Summary of Benefits. Member Services: (TTY 711) Monday through Friday from 8 a.m. to 8 p.m. local time

Transcription

1 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) Summary f Benefits TXDMKT Member Services: (TTY 711) Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time H8786_16_25637_U CMS Accepted 09/08/2015

2 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits H8786_16_ 25637_U CMS Accepted 09/08/2015 This is a summary f health services cvered by Amerigrup STAR+PLUS MMP (Medicare- Medicaid Plan) fr This is nly a summary. Please read the Member Handbk fr the full list f benefits. Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) is a health plan that cntracts with bth Medicare and Texas Medicaid t prvide benefits f bth prgrams t enrllees. It is fr peple with bth Medicare and Texas Medicaid. Under Amerigrup STAR+PLUS MMP yu can get yur Medicare and Texas Medicaid services in ne health plan. An Amerigrup STAR+PLUS MMP service crdinatr will help manage yur health care needs. This is nt a cmplete list. The benefit infrmatin is a brief summary, nt a cmplete descriptin f benefits. Fr mre infrmatin cntact the plan r read the Member Handbk. Limitatins, c-pays and restrictins may apply. Fr mre infrmatin, call Amerigrup STAR+PLUS MMP Member Services r read the Amerigrup STAR+PLUS MMP Member Handbk. The List f Cvered Drugs and/r pharmacy and prvider netwrks may change thrughut the year. We will send yu a ntice befre we make a change that affects yu. Benefits and csts may change n January 1 f each year. C-pays fr prescriptin drugs may vary based n the level f Extra Help yu receive. Please cntact the plan fr mre details. Yu can get this infrmatin fr free in ther frmats, such as large print, braille r audi. Call Member Services at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Yu can get this infrmatin fr free in ther languages. Call Member Services at (TTY 711). Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Usted puede btener esta infrmación gratuitamente en trs idimas. Llame al (TTY 711) de lunes a viernes de 8 a.m. a 8 p.m. hra lcal. La llamada es gratuita. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 1

3 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits The fllwing chart lists frequently asked questins. Frequently Asked Questins (FAQ) What is a Medicare-Medicaid Plan What is an Amerigrup STAR+PLUS MMP service crdinatr What are lng-term services and supprts Will yu get the same Medicare and Texas Medicaid benefits in Amerigrup STAR+PLUS MMP that yu get nw Answers A Medicare-Medicaid Plan is an rganizatin made up f dctrs, hspitals, pharmacies, prviders f lng-term services and supprts, and ther prviders. It als has service crdinatrs t help yu manage all yur prviders and services. They all wrk tgether t prvide the care yu need. An Amerigrup STAR+PLUS MMP service crdinatr is ne main persn fr yu t cntact. This persn helps manage all yur prviders and services and makes sure yu get what yu need. Lng-term services and supprts are help fr peple wh need assistance t d everyday tasks like taking a bath, getting dressed, making fd, and taking medicine. Mst f these services are prvided at yur hme r in yur cmmunity but culd be prvided in a nursing hme r hspital. Yu will get yur cvered Medicare and Texas Medicaid benefits directly frm Amerigrup STAR+PLUS MMP. Yu will wrk with a team f prviders wh will help determine what services will best meet yur needs. This means that sme f the services yu get nw may change. When yu enrll in Amerigrup STAR+PLUS MMP, yu and yur service crdinatin team will wrk tgether t develp a Plan f Care t address yur health and supprt needs. During this time, yu can keep seeing yur dctrs and getting yur current services fr 90 days r 180 days if yu are receiving Lng Term Supprt Services r until yur Plan f Care is cmplete. When yu jin ur plan, if yu are taking any Medicare Part D prescriptin drugs that Amerigrup STAR+PLUS MMP des nt nrmally cver, yu can get a temprary supply. We will help yu get anther drug r get an exceptin fr Amerigrup STAR+PLUS MMP t cver yur drug, if medically necessary. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 2

4 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits Frequently Asked Questins (FAQ) Can yu g t the same dctrs yu see nw Answers Often that is the case. If yur prviders (including dctrs, therapists, and pharmacies) wrk with Amerigrup STAR+PLUS MMP and have a cntract with us, yu can keep ging t them. Prviders with an agreement with us are in-netwrk. Yu must use the prviders in Amerigrup STAR+PLUS MMP s netwrk. If yu need urgent r emergency care r ut-f-area dialysis services, yu can use prviders utside f Amerigrup STAR+PLUS MMP's plan. T find ut if yur dctrs are in the plan s netwrk, call Member Services r read Amerigrup STAR+PLUS MMP s Prvider and Pharmacy Directry. If Amerigrup STAR+PLUS MMP is new fr yu, yu can cntinue seeing the dctrs yu g t nw (including ut-f-netwrk prviders) fr 90 days, r 180 days if yu are receiving lng-term services and supprts, r until yur Plan f Care is cmplete. During that time, we will try t get yur prvider in ur netwrk. What happens if yu need a service but n ne in Amerigrup STAR+PLUS MMP s netwrk can prvide it Where is Amerigrup STAR+PLUS MMP available Mst services will be prvided by ur netwrk prviders. If yu need a service that cannt be prvided within ur netwrk, Amerigrup STAR+PLUS MMP will pay fr the cst f an ut-fnetwrk prvider. The service area fr this plan includes: Bexar, El Pas, Harris, and Tarrant cunties in Texas. Yu must live in ne f these areas t jin the plan. D yu pay a mnthly amunt (als called a premium) under Amerigrup STAR+PLUS MMP Yu will nt pay any mnthly premiums t Amerigrup STAR+PLUS MMP fr yur health cverage. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 3

5 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits Frequently Asked Questins (FAQ) What is prir authrizatin What is a referral What is Extra Help Wh shuld yu cntact if yu have questins r need help Answers Prir authrizatin means that yu must get apprval frm Amerigrup STAR+PLUS MMP befre yu can get a specific service r drug r see an ut-f-netwrk prvider. Amerigrup STAR+PLUS MMP may nt cver the service r drug if yu dn t get apprval. If yu need urgent r emergency care r ut-f-area dialysis services, yu dn't need t get apprval first. A referral means that yur primary care prvider must give yu apprval t see smene that is nt yur primary care prvider. If yu dn t get apprval, Amerigrup STAR+PLUS MMP may nt cver the services. There are certain specialists in which yu d nt need a referral, such as wmen s health specialists. Fr mre infrmatin n when a referral is necessary, see the Member Handbk. Extra Help is a Medicare prgram that helps reduce yur prescriptin drug prgram csts such as c-pays. Yur prescriptin drug c-pays under Amerigrup STAR+PLUS MMP already include the amunt f Extra Help yu qualify fr. Fr mre infrmatin abut Extra Help, cntact yur lcal Scial Security Office, r call Scial Security at TTY users may call If yu have general questins r questins abut ur plan, services, service area, billing, r member cards, please call Amerigrup STAR+PLUS MMP Member Services: CALL Calls t this number are free. Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. Member Services als has free language interpreter services available fr peple wh d nt speak English. TTY 711 Calls t this number are free. Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 4

6 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits Frequently Asked Questins (FAQ) Answers If yu have questins abut yur health, please call the Nurse HelpLine: CALL Calls t this number are free. 24 hurs a day, 7 days a week. TTY 711 Calls t this number are free. 24 hurs a day, 7 days a week. If yu need immediate behaviral health services, please call the Behaviral Health Crisis Line: CALL Calls t this number are free. 24 hurs a day, 7 days a week. TTY 711 Calls t this number are free. 24 hurs a day, 7 days a week. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 5

7 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits The fllwing chart is a quick verview f what services yu may need, yur csts and rules abut the benefits. Yur csts fr Health need r prblem Services yu may need in - netwrk prviders Yu want t see a dctr Visits t treat an injury r illness $0 c-pay Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Wellness visits, such as a physical Transprtatin t medical r dental appintments $0 c-pay $0 c-pay The plan ffers twenty fur (24) ne-way trips per year t plan-apprved lcatins. Referral may be required. Please cntact yur Service Crdinatr. Specialist care $0 c-pay Prir authrizatin and referral may be required. Care t keep yu frm getting sick, such as flu shts Welcme t Medicare preventive visit (ne time nly) $0 c-pay $0 c-pay Yu need medical tests Lab tests, such as bld wrk $0 c-pay Prir authrizatin and referral may be required. X-rays r ther pictures, such as CAT scans Screening tests, such as tests t check fr cancer $0 c-pay Prir authrizatin and referral may be required. $0 c-pay Prir authrizatin and referral may be required. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 6

8 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits Health need r prblem Services yu may need Yur csts fr in - netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need drugs t treat yur illness r cnditin Generic drugs (n brand name) Tier 1: $0 c-pay Tier 2: $0 - $7.40 cpay Tier 3: $0 c-pay Tier 4: $0 c-pay C-pays fr prescriptin drugs may vary based n the level f Extra Help yu receive. Please cntact the plan fr mre details. Our plan s mail-rder service allws yu t rder a 93-day supply that has the same c-pay as a nemnth supply. There may be limitatins n the types f drugs cvered. Please see Amerigrup STAR+PLUS MMP s List f Cvered Drugs (Drug List) fr mre infrmatin. Sme prescriptin drugs may require prir authrizatin. Brand-name drugs Tier 1: $0 c-pay Tier 2: $0-$7.40 cpay Tier 3: $0 c-pay Tier 4: $0 c-pay C-pays fr prescriptin drugs may vary based n the level f Extra Help yu receive. Please cntact the plan fr mre details. Our plan s mail-rder service allws yu t rder a 93-day supply that has the same c-pay as a nemnth supply. There may be limitatins n the types f drugs cvered. Please see Amerigrup STAR+PLUS MMP s List f Cvered Drugs (Drug List) fr mre infrmatin. Sme prescriptin drugs may require prir authrizatin. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 7

9 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits Health need r prblem Yu need drugs t treat yur illness r cnditin (cntinued) Services yu may need Yur csts fr in - netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Over-the-cunter (OTC) drugs $0 c-pay There may be limitatins n the types f drugs cvered. Please see Amerigrup STAR+PLUS MMP s List f Cvered Drugs (Drug List) fr mre infrmatin. Amerigrup STAR+PLUS MMP cvers sme OTC drugs when they are written as prescriptins by yur prvider. These drugs are in Tier 4 f the Drug List. OTC benefit des nt apply t members in a stateperated waiver prgram. Medicare Part B prescriptin drugs $0 c-pay Part B drugs include drugs given by yur dctr in his r her ffice, sme ral cancer drugs, and sme drugs used with certain medical equipment. Read the Member Handbk fr mre infrmatin n these drugs. There may be limitatins n the types f drugs cvered. Prir authrizatin frm yur primary care physician may be required. Yu need therapy after a Occupatinal, physical, r speech $0 c-pay Cvered Occupatinal Therapy (OT), strke r accident therapy Physical Therapy (PT), Speech Therapy (ST) and, Cvered Cgnitive Rehabilitatin Therapy. Medically necessary services are cvered with prir authrizatin and referral required. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 8

10 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits Health need r prblem Yu need emergency care Services yu may need Yur csts fr in - netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Emergency rm services $0 c-pay N prir authrizatin is required fr emergency services. Out-f-netwrk services are cvered. Services are nt cvered utside the U.S. and its territries except under limited circumstances. Call Member Services fr details. Ambulance services $0 c-pay Medically necessary ambulance services are cvered. Prir authrizatin is required fr nn-emergency services. Urgent care $0 c-pay N prir authrizatin is required fr urgent care services. Out-f-netwrk services are cvered. Services are nt cvered utside the U.S. and its territries except under limited circumstances. Call Member Services fr details. Yu need hspital care Hspital stay $0 c-pay Except in an emergency, yur dctr must tell the plan that yu are ging t be admitted t the hspital. Limitatins may apply. The plan ffers thirty (30) additinal days per benefit perid. Prir authrizatin may be required. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 9

11 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits Health need r prblem Yu need hspital care (cntinued) Services yu may need Yur csts fr in - netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Dctr r surgen care $0 c-pay A dctr r surgen s care is cvered during a hspital stay. Except in an emergency, yur dctr must tell the plan that yu are ging t be admitted t the hspital. Yu need help getting better r have special health needs Rehabilitatin services $0 c-pay Inpatient rehabilitatin services are cvered. N limit t number f days cvered fr each inpatient hspital stay. The plan ffers twelve (12) additinal cardiac rehabilitatin services visits each year. A referral frm yur dctr is required and prir authrizatin rules may apply. Medical equipment fr hme care $0 c-pay Prir authrizatin and referral required. Skilled nursing care $0 c-pay Prir authrizatin and referral required. Yu need eye care Eye exams $0 c-pay One eye exam every year Glasses r cntact lenses $0 c-pay One pair f eyeglass lenses, frames r cntact lenses every year. $100 can be used t upgrade frames r buy thinner lenses (plycarbnate/plastic) and/r cntact lenses. Prir authrizatin is required. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 10

12 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits Health need r prblem Services yu may need Yur csts fr in - netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need dental care Dental check-ups $0 c-pay One preventive dental exam every six mnths. One prphylaxis (cleaning) every six mnths. One dental x-ray every year. Cmprehensive dental care $0 c-pay Up t $425 every three (3) mnths r $1,700 a year. Benefits include: Nn-rutine services Diagnstic services Restrative services Enddntics, peridntics and extractins Prir authrizatin and referral may be required. Limitatins apply. Call Member Services fr details. Benefit differs fr members qualified fr and enrllment in a state-perated waiver prgram (see Dental benefit n page 19.) Yu need hearing/auditry services Hearing screenings $0 c-pay Benefits include unlimited: Rutine hearing exams Fitting/evaluatins fr hearing aid Prir authrizatin may be required. Hearing aids $0 c-pay Up t $1,500 fr tw hearing aids every 2 years. Prir authrizatin and referral rules may apply. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 11

13 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits Health need r prblem Services yu may need Yur csts fr in - netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu have a chrnic cnditin, such as diabetes r heart disease Services t help manage yur disease $0 c-pay Benefits include diabetes self-management training and kidney disease educatin. Limitatins apply. Prir authrizatin and referral may be required. Diabetes supplies and services $0 c-pay Benefit includes: Diabetic mnitring supplies, Custm-mlded shes and inserts r ne pair f extra-depth shes per year. Additinal inserts prvided based n yur needs. Limitatins apply. Cntact Member Services fr a list f cvered supplies. Prir authrizatin may apply. Yu have a mental health cnditin Mental r behaviral health services $0 c-pay Benefit includes: Individual therapy visits Grup therapy visits Individual therapy visits with a psychiatrist Grup therapy visits with a psychiatrist Partial hspitalizatin prgram services Residential Treatment Facility Inpatient hspitalizatin services Exclusins, limitatins, and prir authrizatin may apply. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 12

14 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits Health need r prblem Yu have a substance abuse prblem Services yu may need Yur csts fr in - netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Substance abuse services $0 c-pay Benefit includes: Individual substance abuse utpatient treatment visits Grup substance abuse utpatient treatment visits Residential Treatment Facility Inpatient hspitalizatin services Yu need lng-term mental health services Inpatient care fr peple wh need mental health care Exclusins, limitatins, and prir authrizatin and referral may be required. $0 c-pay Unlimited inpatient days in a psychiatric hspital. Prir authrizatin and referral may be required. Except in an emergency, yur dctr must tell the plan that yu are ging t be admitted t the hspital. Yu need durable medical equipment (DME) Wheelchairs $0 c-pay Prir authrizatin and referral may be required. Canes $0 c-pay Prir authrizatin and referral rules may be required. Crutches $0 c-pay Prir authrizatin and referral rules may be required. Walkers $0 c-pay Prir authrizatin and referral rules may be required. Oxygen $0 c-pay Prir authrizatin and referral rules may be required. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 13

15 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits Health need r prblem Yu need help living at hme Services yu may need Yur csts fr in - netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Meals brught t yur hme $0 c-pay Prir authrizatin may be required Benefit requires qualificatin fr and enrllment in a state-perated waiver prgram. Hme services, such as cleaning r husekeeping $0 c-pay Prir authrizatin may be required. State eligibility requirements may apply. Changes t yur hme, such as ramps and wheelchair access Persnal Care Assistant (Yu may be able t emply yur wn assistant. Call Member Services fr mre infrmatin.) $0 c-pay Benefits are limited: Up t $7,500 maximum lifetime limit. Up t $300 annual limit. Prir authrizatin may be required. Benefit requires qualificatin fr and enrllment in a state-perated waiver prgram. $0 c-pay Prir authrizatin may be required. Services require qualificatin fr and enrllment in a state-perated waiver prgram. Training t help yu get paid r unpaid jbs $0 c-pay Prir authrizatin and referral may be required. Benefit requires qualificatin and enrllment in a state-perated waiver prgram. Hme health care services $0 c-pay These services are available t all members based n need. Prir authrizatin and referral may be required. Services t help yu live n yur wn Adult day services r ther supprt services $0 c-pay Prir authrizatin may be required State eligibility requirements may apply. $0 c-pay Prir authrizatin may be required. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 14

16 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits Health need r prblem Yu need a place t live with peple available t help yu Services yu may need Assisted living r ther husing services Yur csts fr in - netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) $0 c-pay Prir authrizatin may be required. Benefit requires qualificatin fr and enrllment in a state-perated waiver prgram. Nursing hme care $0 c-pay Services are available t members meeting specific level f care criteria. Prir authrizatin and referral required. Yur caregiver needs sme time ff Respite care $0 c-pay The plan ffers 8 hurs f respite care fr members nt in a state-perated waiver prgram. The plan ffers 30 visits fr members qualified fr and enrlled in a state-perated waiver prgram. Cvered places f service include member s hme r place f residence, fster hmes, hspitals, nursing facilities, and ther cmmunity care residential facilities. Prir authrizatin and referral may be required. Services require qualificatin fr and enrllment in a state-perated waiver prgram. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 15

17 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits Other services that Amerigrup STAR+PLUS MMP cvers This is nt a cmplete list. Call Member Services r read the Member Handbk t find ut abut ther cvered services. Other services cvered by Amerigrup STAR+PLUS MMP Smking cessatin caching and Nictine Replacement Therapy (NRT) prducts: 1. Up t five (5) scheduled caching calls 2. Access t inbund caching calls is available fr ninety (90) days fllwing enrllment in the caching prgram. 3. NRT prducts include ver-the-cunter nictine replacement in the frm f patches, gum r lzenges fr eight (8) ttal weeks. 4. Educatinal materials. Membership in Health Club/Fitness Classes Tbacc cessatin cunseling fr pregnant wmen Yur csts fr in-netwrk prviders $0 c-pay; cntact plan fr mre details Prir authrizatin and referral may be required. $0 c-pay Membership in SilverSneakers fitness prgram. Members are instructed n the use f cntracted fitness centers equipment and hme self-paced exercise prgrams thrugh an rientatin f the prgram. Cntact Member Services fr mre details. $0 c-pay Prir authrizatin and referral may be required. Cntact Member Services fr mre details. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 16

18 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits Other services cvered by Amerigrup STAR+PLUS MMP Freestanding Birth Center Services Family Planning Services Cunseling Services Habilitatin Self-Directed Persnal Assistance Services Institutin fr Mental Disease Services fr Individuals 65 r lder Yur csts fr in-netwrk prviders $0 c-pay Prir authrizatin and referral may be required. Cntact Member Services fr mre details. $0 c-pay Prir authrizatin and referral may be required. Cntact Member Services fr mre details. $0 c-pay Prir authrizatin and referral may be required. $0 c-pay Prir authrizatin and referral may be required. State eligibility requirements may apply r benefit requires qualificatin fr and enrllment in a state-perated waiver prgram. $0 c-pay Prir authrizatin and referral may be required. Cntact Member Services fr mre details. $0 c-pay Prir authrizatin and referral required. Cntact Member Services fr mre details. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 17

19 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits Other services cvered by Amerigrup STAR+PLUS MMP Supprted Emplyment Acupuncture Annual Physical Exam Emplyment Assistance Nursing Services Yur csts fr in-netwrk prviders $0 c-pay Prir authrizatin and referral may be required. Benefit requires qualificatin fr and enrllment in a state-perated waiver prgram $0 c-pay Prir authrizatin and referral may be required. Benefit is limited t six (6) treatments every year. Cntact Member Services fr mre details. $0 c-pay Cmplete annual physical exam and assciated labs are cvered. Benefit is limited t ne (1) physical per year. $0 c-pay Prir authrizatin and referral may be required. Benefit requires qualificatin fr and enrllment in a state-perated waiver prgram. $0 c-pay Prir authrizatin and referral may be required. Benefit requires qualificatin fr and enrllment in a state-perated waiver prgram. Cntact Member Services fr mre details. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 18

20 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits Other services cvered by Amerigrup STAR+PLUS MMP Emergency Respnse Services Adult Fster Care Transitinal Assistance Services Dental Yur csts fr in-netwrk prviders $0 c-pay Prir authrizatin may be required. State eligibility requirements may apply r benefit requires qualificatin fr and enrllment in a state-perated waiver prgram. Cntact Member Services fr mre details. $0 c-pay Prir authrizatin and referral may be required. Benefit requires qualificatin fr and enrllment in a state-perated waiver prgram. Cntact Member Services fr mre details. $0 c-pay Prir authrizatin and referral may be required. Benefit is limited t $2,500 per lifetime. State eligibility requirements may apply. Cntact Member Services fr mre details. $0 c-pay Prir authrizatin may be required. Benefit is limited t $5,000 every year. Cntact Member Services fr mre details. Benefit requires qualificatin fr and enrllment in a state-perated waiver prgram. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 19

21 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits Other services cvered by Amerigrup STAR+PLUS MMP Behaviral Health Services Cgnitive Rehabilitatin Therapy Adaptive Aids and Medical Supplies Minr Hme Mdificatins Yur csts fr in-netwrk prviders $0 c-pay Prir authrizatin and referral may be required. Services include in-patient mental health services, ut-patient mental health services, detxificatin services, psychiatry services, mental health targeted case management, and mental health rehabilitative services. Cntact Member Services fr mre details. $0 c-pay Prir authrizatin and referral may be required. Benefit requires qualificatin fr and enrllment in a state-perated waiver prgram. Cntact Member Services fr mre details. $0 c-pay Prir authrizatin and referral may be required. Benefit requires qualificatin fr and enrllment in a state-perated waiver prgram. Benefit is limited t $10,000 every year per waiver plan year. Cntact Member Services fr mre details. $0 c-pay Subject t a $7,500 lifetime limit and $300 annually fr repairs. Benefit requires qualificatin fr and enrllment in a state-perated waiver prgram. Prir authrizatin and referral may be required. Cntact Member Services fr mre details. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 20

22 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits Other services cvered by Amerigrup STAR+PLUS MMP Supprt Cnsultatin Pdiatry Services Alzheimer s Care Pest Cntrl Prsthetics/Medical Supplies Yur csts fr in-netwrk prviders $0 c-pay State eligibility requirements may apply r benefit requires qualificatin fr and enrllment in a state-perated waiver prgram. Prir authrizatin and referral may be required. One (1) rutine ft care visit is cvered every three (3) mnths. Prir authrizatin and referral may be required. A memry album fr phts fr members with memry lss r in a Nursing Facility t encurage memry retentin. One treatment every three (3) mnths t eliminate rdents, raches and ther unsafe pests frm the hme in rder t prvide a healthier cmmunitybased envirnment fr members Includes dispsable medical supplies. Prir authrizatin may be required. Cntact Member Services fr mre details. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 21

23 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits Benefits cvered utside f Amerigrup STAR+PLUS MMP This is nt a cmplete list. Call Member Services t find ut abut ther services nt cvered by Amerigrup STAR+PLUS MMP but available thrugh Medicare r Texas Medicaid. Other services cvered by Medicare r Texas Medicaid Yur csts Hspice care services $0 Nnemergency medical transprtatin services cvered by Texas Medicaid $0 Pre-admissin screening and resident review (PASRR) $0 Benefits nt cvered by Amerigrup STAR+PLUS MMP, Medicare, r Texas Medicaid This is nt a cmplete list. Call Member Services r read the Member Handbk t find ut abut ther excluded services. Benefits nt cvered by Amerigrup STAR+PLUS MMP, Medicare, r Texas Medicaid Private Rm Private duty nurses Csmetic Surgery Chirpractic Care Elective r Vluntary Enhancement Prcedures Naturpath Services Services prvided t veterans in Veterans Affairs (VA) facilities A private rm in a hspital is nt cvered, except when it is medically needed. Private duty nursing services prvided in a hspital are nt cvered by ur plan. Csmetic surgery r ther csmetic wrk, unless it is needed because f an accidental injury r t imprve a part f the bdy that is nt shaped right. Hwever, the plan will pay fr recnstructin f a breast after a mastectmy and fr treating the ther breast t match it. Other than manual manipulatin f the spine cnsistent with Medicare cverage guidelines r fr an acute cnditin r an acute exacerbatin f a chrnic cnditin cnsistent with Texas Medicaid cverage guidelines. Including weight lss, hair grwth, sexual perfrmance, athletic perfrmance, csmetic purpses, anti-aging and mental perfrmance, except when medically needed. Naturpath services (the use f natural r alternative treatments). When a veteran gets emergency services at a VA hspital and the VA cst sharing is mre than the cst sharing under ur plan, we will reimburse the veteran fr the difference. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 22

24 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits Yur rights as a member f the plan As a member f Amerigrup STAR+PLUS MMP, yu have certain rights. Yu can exercise these rights withut being punished. Yu can als use these rights withut lsing yur health care services. We will tell yu abut yur rights at least nce a year. Fr mre infrmatin n yur rights, please read the Member Handbk. Yur rights include, but are nt limited t, the fllwing: Yu have a right t respect, fairness and dignity. This includes the right t: Get cvered services withut cncern abut race, ethnicity, natinal rigin, religin, gender, age, mental r physical disability, sexual rientatin, genetic infrmatin, ability t pay, r ability t speak English Get infrmatin in ther frmats (e.g., large print, braille, audi) Be free frm any frm f restraint r seclusin Nt be billed by netwrk prviders. Yu have the right t get infrmatin abut yur health care. This includes infrmatin n treatment and yur treatment ptins. This infrmatin shuld be in a frmat yu can understand. These rights include getting infrmatin n: Descriptin f the services we cver Hw t get services Hw much services will cst yu Names f health care prviders and care managers Yu have the right t make decisins abut yur care, including refusing treatment. This includes the right t: Chse a Primary Care Prvider (PCP) and yu can change yur PCP at any time See a wmen s health care prvider withut a referral Get yur cvered services and drugs quickly Knw abut all treatment ptins, n matter what they cst r whether they are cvered Refuse treatment, even if yur dctr advises against it Stp taking medicine Ask fr a secnd pinin. Amerigrup STAR+PLUS MMP will pay fr the cst f yur secnd pinin visit. Yu have the right t timely access t care that des nt have any cmmunicatin r physical access barriers. This includes the right t: Get medical care timely Get in and ut f a health care prvider s ffice. This means barrier free access fr peple with disabilities, in accrdance with the Americans with Disabilities Act. Have interpreters t help with cmmunicatin with yur dctrs and yur health plan Yu have the right t seek emergency and urgent care when yu need it. This means yu have the right t: If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 23

25 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits Get emergency services withut prir apprval in an File a cmplaint r grievance against us r ur prviders emergency Ask fr a state fair hearing See an ut f netwrk urgent r emergency care prvider, when necessary Get a detailed reasn fr why services were denied Yu have a right t cnfidentiality and privacy. This includes the right t: Ask fr and get a cpy f yur medical recrds in a way that yu can understand and t ask fr yur recrds t be changed r crrected. Have yur persnal health infrmatin kept private. Yu have the right t make cmplaints abut yur cvered services r care. This includes the right t: Fr mre infrmatin abut yur rights, yu can read the Amerigrup STAR+PLUS MMP Member Handbk. If yu have questins, yu can als call Amerigrup STAR+PLUS MMP Member Services. If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 24

26 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits If yu have a cmplaint r think we shuld cver smething we denied If yu have a cmplaint r think Amerigrup STAR+PLUS MMP shuld cver smething we denied, call Amerigrup STAR+PLUS MMP at (TTY 711) Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. Yu may be able t appeal ur decisin. Fr questins abut cmplaints and appeals, yu can read Chapter 9 f the Amerigrup STAR+PLUS MMP Member Handbk. Yu can als call Amerigrup STAR+PLUS MMP Member Services. By mail t: By fax t: Cmplaints, Appeals and Grievances Amerigrup STAR+PLUS MMP P.O. Bx Virginia Beach, VA If yu have a cmplaint, als called a grievance, yu can call Member Services and tell us. Call Member Services at (TTY 711). Or yu can send it t us in writing: By mail t: By fax t: Cmplaints, Appeals and Grievances Amerigrup STAR+PLUS MMP P.O. Bx Virginia Beach, VA If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 25

27 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits If yu suspect fraud Mst health care prfessinals and rganizatins that prvide services are hnest. Unfrtunately, there may be sme wh are dishnest. If yu think a dctr, hspital r ther pharmacy is ding smething wrng, please cntact us. Call us at Amerigrup STAR+PLUS MMP Member Services. Phne numbers are n the cver f this summary. Or, call Medicare at MEDICARE ( ). TTY users shuld call Yu can call these numbers fr free, 24 hurs a day, 7 days a week. Let us knw if yu think a dctr, dentist, pharmacist at a drug stre, ther health care prviders, r a persn getting benefits is ding smething wrng. Ding smething wrng culd be fraud, waste, r abuse, which is against the law. Fr example, tell us if yu think smene is: Getting paid fr services that weren t given r weren t necessary. Nt telling the truth abut a medical cnditin t get medical treatment. Letting smene else use their Texas Medicaid ID. Using smene else s Texas Medicaid ID. Nt telling the truth abut the amunt f mney r resurces he r she has t get benefits. T reprt fraud, waste, r abuse, chse ne f the fllwing: Call the OIG Htline at ; Visit and pick Click Here t Reprt Waste, Abuse, and Fraud t cmplete the nline frm; r Yu can reprt directly t yur health plan: Amerigrup STAR+PLUS MMP 3800 Buffal Speedway, Ste 400 Hustn, TX If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 26

28 Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan): Summary f Benefits (TTY 711) T reprt fraud, waste, r abuse, gather as much infrmatin as pssible. When reprting abut a prvider (a dctr, dentist, cunselr, etc.), include: Name, address, and phne number f prvider Name and address f the facility (hspital, nursing hme, hme health agency, etc.) Texas Medicaid number f the prvider and facility, if yu have it Type f prvider (dctr, dentist, therapist, pharmacist, etc.) Names and phne numbers f ther witnesses wh can help in the investigatin Dates f events Summary f what happened When reprting abut smene wh gets benefits, include: The persn s name The persn s date f birth, Scial Security Number, r case number if yu have it The city where the persn lives Specific details abut the fraud, waste, r abuse Yu may als reprt fraud by cntacting the Texas Department f Insurance at r yu may visit them nline at If yu have questins, please call Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) at (TTY 711), Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit 27

29 Have questins Call us tll-free at (TTY 711) Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. Or visit Amerigrup STAR+PLUS MMP (Medicare-Medicaid Plan) is a health plan that cntracts with bth Medicare and Texas Medicaid t prvide benefits f bth prgrams t enrllees. This is nt a cmplete list. The benefit infrmatin is a brief summary, nt a cmplete descriptin f benefits. Fr mre infrmatin cntact the plan r read the Member Handbk. Limitatins and restrictins may apply. Fr mre infrmatin, call Amerigrup STAR+PLUS MMP Member Services r read the Amerigrup STAR+PLUS MMP Member Handbk. The List f Cvered Drugs and/r pharmacy and prvider netwrks may change thrughut the year. We will send yu a ntice befre we make a change that affects yu. Benefits and/r cpays may change n January 1 f each year. Yu can ask fr this Summary f Benefits in ther frmats, such as Braille r large print. Call (TTY 711) frm 8 a.m. t 8 p.m. Mnday thrugh Friday. H8786_16_25637_U CMS Accepted 09/08/2015