicare Advantage HMO plan with a Medicare contract. Enrollment in the plan depends on contract renewal. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. This information is not a complete description of benefits. Limitations, copayments, and restrictions may apply. To get a complete list of benefits and services we cover contact the plan or please refer to the Evidence of Coverage. You may easily download a copy of the Evidence of Coverage from our website, and select For Members at the top of the page. You may also request a copy by calling customer service. To enroll in Presbyterian Senior Care (HMO): You must be entitled to Medicare Part A and enrolled in Medicare Part B. You cannot have permanent kidney failure. Exceptions may apply. You must live in one of these New Mexico counties: Bernalillo, Cibola, Rio Arriba, Sandoval, Santa Fe, Socorro, Torrance or Valencia. Presbyterian Senior Care (HMO) has a network of doctors, hospitals, pharmacies, and other providers. If you use providers that are not in our network, the plan may not pay for these services. Y0055_MPC061681_Accepted_

2 2017 Summary of Benefits Presbyterian Senior Care (HMO) Plan 2 with Rx Plan 3 with Rx Plan 1 Monthly Plan Premium (You must also continue to pay your Medicare Part B premium.) $87 Includes prescription drug coverage Does not includes prescription drug coverage Deductible Maximum Annual Out-of-Pocket Responsibility (This is the most you pay in a calendar year for covered medical and hospital services. It does not include prescription drugs.) Inpatient Hospital Care (per admission) Days 1 3 Additional Days $3,400 $2,500 $2,500 $325 per day $225 per day $275 per day Doctor Visits Primary Care Specialists Video Visits $5 $50 $5 $35 $5 $35 Preventive Care Emergency Care (worldwide) (This copay is waived if admitted to the hospital.) $75 $75 $75 Urgently Needed Services In-network Out-of-network Outside of United States $5 $65 $75 $5 $65 $75 $5 $65 $75

3 2017 Summary of Benefits Presbyterian Senior Care (HMO) Plan 2 with Rx Plan 3 with Rx Plan 1 Diagnostic Services/Labs/ Imaging (Prior authorization may be required.) Lab services Diagnostic tests and procedures Outpatient x-rays Diagnostic radiology service (such as CT, MRA, MRI, PET scans) $300 $250 $250 Hearing Services Hearing exam Hearing aid $50 Not covered $35 Not covered $35 Not covered Dental Services - routine Not covered Not covered Not covered Vision Services (annual routine exam and diagnosis and treatment of diseases and conditions of eye) Eyeglasses or contact lenses after cataract surgery Mental Health Services Inpatient visit (Days 1-3) Additional days Outpatient group therapy visit Outpatient individual therapy visit for first visit of the year; specialist copay thereafter 20% 10% 20% $325 per day $225 per day $275 per day Skilled Nursing Facility (SNF) Days 1-20 Days (Our plan covers up to 100 days in a SNF.) per day $65 per day per day $35 per day per day $35 per day

4 2017 Summary of Benefits Presbyterian Senior Care (HMO) Plan 2 with Rx Plan 3 with Rx Plan 1 Rehabilitation Services Cardiac and Pulmonary rehab Occupational, Physical, and Speech and Language therapy visits $15 $10 $10 Ambulance $100 $100 $100 Transportation Not covered Not covered Not covered Foot Care (podiatry services) Foot exams and treatment (Medicare covered) Routine foot care Not covered Not covered Not covered Medical Equipment/Supplies Durable Medical Equipment (e.g., wheelchairs, oxygen) Prosthetics (e.g., braces, artificial limbs) Diabetes supplies, services, and training 20% 20% 10% 10% 20% 20% Wellness Programs (e.g., fitness) Medicare Part B Drugs and Chemotherapy Drugs Silver Sneakers Fitness Program For participating locations visit 0% - 10% 0% - 5% 0% - 5%

5 2017 Summary of Benefits Presbyterian Senior Care (HMO) Prescription drug coverage is a part of Plan 2 and Plan 3. The drug coverage is identical except in the Coverage Gap. Coverage Starts Initial coverage limit $3,700; includes what both you and your plan pay Coverage Gap "Donut Hole" Catastrophic Coverage Part D Covered Drugs 30-day supply 90-day mail order (preferred) Plan 2 Plan 3 Plan 2 and Plan 3 Tier 1: Preferred Generic Tier 2: Non- Preferred Generic Tier 3: Preferred Brand Tier 4: Non- Preferred Brand Tier 5: Specialty Drugs $4 $8 $10 $20 $45 $ $95 $285 33% NA 51% generic 40% brand applies to all tiers Refer to Formulary. Tier 1 and 2 drugs noted with "GC" are $4 or $10. 51% generic 40% brand $3.30 or 5% for generics (whichever is greater) $8.25 or 5% for brand names (whichever is greater) You stay in this stage for the rest of the year. Catastrophic coverage begins after your out-of-pocket costs = $4,950

6 2017 Summary of Benefits Presbyterian Senior Care (HMO) OTHER BENEFITS Acupuncture (limited to 20 visits/year) Chiropractic (to correct subluxation) Plan 2 with Rx Plan 3 with Rx Plan 1 $20 $15 $15 $20 $20 $20 Home Health Care Hospice Covered by Original Medicare Outpatient Surgery $325 $225 $225 Financial assistance As a Medicare beneficiary, you may qualify for money-saving programs based on your income to help you pay your plan premiums and drug copays. Extra Help / Low-Income Subsidy (LIS) If you qualify for Extra Help, also called Low-Income Subsidy (LIS), your plan premium and drug copays will be reduced. The coverage gap (also known as the donut hole) in your prescription drug coverage is also eliminated. You must be on a plan that includes prescription drug coverage to qualify for Extra Help. Qualifying income levels for To qualify, your annual income and resources / assets need to be at or below the following: Single Married Monthly Income 1 : $1,485 Monthly Income 1 : $ 2, Resources / Assets 2 : $13,640 Resources / Assets 2 : $ 27, Income limits may change in The house you live in, the car you drive, life insurance policies, and burial plots do not count toward the resource / asset limit. Contact Social Security for other income / resource exclusions.

7 Medicaid and Other Medicare Savings Programs (MSP) Those who qualify for Extra Help may also qualify for Medicare Savings Programs that help pay Part A and/or Part B premiums. Medicaid programs may also lower your copays, depending on the level for which you qualify. FIND OUT IF YOU QUALIFY FOR ASSISTANCE Presbyterian offers a personal service that helps you find out if you qualify for these money-saving programs. A trusted partner since 2006, My Advocate, helps you apply for Extra Help / Low-Income Subsidy and Medicare Savings Programs. Call My Advocate at You also have the option to contact: Medicare ( ), 24 hours a day, seven days a week (TTY ) Social Security, (TTY ) NM State Human Services Department, (TTY )

8 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, seven days a week. TTY users should call For more information about Presbyterian Medicare Advantage plans, please call us at the phone numbers below or visit us at Presbyterian Medicare Sales Consultants (505) or (TTY 711), 8 a.m. to 8 p.m., seven days a week Presbyterian Customer Service Center (for members) (505) or (TTY 711), 8 a.m. to 8 p.m., seven days a week You can see our plan s provider and pharmacy directory if you visit our website at and select Providers at the top of the page. We cover Part D drugs on certain plans. In addition, we 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 if you visit our website at and select Prescription Drugs at the top of the page. This information is available for free in other languages. To learn how we safeguard your Protected Health Information and your rights, call us at (505) or (TTY 711) or visit medicare and select Privacy Notice at the bottom of the page.

9 MULTI-LANGUAGE INTERPRETER SERVICES English Attention: If you speak English, language assistance services, free of charge, are available to you. Call (TTY: 711). Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). Navajo (TTY: 711). Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (TTY: 711). German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (TTY: 711). 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: 711) Arabic ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم (رقم ھاتف الصم والبك)( 711.(TTY: Korean 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (TTY: 711) 번으로전화해주십시오. Y0055_MPC071602_rev1_Accepted_

10 Tagalog PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa (TTY: 711). 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:711) まで お電話にてご連絡ください French ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le (ATS: 711). Italian ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero (TTY: 711). Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните (телетайп: 711). Hindi य द: यद आप हद ब लत ह त आपक लए म त म भ ष सह यत स व ए पल ह (TTY: 711) पर क ल कर Farsi/Persian توجه: اگر به زبان فارسی گفتگو می کنيد تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد. با (711 (TTY: تماس بگيريد. Thai เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (TTY: 711).

11 NONDISCRIMINATION NOTICE Presbyterian Health Plan, Inc./Presbyterian Insurance Company, Inc. (Presbyterian) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Presbyterian does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Presbyterian: provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and 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 and information written in other languages. If you need these services, contact the Presbyterian Customer Service Center at (TTY 711). If you believe that Presbyterian 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 Sophia Collaros, Privacy Officer and Civil Rights Coordinator, P.O. Box 27489, Albuquerque, NM, 87125, phone (505) , fax (505) , or scollaros@phs.org. You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, Sophia Collaros 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 jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, , (TDD). Complaint forms are available at Y0055_MPC081640_Accepted_

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