AETNA BETTER HEALTH SM PREMIER PLAN 2015 Summary of Benefits

Transcription

1 AETNA BETTER HEALTH PREMIER PLAN 2015 Summary of Benefits Aetna Better Health Premier Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees. IL H2506_15_004 CMS ACCEPTED

2 Helpful information Aetna Better Health Premier Plan Member Services (toll free) Representatives available 24 hours a day, 7 days a week Address Aetna Better Health Premier Plan One South Wacker Drive Suite 1200, Mail Stop F646 Chicago, IL Services for the Hearing Impaired Illinois Relay Enrollment and Application Services Illinois Client Enrollment Broker (ICEB) (toll free) TTY: Transportation Services Medical Transportation Management, Inc. Non-Emergency Transportation Dental Services DentaQuest (toll free) Behavioral Health Services (toll free) Vision Services March Vision (toll free) Pharmacy Services Aetna Better Health Premier Plan Call Member Services (toll free) Prescriptions by Mail CVS Caremark PO Box 2110 Pittsburgh, PA (toll free) TTY: Monday through Friday 8 a.m. to 8 p.m. EST Language Interpretation Services Including Sign Language Interpretation and CART Reporting Call Aetna Better Health Premier Plan Member Services (toll free) Representatives available 24 hours a day, 7 days a week Appeals and Grievances Aetna Better Health Premier Plan Attn: Appeals and Grievances Manager One South Wacker Drive Mail Stop F646 Chicago, IL Illinois Relay (hearing impaired) To make a request for a fair hearing: Illinois Department of Healthcare and Family Services Bureau of Assistance Hearings 401 South Clinton, Sixth Floor Chicago, IL (toll free) TTY: Fraud and Abuse Hotline (toll free)

3 2015 Summary of Benefits AETNA BETTER HEALTH PREMIER PLAN! This is a summary of health services covered by AETNA BETTER HEALTH PREMIER PLAN for This is only a summary. Please read the Member Handbook for the full list of benefits. AETNA BETTER HEALTH PREMIER PLAN is a health plan that contracts with both Medicare and Illinois Medicaid to provide benefits of both programs to enrollees. It is for people with both Medicare and Medicaid. The AETNA BETTER HEALTH PREMIER PLAN will be available to individuals who meet the following criteria: Age 21 and older at time of enrollment; Entitled to benefits under Medicare Part A and enrolled under Medicare Part B and D, and receiving full Medicaid benefits; and Enrolled in the Medicare Aid to the Aged, Blind, Disabled (ABD) category of assistance. Individuals with End Stage Renal Disease (ESRD) at the time of enrollment Eligible populations include: Beneficiaries who meet all other Demonstration criteria and are in the following: Medicaid 1915 waivers; Persons who are elderly; Persons with Disabilities; Persons with HIV/AIDS; Persons with Brain Injury; and Persons residing in Supportive Living Facilities.

4 AETNA BETTER HEALTH PREMIER PLAN: Summary of Benefits Under AETNA BETTER HEALTH PREMIER PLAN you can get your Medicare and Medicaid services in one health plan. An AETNA BETTER HEALTH PREMIER PLAN care management team, led by a care manager, will help manage your health care needs. This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook. Limitations and restrictions may apply. For more information, call AETNA BETTER HEALTH PREMIER PLAN Member Services or read the AETNA BETTER HEALTH PREMIER PLAN Member Handbook. Benefits, List of Covered Drugs, and pharmacy and provider networks may change from time to time throughout the year and on January 1 of each year. You can ask for this information in other formats, such as Braille or large print. Call , (TTY/TDD IL Relay 7 1 1), 24 hours a day, 7 days a week. The call is free. You can get this document in Spanish, or speak with someone about this information in other languages for free. Call , (TTY/TDD IL Relay 7 1 1), 24 hours a day, 7 days a week. The call is free. Uste puede obtener este document en espanol, o hablar gratuitamente con una persona en otros idiomas sobre esta informacion. Llame a Servicios al Miembro at , (TTY/TDD at IL Relay 7 1 1), 24 horas al dia, siete dias de la semana. La llamada es gratis.

5 AETNA BETTER HEALTH PREMIER PLAN: Summary of Benefits The following chart lists frequently asked questions. Frequently Asked Questions (FAQ) Answers What is a Medicare Medicaid Plan A Medicare Medicaid Plan is an organization made up of doctors, hospitals, pharmacies, providers of long term services, and other providers. It also has care managers to help you manage all your providers and services. They all work together to provide the care you need. What is an AETNA BETTER HEALTH PREMIER PLAN care manager What are long term services and supports Will you get the same Medicare and Medicaid benefits in AETNA BETTER HEALTH PREMIER PLAN that you get now An AETNA BETTER HEALTH care manager is one main person for you to contact. This person helps manage all your providers and services and makes sure you get what you need. Long term services and supports are services provided through a Long Term Care Facility or through a Home and Community Based Waiver. Enrollees have the option to receive long term services and supports (LTSS) in the least restrictive setting when appropriate, with a preference for the home and the community, and in accordance with the Enrollee s wishes and Care Plan. You will get your covered Medicare and Medicaid benefits directly from AETNA BETTER HEALTH PREMIER PLAN. You will work with a team of providers who will help determine what services will best meet your needs. This means that some of the services you get now may change. When you enroll in AETNA BETTER HEALTH PREMIER PLAN, you and your care team will work together to develop an Individualized Care Plan to address your health and support needs. During this time, you can keep seeing your doctors and getting your current services for 180 days, or until your care plan is complete. When you join our plan, if you are taking any Medicare Part D prescription drugs that AETNA BETTER HEALTH PREMIER PLAN does not normally cover, you can get a temporary supply. We will help you get another drug or get an exception for AETNA BETTER HEALTH PREMIER PLAN to cover your drug, if medically necessary

6 AETNA BETTER HEALTH PREMIER PLAN: Summary of Benefits Frequently Asked Questions (FAQ) Can you go to the same doctors you see now What happens if you need a service but no one in AETNA BETTER HEALTH PREMIER PLAN s network can provide it Where is AETNA BETTER HEALTH PREMIER PLAN available Do you pay a monthly amount (also called a premium) under AETNA BETTER HEALTH PREMIER PLAN What is prior authorization Answers Often that is the case. your providers (including doctors, therapists, and pharmacies) work with AETNA BETTER HEALTH PREMIER PLAN and have a contract with us, you can keep going to them. Providers with an agreement with us are in network. You must use the providers in AETNA BETTER HEALTH PREMIER PLAN s network. you need urgent or emergency care or out of area dialysis services, you can use providers outside of AETNA BETTER HEALTH PREMIER PLAN s network. AETNA BETTER HEALTH PREMIER PLAN is unable to provide necessary medical/surgical services covered under your benefits, AETNA BETTER HEALTH PREMIER PLAN will cover these services out of network for you, for as long as AETNA BETTER HEALTH PREMIER PLAN is unable to provide the services in network. To find out if your doctors are in the plan s network, call Member Services at , (TTY/TDD IL Relay 7 1 1), 24 hours a day, 7 days a week or read AETNA BETTER HEALTH PREMIER PLAN s Provider and Pharmacy Directory on our website at AETNA BETTER HEALTH PREMIER PLAN is new for you, you can continue seeing the doctors you go to now for the next 180 days or until you and your care manager decide who is best to care for you and your health needs. Most services will be provided by our network providers. you need a service that cannot be provided within our network, AETNA BETTER HEALTH PREMIER PLAN will pay for the cost of an out of network provider. The service area for this plan includes: Cook County, DuPage County, Kane County, Kankakee County and Will County in Illinois. You must live in one of these areas to join the plan. You will not pay any monthly premiums to AETNA BETTER HEALTH PREMIER PLAN for your health coverage. Prior authorization means that you must get approval from AETNA BETTER HEALTH PREMIER PLAN before you can get a specific service or drug or see an out of network provider. AETNA BETTER HEALTH PREMIER PLAN may not cover the service or drug if you don t get approval. you need urgent or emergency care or out of area dialysis services, you don t need to get approval first.

7 AETNA BETTER HEALTH PREMIER PLAN: Summary of Benefits Frequently Asked Questions (FAQ) What is a referral Who should you contact if you have questions or need help Answers A referral means that your primary care provider must give you approval to see someone that is not your primary care provider. you don t get approval, AETNA BETTER HEALTH PREMIER PLAN may not cover the services. There are certain specialists in which you do not need a referral, such as women health specialists. For more information on when a referral is necessary, see the Member Handbook. you have general questions or questions about our plan, services, billing, or member cards, please call AETNA BETTER HEALTH PREMIER PLAN Member Services: CALL Calls to this number are free. 24 hours a day, 7 days a week. Member Services also has free language interpreter services available for people who do not speak English. TTY IL Relay This number is for people who have hearing or speaking problems. You must have special telephone equipment to call it. Calls to this number are free. 24 hours a day, 7 days a week.

8 AETNA BETTER HEALTH PREMIER PLAN: Summary of Benefits Frequently Asked Questions (FAQ) Who should you contact if you have questions or need help (continued) Answers you have questions about your health, please call the Nurse Advice Call line: CALL , Option 4 Calls to this number are free. 24 hours a day, 7 days a week. Member Services also has free language interpreter services available for people who do not speak English. TTY IL Relay This number is for people who have hearing or speaking problems. You must have special telephone equipment to call it. Calls to this number are free. 24 hours a day, 7 days a week. you need immediate behavioral health, please call the Behavioral Health Crisis Line: CALL follow the prompts for the Behavioral Health Crisis Line. Calls to this number are free. 24 hours a day, 7 days a week. Member Services also has free language interpreter services available for people who do not speak English. TTY IL Relay This number is for people who have hearing or speaking problems. You must have special telephone equipment to call it. Calls to this number are free. 24 hours a day, 7 days a week.

9 AETNA BETTER HEALTH PREMIER PLAN: Summary of Benefits The following chart is a quick overview of what services you may need, your costs and rules about the benefits. Health need or problem Services you may need Your costs for in-network providers Limitations, exceptions, & benefit information (rules about benefits) You want to see a doctor Visits to treat an injury or illness $0 100% - no limitations/no authorizations Wellness visits, such as a physical $0 100% - no limitations/no authorizations Transportation to a doctor s office $0 100% - prior authorization required Specialist care Prof Behavioral Heath, Non-Medical Prof Cardiac Rehabilitation Prof Chiropractic Prof Intensive Cardiac Rehabilitation Prof Orthopedic Shoes Prof Preventative Services Prof - Lab Tests and Services Prof Pulmonary Rehabilitation Prof Routine Foot Care $0 In some cases an authorization may be required None 36 visit limit 12 per year 36 visit limit 5 per year with diabetic diagnosis None None 36 visit limit 1 visit every 3 months with routine foot care diagnosis $0 100% - no limitations/no authorizations $0 100% - no limitations/no authorizations Care to keep you from getting sick, such as flu shots Welcome to Medicare preventive visit (one time only) You need medical tests Lab tests, such as blood work $0 100% - prior authorization may be required for certain tests X-rays or other pictures, such as CAT scans $0 100% - some radiology tests require authorizations Screening tests, such as tests to check for cancer $0 100% - no authorizations required if seeing a network provider

10 AETNA BETTER HEALTH PREMIER PLAN: Summary of Benefits Health need or problem You need drugs to treat your illness or condition There may be limitations on the types of drugs covered. Please see AETNA BETTER HEALTH PREMIER PLAN s List of Covered Drugs (Drug List) for more information. Services you may need Generic drugs (no brand name) Your costs for in-network providers $0 for a 30-day supply. Limitations, exceptions, & benefit information (rules about benefits) Extended day supplies of covered drugs are available at network, retail and mail order pharmacies. These drugs are usually considered maintenance drugs. Your copay for the extended day supply is the same as the 30- day supply Some drugs have coverage rules or have limits on the amount you can get. For example: For some drugs, you or your doctor must get approval from the plan before you fill your prescription. Sometimes the plan limits the amount of a drug you can get Step therapy: Sometimes the plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. your doctor thinks the first drug doesn t work for you, then we will cover the second.

11 AETNA BETTER HEALTH PREMIER PLAN: Summary of Benefits Health need or problem You need drugs to treat your illness or condition (continued) Services you may need Brand name drugs Your costs for in-network providers $0 for a 30-day supply. Limitations, exceptions, & benefit information (rules about benefits) Extended day supplies of covered drugs are available at network, retail and mail order pharmacies. These drugs are usually considered maintenance drugs. Your copay for the extended day supply is the same as the 30- day supply Some drugs have coverage rules or have limits on the amount you can get. For example: For some drugs, you or your doctor must get approval from the plan before you fill your prescription. Sometimes the plan limits the amount of a drug you can get You need drugs to treat your illness or condition Step therapy: Sometimes the plan requires you to do step therapy. This means you will have to try drugs in a certain order for your medical condition. You might have to try one drug before we will cover another drug. your doctor thinks the first drug doesn t work for you, then we will cover the second. Over-the-counter drugs $0 100% (in accordance with Medicaid covered benefits) (continued)

12 AETNA BETTER HEALTH PREMIER PLAN: Summary of Benefits Health need or problem You need drugs to treat your illness or condition (continued) Services you may need Medicare Part B prescription drugs Your costs for in-network providers $0 Limitations, exceptions, & benefit information (rules about benefits) Part B drugs include drugs given by your doctor in his or her office, some oral cancer drugs, and some drugs used with certain medical equipment. Read the Member Handbook for more information on these drugs. Occupational, physical, or speech therapy $0 100% - Maintenance therapy not covered. You need therapy after a stroke or accident You need emergency care Emergency room services $0 Emergency room services can be provided by in network and out-of-network providers and do not require prior authorization Ambulance services $0 Emergency ambulance services do not require a prior authorization Urgent care $0 Urgent care services can be provided by in network and out-of-network providers and do not require prior authorization You need hospital care Hospital stay $0 Emergency admissions: hospitals are required to notify the health plan. Elective admissions require prior authorization. Doctor or surgeon care $0 100% - no limitations/no authorizations

13 AETNA BETTER HEALTH PREMIER PLAN: Summary of Benefits Health need or problem You need help getting better or have special health needs Services you may need Your costs for in-network providers Limitations, exceptions, & benefit information (rules about benefits) Rehabilitation services $0 Rehabilitation: limit of 36 visits with an innetwork provider (cardiac, pulmonary) Chiropractic: limit of 12 visits with an innetwork provider Medical equipment for home care $0 100% - with prior authorization requirements Skilled nursing care $0 100% - SNF copay days = Medicare and Medicaid = $0 copay You need eye care Eye exams $0 1 exam every 12 months Glasses or contact lenses $0 1 pair of glasses or contacts every 24 months You need dental care Dental check-ups $0 Preventive (exams, cleaning, x-rays) 2 per year. You need hearing/auditory services You have a chronic condition, such as diabetes or heart disease You have a mental health condition You have a substance abuse problem Comprehensive dental: including non-routine diagnostic, restorative, endodontic, periodontic, prosthodontic, orthodontic, and surgery services Hearing screenings $0 100% - no limitations/no authorizations Hearing aids $0 100% - prior authorization required (in accordance with Medicare covered) Hearing aids every 3 years. Services to help manage your disease $0 100% - no limitations/no authorizations Diabetes supplies and services $0 100% - no limitations/no authorizations Mental or behavioral health services $0 100% - no limitations/no authorizations Substance abuse services $0 100% - no limitations/no authorizations

14 AETNA BETTER HEALTH PREMIER PLAN: Summary of Benefits Health need or problem You need long-term mental health services You need durable medical equipment (DME) You need help living at home Services you may need Your costs for in-network providers Limitations, exceptions, & benefit information (rules about benefits) Inpatient care for people who need mental health care $0 100% - no limitations/no authorization required Wheelchairs $0 100% - prior authorization required Canes $0 100% - no limitations/no authorizations Crutches $0 100% - no limitations/no authorizations Walkers $0 100% - no limitations/no authorizations Oxygen $0 100% - no limitations/no authorizations Meals brought to your home $0 These services are only available if you are Home services, such as cleaning or $0 These services are only available if you are housekeeping Changes to your home, such as ramps and wheelchair access Personal care assistant (You may be able to employ your own assistant. Call Member Services for more information.) Training to help you get paid or unpaid jobs $0 These services are only available if you are $0 These services are only available if you are $0 These services are only available if you are

15 AETNA BETTER HEALTH PREMIER PLAN: Summary of Benefits Health need or problem You need help living at home (continued) You need a place to live with people available to help you Your caregiver needs some time off Services you may need Your costs for in-network providers Limitations, exceptions, & benefit information (rules about benefits) Home health care services $0 These services are only available if you are Services to help you live on your own $0 These services are only available if you are Adult day services or other support services $0 These services are only available if you are Assisted living or other housing services $0 These services are only available if you are Nursing home care $0 These services are only available if you are Respite care $0 These services are only available if you are

16 AETNA BETTER HEALTH PREMIER PLAN: Summary of Benefits Other services that AETNA BETTER HEALTH PREMIER PLAN covers: Other services AETNA BETTER HEALTH PREMIER PLAN covers (This is not a complete list. Call Member Services at , (TTY/TDD IL Relay 7-1-1), 24 hours a day, 7 days a week or read the Member Handbook to find out about other covered services.) Podiatry expanded benefit 1 annual visit for routine foot care Over the counter products $20 per month through mail order catalog service; no carry overs Health Education Wide array of health and education tools and programs that is available to members at no additional cost Smoking and Tobacco Use Cessation Medically necessary cessation counseling sessions (up to 50 per year), nicotine patches, gum, and lozenges, as well as certain pharmacy medications without needing prior authorization Health and Wellness Access to the Silver & Fit program at no cost at participating locations Nursing Hotline Access to a registered nurse 24 hours a day, 7 days a week, 365 days a year Nutrition Education Health and nutrition tools and programs that are available to members at no additional cost Services that AETNA BETTER HEALTH PREMIER PLAN does not cover: Services AETNA BETTER HEALTH PREMIER PLAN does not cover (This is not a complete list. Call Member Services to find out about other excluded services.) Services considered not reasonable and necessary, according to the Cosmetic surgery or other cosmetic work, unless it is needed because of standards of Medicare and Medicaid, unless these services are listed by an accidental injury or to improve a part of the body that is not shaped our plan as covered services. right. However, the plan will cover reconstruction of a breast after a mastectomy and for treating the other breast to match it. Experimental medical and surgical treatments, items, and drugs, unless covered by Medicare or under a Medicare-approved clinical research study or by our plan. See pages <page numbers> for more information on clinical research studies. Experimental treatment and items are those that are not generally accepted by the medical community. Routine foot care, except for the limited coverage provided according to Medicare guidelines.

17 AETNA BETTER HEALTH PREMIER PLAN: Summary of Benefits Surgical treatment for morbid obesity, except when it is medically needed and Medicare pays for it. A private room in a hospital, except when it is medically needed. Personal items in your room at a hospital or a nursing facility, such as a telephone or a television. Full-time nursing care in your home. Elective or voluntary enhancement procedures or services (including weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance), except when medically needed. Radial keratotomy, LASIK surgery, and vision therapy. Chiropractic care, other than manual manipulation of the spine consistent with Medicare coverage guidelines. Acupuncture Naturopath services (the use of natural or alternative treatments). Services provided to veterans in Veterans Affairs (VA) facilities. However, when a veteran gets emergency services at a VA hospital and the VA cost sharing is more than the cost sharing under our plan, we will reimburse the veteran for the difference. Members are still responsible for their cost sharing amounts.

18 AETNA BETTER HEALTH PREMIER PLAN: Summary of Benefits Your rights as a member of the plan As a member of AETNA BETTER HEALTH PREMIER PLAN, you have certain rights. You can exercise these rights without being punished. You can also use these rights without losing your health care services. We will tell you about your rights at least once a year. For more information on your rights, please read the Member Handbook. Your rights include, but are not limited to, the following: You have a right to respect, fairness and dignity. This includes: The right to get covered services without concern about race, ethnicity, national origin, religion, gender, age, mental or physical disability, sexual orientation, genetic information, ability to pay, or ability to speak English The right to request information in other formats (e.g., audio CD_ ROM, large print, cassette, Braille) The right to be free from any form of restraint or seclusion The right not to be billed by providers You have the right to get information about your health care. This includes information on treatment and your treatment options. This information should be in a format you can understand. These rights include getting information on: Description of the services we cover How to get services How much services will cost you Names of health care providers and care managers You have the right to make decisions about your care, including refusing treatment. This includes the right: To choose a Primary Care Provider (PCP) and you can change your PCP at any time To see a women s health care provider without a referral To get your covered services and drugs quickly To know about all treatment options, no matter what they cost or whether they are covered To refuse treatment, even if your doctor advises against it To stop taking medicine To ask for a second opinion. AETNA BETTER HEALTH PREMIER PLAN will pay for the cost of your second opinion visit. You have the right to timely access to care that does not have any communication or physical access barriers. This includes the right to: Get medical care timely Get in and out of a health care provider s office. This means barrier free access for people with disabilities, in accordance with the Americans with Disabilities Act Have interpreters to help with communication with your doctors and your health plan.

19 AETNA BETTER HEALTH PREMIER PLAN: Summary of Benefits You have the right to seek emergency and urgent care when you need it. This means: You have the right to get emergency services without prior approval in an emergency You have the right to see an out of network urgent or emergency care provider, when necessary You have a right to confidentiality and privacy. This includes: The right to ask for and get a copy of your medical records in a way that you can understand and to ask for your records to be changed or corrected. The right to have your personal health information kept private. You have the right to make complaints about your covered services or care. This includes the right to: File a complaint or grievance against us or our providers Ask for a state fair hearing Get a detailed reason for why services were denied For more information about your rights, you can read the AETNA BETTER HEALTH PREMIER PLAN Member Handbook. you have questions, you can also call AETNA BETTER HEALTH PREMIER PLAN Member Services. you have a complaint or think we should cover something we denied you have a complaint or think AETNA BETTER HEALTH PREMIER PLAN should cover something we denied, call AETNA BETTER HEALTH PREMIER PLAN at You may be able to appeal our decision. For questions about complaints and appeals, you can read Chapter 9 of the AETNA BETTER HEALTH PREMIER PLAN Member Handbook. You can also call AETNA BETTER HEALTH PREMIER PLAN Member Services. For information and questions on complaints, grievances and appeals you can call AETNA BETTER HEALTH PREMIER PLAN Member Services at you suspect fraud Most health care professionals and organizations that provide services are honest. Unfortunately, there may be some who are dishonest. you think a doctor, hospital or other pharmacy is doing something wrong, please contact us. Call us at AETNA BETTER HEALTH PREMIER PLAN Member Services. Phone numbers are on the cover of this summary. Or, call Medicare at MEDICARE ( ). TTY users should call You can call these numbers for free, 24 hours a day, 7 days a week.

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