2018 Summary of Benefits Allwell Dual Medicare (HMO SNP) Bexar and Nueces counties, TX H5294-002-004 Benefits effective January 1, 2018 H5294_18_2765SB_002_004_A_Accepted 09172017
This booklet provides you with a summary of what we cover and your cost-sharing. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please call us at the number listed on the last page of this booklet, and ask for the Evidence of Coverage (EOC), or you may access the EOC on our website at https://allwell.superiorhealthplan.com You are eligible to enroll in Allwell Dual Medicare (HMO SNP) if: You are entitled to Medicare Part A and enrolled in Medicare Part B. Members must continue to pay their Medicare Part B premium if not otherwise paid for under Medicaid or by another third party. You must be a United States citizen, or are lawfully present in the United States and permanently reside in the service area of the plan (in other words, your permanent residence is within one of the Allwell Dual Medicare (HMO SNP) service area counties). Our service area includes the following counties in Texas: Bexar and Nueces counties. You do not have end-stage renal disease (ESRD). (Exceptions may apply for individuals who develop ESRD while enrolled in an Allwell Dual Medicare (HMO SNP) commercial or group health plan, or a Medicaid plan.) For Allwell Dual Medicare (HMO SNP), you must also be enrolled in Texas Medicaid. Premiums, copays, coinsurance, and deductibles may vary based on your Medicaid eligibility category and/or the level of Extra Help you receive. Your Part B premium is paid by the State of Texas for full-dual enrollees. Please contact the plan for further details. The Allwell Dual Medicare (HMO SNP) plan gives you access to our network of highly skilled medical providers in your area. You can look forward to choosing a primary care provider (PCP) to work with you and coordinate your care. You can ask for a current provider directory or, for an up-to-date list of network providers, visit https://allwell.superiorhealthplan.com (Please note that, except for emergency care, urgently needed care when you are out of the network, out-of-area dialysis services, and cases in which our plan authorizes use of out-of-network providers, if you obtain medical care from out-of-plan providers, neither Medicare nor Allwell Dual Medicare (HMO SNP) will be responsible for the costs.) This Allwell Dual Medicare (HMO SNP) plan also includes Part D coverage, which provides you with the ease of having both your medical and prescription drug needs coordinated through a single convenient source
Summary of Benefits JANUARY 1, 2018--DECEMBER 31, 2018 Premiums and benefit Monthly Plan Premium, including Part C and Part D premium. Deductible Allwell Dual Medicare (HMO SNP) $0 You must continue to pay your Medicare Part B premium, if not otherwise paid for by Medicaid or another third party. $0 plan deductible for Part C services. $50 deductible for Part D prescription drugs (applies to drugs on Tiers 2-5. Maximum Out-of-Pocket Responsibility (does not include prescription drugs) Inpatient Hospital Coverage $6,700 annually This is the most you will pay in copays and coinsurance for medical services for the year. You will still need to pay your cost sharing for your Part D prescription drugs. Days 1-90: $0 copay per day Lifetime reserve days: $0 copay per day Beyond lifetime reserve days: Member is responsible for all cost Prior authorization (approval in advance) may be required. Referral may be required. Outpatient Hospital Hospital Visit : $0 copay (including services provided at Ambulatory Surgical Center Visit : $0 Copay hospital outpatient facilities and ambulatory surgical centers) Prior authorization (approval in advance) may be required. Referral may be required. Doctor Visits Primary Care: $0 copay per visit Specialist $0 copay per visit Some specialist services may require Prior Authorization (approval in advance). A referral may be required for specialist visits.
Premiums and benefit Preventive Care Allwell Dual Medicare (HMO SNP) $0 copay for Medicare-covered zero cost-sharing preventive services Some services may require Prior Authorization (approval in advance). Emergency Care Urgently Needed Services Diagnostic Services/Labs/ Imaging $0 copay per visit for Medicare-covered emergency room visits. $0 copay per visit Lab services: $0 copay Diagnostic tests and procedures: $0 copay Outpatient x-ray services: $0 copay Diagnostic radiology services (such as MRI, MRA, CT, PET): $0 copay Therapeutic radiological services (such as radiation treatment for cancer $0 copay Some services may require Prior Authorization (approval in advance). Referral may be required. Hearing Services Hearing exam (Medicare-covered): $0 copay Medicare-covered services include an exam to diagnose and treat hearing and balance issues. Routine hearing exam (non Medicare-covered): $0 copay per visit (up to 1 every calendar year). Hearing aid: $0 copay. There is a maximum plan benefit coverage amount of $1,000 for one hearing aid (for either the left or right ear) every calendar year. Members are responsible for any remaining balance over the maximum coverage limit. Hearing aids are covered when determined to be medically necessary during the hearing exam.
Premiums and benefit Dental Services Allwell Dual Medicare (HMO SNP) Dental services (Medicare-covered): $0 copay per visit Medicare-covered Services: Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth). Preventive dental services: Oral exam: $0 copay (up to 2 every year) Cleaning: $0 copay (up to 2 every year) Dental x-ray: $0 copay (up to 1 every year) Comprehensive dental services: Diagnostic services: $0 copay Restorative services: $0 copay Endodontics/Periodontics/ Extractions: $0 copay Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services: $0 copay Dental x-rays include bitewing series only. Vision Services There is a maximum plan benefit coverage amount of $1,750 every calendar year, which applies to all comprehensive dental benefits. Members are responsible for any remaining balance over the $1,750 limit. Vision exam to diagnose and treat diseases and conditions of the eye: $0 copay per visit Eyeglasses or contact lenses after cataract surgery: $0 copay Routine eye exam: $0 copay per visit (up to 1 every calendar year) There is a maximum plan benefit coverage amount of $200 every calendar year for contact lenses and/or eyeglasses (frames and lenses) every calendar year. Members are responsible for any remaining balance over the $200 limit. Mental Health Services Outpatient: $0 copay for each individual or group therapy session Inpatient: Days 1-90: $0 copay per day Lifetime reserve days: $0 copay per day Beyond lifetime reserve days: Member is responsible for all costs Some services may require Prior Authorization (approval in advance). Referral may be required.
Premiums and benefit Skilled Nursing Facility Physical Therapy Allwell Dual Medicare (HMO SNP) Days 1 through 100: $0 copay per day Beyond day 100: Member is responsible for all costs Some services may require Prior Authorization (approval in advance). Referral may be required. $0 copay per visit Some services may require Prior Authorization (approval in advance). Ambulance Transportation Referral may be required. $0 copay Cost is per one-way trip for Medicare-covered Ambulance services. Prior authorization (approval in advance) is required for nonemergency ambulance services. $0 copay per trip Up to 30 one-way trips to plan approved locations each calendar year through the plan s contracted transportation providers. Medicare Part B Drugs Prior authorization (approval in advance) may be required. Chemotherapy drugs: $0 copay Other Part B drugs: $0 copay Prior Authorization (approval in advance) may be required. Over-the-Counter (OTC) Items $0 copay The plan covers $60 per month for items available via mail order. Any unused plan benefit amounts will not carry forward into the next month. Please visit the plan s website to see the list of covered over-thecounter items. Wellness Programs Fitness program: $0 copay The plan covers a basic gym membership at participating fitness facilities. Members can also request an in-home fitness program Nursing Hotline: $0 copay You can call the nursing hotline 24 hours a day, 365 days a year with questions about your health.
Outpatient Prescription Drugs Deductible Phase $0 or $50 Deductible. Deductible does not apply to Tiers 1 and 6. Initial Coverage Phase (After you pay your deductible, if applicable) Important Info: Cost-sharing is based on your level of Extra Help Cost-Sharing may change depending on the pharmacy you choose (Such as Standard Retail, mail-order, Long Term Care or Home Infusion) and when you enter another of the four phases of the Part D benefit. Tier 1: Preferred Generic Tier 2: Generic Tier 3: Preferred Brand Tier 4: Non- Preferred Drug Tier 5: Specialty Tier 6: Select Standard Retail Cost Sharing Rx 30-day supply Mail Order 90-day supply $0 copay $0 copay $19 copay $57 copay $47 copay $141 copay $100 copay $300 copay 32% coinsurance Not available $0 copay $0 copay Care Drugs For more information about the costs for Long Term Supply, Home Infusion or additional pharmacy-specific cost-sharing and the phases of the benefit, please call us or access our Evidence of Coverage online. Premium, copays, coinsurance and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. If you qualify for Extra Help with your prescription drug costs, the Extra Help program will pay all or part of your monthly plan premium and your prescription drug deductibles and copays/coinsurance. If you are not eligible for Extra Help, refer to the Evidence of Coverage, Chapter 6, for outpatient prescription drug cost-sharing information. This is not a complete list of our drugs covered by our plan. For a complete listing, please call 1-877-935-8023 (TTY:711) or visit https://allwell.superiorhealthplan.com.
Comprehensive Written Statement The benefits described in the previous section are covered by Medicare. No matter what your level of Medicaid eligibility is, Allwell Dual Medicare (HMO SNP) will cover the benefits listed in this section. The benefits described below are covered by Medicaid. For each benefit listed below, you can see what Texas Medicaid covers. Coverage of these benefits depends on your level of Medicaid eligibility. If you have questions about your Medicaid eligibility and what benefits you are entitled to, call: 1-800-335-8957 (TTY 711). The services described below is only a summary of benefits. Those who meet Qualified Medicare Beneficiary (QMB) requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare, including Medicaid waiver services. Waiver services are limited to individuals who meet additional Medicaid waiver eligibility criteria. For more information, please contact Texas Medicaid for more information. Benefit Ambulance Services (medically necessary ambulance services) Assistive Communication Devices (also known as Augmentative Communication Device (ACD) System) Bone Mass Measurement (for people who are at risk) Cardiac Rehabilitation Chiropractic Services Description For Members who meet the criteria, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. Bone density screening is a benefit of Texas Medicaid. For Members who meet the criteria, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. Chiropractic manipulative treatment (CMT) performed by a chiropractor licensed by the Texas State Board of Chiropractic Examiners is a benefit of Texas Medicaid. Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted.
Colorectal Screening Exams (for people aged 50 and older) Dental Services (for people who are 20 years of age or younger; or 21 years of age or older in an ICF-MR) Diabetic Supplies (includes coverage for test strips, lancets, and screening tests) Diagnostic Tests, X-Rays, Lab Services, and Radiology Services Doctor and Hospital Choice Doctor Office Visits Durable Medical Equipment (includes wheelchairs, oxygen) Emergency Care (Any emergency room visit if the member reasonably believes he or she needs emergency care.) End-Stage Renal Disease Health/Wellness Education (smoking cessation for pregnant Women and adult annual exam) Hearing Services All Medicaid recipients may receive medically necessary community behavioral health services in accordance with coverage and limitations requirements. Please contact Texas Medicaid for cost-sharing information. For Members who meet the criteria, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. Members should follow Medicare guidelines related to hospital and doctor choice.
Home Health Care (includes medically necessary intermittent skilled nursing care, home health aide services, private duty nursing services, and personal care services) Hospice Immunizations Inpatient Hospital Care Inpatient Mental Health Care Mammograms (Annual Screening) Monthly Premium Outpatient Rehabilitation Services Outpatient Substance Use Disorder (assessment, ambulatory treatment/detox, and MAT) Medicaid pays for this service for certain Waiver Members if it is not covered by Medicare or when the Medicare benefit is exhausted. Note: When adult clients elect hospice services, they waive their rights to all other Medicaid services related to their terminal illness. They do not waive their rights to Medicaid services unrelated to their terminal illness Inpatient hospital stays are a covered benefit. Medicaid pays coinsurance, copayments, and deductibles for Medicare covered services. Members should follow Medicare guidelines related to hospital choice. Inpatient hospital stays for acute psychiatric treatment are a covered benefit for adults. Medicaid pays coinsurance, copayments, and deductibles for Medicare covered services. Members should follow Medicare guidelines related to hospital choice. Medicaid assistance with premium payment may vary based on your level of Medicaid eligibility. For Members birth through age 20, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted.
Pap Smears and Pelvic Exams (for women) Podiatry Services Prescription Drugs Prostate Cancer Screening Exams Skilled Nursing Facility (SNF) (in a Medicare-certified Skilled Nursing Facility) Telemedicine Services Transportation (routine) Urgently Needed Care (this is NOT emergency care, and in most cases, is out of the service area) Vision Services $0 copay for Medicaid covered prescription drugs not covered by Medicare Part D Note: Medicaid will not cover any Medicare Part D drug. The Medicaid Medical Transportation Program (MTP) provides non-emergency transportation, if it is not covered by Medicare. Note: Services by an optician are limited to fitting and dispensing of medically necessary eyeglasses and contact lenses.
HOME AND COMMUNITY BASED WAIVER SERVICES Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare, including Medicaid waiver services. Waiver services are limited to individuals who meet additional Medicaid waiver eligibility criteria. Community Living Assistance and Support Services (CLASS) Waiver Deaf Blind with Multiple Disabilities Waiver (DB-MD) For information on waiver services and eligibility for this waiver, contact the Department of Aging and Disability Services (DADS). For information on waiver services and eligibility for this waiver, contact the Department of Aging and Disability Services (DADS). Home and Community Services (HCS) Waiver Medically Dependent Children Program (MDCP) STAR+PLUS Program (operating under the Texas Healthcare Transformation and Quality Improvement Program Waiver) Texas Home Living Waiver (TxHmL) For information on waiver services and eligibility for this waiver, contact the Department of Aging and Disability Services (DADS). For information on waiver services and eligibility for this waiver, contact the Department of Aging and Disability Services (DADS). For information on waiver services and eligibility for this waiver, contact the Department of Aging and Disability Services (DADS). For information on waiver services and eligibility for this waiver, contact the Department of Aging and Disability Services (DADS).
For more information, please contact: Allwell Dual Medicare (HMO SNP) Forum II Building 7990 IH 10 West, Suite 300, San Antonio, TX 78230 https://allwell.superiorhealthplan.com Current members should call: 1-877-935-8023 (TTY: 711) Prospective members should call: 1-877-826-5520 (TTY: 711) From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. 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 www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. This plan is available to anyone who has both Medical Assistance from the State and Medicare. 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/ coinsurance may change on January 1 of each year. Coinsurance is the percentage you pay of the total cost of certain medical services. You pay a coinsurance at the time you get the medical service. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. This document is available in other formats such as Braille, large print or audio. Allwell is an HMO plan with a Medicare contract. Enrollment in Allwell depends on contract renewal. Allwell is a Coordinated Care plan with a Medicare contract and a contract with the Texas Medicaid program. Enrollment in Allwell depends on contract renewal.
Allwell Dual Medicare complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Allwell Dual Medicare does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Allwell Dual Medicare: 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, 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 Allwell Dual Medicare Customer Contact Center at: 1-877-935-8023 (TTY: 711). From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. On weekends and holidays, an automated system will handle your call. If you believe that Allwell Dual Medicare 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 by calling the number above and telling them you need help filing a grievance; Allwell Dual Medicare Customer Contact Center 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 https://ocrportal.hhs.gov/ocr/portal/lobby.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, 1-800-368-1019 (TDD: 1-800-537-7697). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
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