Summary of Benefits PENNSYLVANIA. Gateway Health Medicare Assured Ruby SM. (HMO SNP) Gateway Health Medicare Assured Diamond SM (HMO SNP)

Transcription

1 2015 Summary of s PENNSYLVANIA Gateway Health Medicare Assured Ruby SM Gateway Health Medicare Assured Diamond SM For Medicare beneficiaries who are also eligible for Medicaid or assistance from the State. Y0097_396_PA Accepted

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3 SECTION I INTRODUCTION TO SUMMARY OF BENEFITS You have choices about how to get your Medicare benefits. One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Assured Diamond SM and Assured Ruby SM ). Tips for comparing your Medicare choices This Summary of s booklet gives you a summary of what Assured Diamond SM and Assured Ruby SM covers and what you pay. If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of s booklets. Or, use the Medicare Plan Finder on If you want to know more about the coverage and costs of Original Medicare, look in your current "Medicare & You" handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call Sections in this booklet Things to Know About Assured Diamond SM and Assured Ruby SM Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital s Prescription Drug s 1

4 SECTION I INTRODUCTION TO SUMMARY OF BENEFITS This document is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call us at (877) (prospective members); (800) (current members). Things to Know About Assured Diamond SM and Gateway Health Medicare Assured Ruby SM. Hours of Operation From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time. Assured Diamond SM and Assured Ruby SM Phone Numbers and Website If you are a member of this plan, call toll-free (800) If you are not a member of this plan, call toll-free (877) Our website: 2

5 SECTION I INTRODUCTION TO SUMMARY OF BENEFITS Who can join? To join Assured Diamond SM or Assured Ruby SM (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and Pennsylvania Medical Assistance (Medicaid) and live in our service area. Our service area includes the following counties in Pennsylvania: Adams, Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bucks, Butler, Cambria, Chester, Clarion, Crawford, Cumberland, Dauphin, Delaware, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Mercer, Montgomery, Northampton, Northumberland, Perry, Philadelphia, Schuylkill, Somerset, Venango, Washington, Westmoreland, and York. Which doctors, hospitals, and pharmacies can I use? Assured Diamond SM and Assured Ruby SM have a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan's provider and pharmacy directory at our website ( Or, call us and we will send you a copy of the provider and pharmacy directories. 3

6 SECTION I INTRODUCTION TO SUMMARY OF BENEFITS What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers - and more. Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We cover Part D drugs. 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 on our website, Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? The amount you pay depends on the drug's tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage. If you have any questions about this plan's benefits or costs, please contact Assured Diamond SM (HMO SNP) and Assured Ruby SM for detail. 4

7 SECTION II SUMMARY OF BENEFITS How much is the monthly premium? How much is the deductible? Assured Ruby SM $0.00 per month. In addition, you must keep paying your Medicare Part B premium. This plan does not have a deductible. Assured Diamond SM $0.00 per month. This plan does not have a deductible. This plan does not have a deductible for chemotherapy and other drugs administered in your doctor's office (Part B drugs). This plan does not have a deductible for Part D prescription drugs. Is there any limit on how much I will pay for my covered services? Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-ofpocket costs for medical and hospital care. In this plan, you may pay nothing for Medicarecovered services, depending on your level of Pennsylvania Medical Assistance (Medicaid) eligibility. Refer to the "Medicare & You" handbook for Medicare-covered services. For Pennsylvania Medical Assistance (Medicaid)-covered services, refer to the Medicaid Coverage section in this document. Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. In this plan, you may pay nothing for Medicare-covered services, depending on your level of Pennsylvania Medical Assistance (Medicaid) eligibility. Refer to the "Medicare & You" handbook for Medicarecovered services. For Pennsylvania Medical Assistance (Medicaid)-covered services, refer to the Medicaid Coverage section in this document. 5

8 SECTION II - SUMMARY OF BENEFITS Is there any limit on how much I will pay for my covered services? (continued) Assured Ruby SM Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Assured Diamond SM Your yearly limit(s) in this plan: $3,400 for services you receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Is there a limit on how much the plan will pay? Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. Assured Diamond SM and Assured Ruby SM are HMO plans with a Medicare contract. Assured Diamond SM and Assured Ruby SM are HMO plans with a Medicare contract and a contract with Pennsylvania Medicaid. Enrollment in Assured Diamond SM and Assured Ruby SM depends on contract renewal. 6

9 SECTION II - SUMMARY OF BENEFITS Assured Ruby SM COVERED MEDICAL AND HOSPITAL BENEFITS NOTE: SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION. SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR. OUTPATIENT CARE AND SERVICES Acupuncture and Other Alternative Therapies Not covered Assured Diamond SM Not covered Ambulance 1 $0 or $200 copay You pay nothing Chiropractic Care 1 Dental Services Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $0 or $20 copay The enrollee is covered for manual spine manipulation to correct a subluxation. Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): You pay nothing Preventive dental services: Cleaning (for up to 1 every six months): You pay nothing Dental x-ray(s) (for up to 1 every six months): You pay nothing Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): You pay nothing The enrollee is covered for manual spine manipulation to correct a subluxation. Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): You pay nothing Preventive dental services: Cleaning (for up to 1 every six months): You pay nothing Dental x-ray(s) (for up to 1 every six months): You pay nothing 7

10 SECTION II - SUMMARY OF BENEFITS Dental Services (continued) Diabetes Supplies and Services Assured Ruby SM Oral exam (for up to 1 every six months): You pay nothing See the Additional Information Section of this booklet for other covered dental benefits. Diabetes monitoring supplies: 0% or 20% of the cost Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: 0% or 20% of the cost. With regard to limiting Diabetic Supplies and Services: If the member receives diabetic supplies and services at a DME provider, there is no limit to manufacturer. If the member receives diabetic supplies and services from a pharmacy, specified manufacturers are limited. If the doctor provides you services in addition to diabetes self-management training, separate cost share of $15 or $30 copayment may apply. Assured Diamond SM Oral exam (for up to 1 every six months): You pay nothing See the Additional Information Section of this booklet for other covered dental benefits. Diabetes monitoring supplies: You pay nothing Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: You pay nothing With regard to limiting Diabetic Supplies and Services: If the member receives diabetic supplies and services at a DME provider, there is no limit to manufacturer. If the member receives diabetic supplies and services from a pharmacy, specified manufacturers are limited. Diagnostic Tests, Lab and Radiology Services, and X- Rays 1 Diagnostic radiology services (such as MRIs, CT scans): $0 or $140 copay Diagnostic tests and procedures: You pay nothing Lab services: You pay nothing Outpatient x-rays: $0 or $30 copay Therapeutic radiology services (such as radiation treatment for cancer): $0 or $60 copay 8 Diagnostic radiology services (such as MRIs, CT scans): You pay nothing Diagnostic tests and procedures: You pay nothing Lab services: You pay nothing Outpatient x-rays: You pay nothing Therapeutic radiology services (such as radiation treatment for cancer): You pay nothing

11 SECTION II - SUMMARY OF BENEFITS Diagnostic Tests, Lab and Radiology Services, and X- Rays 1 (continued) Assured Ruby SM There is no copayment for Medicare-approved clinical/diagnostic lab services. Depending on the type of physician/professional service provided, a separate cost share may apply. If the doctor provides you services in addition to outpatient diagnostic procedures, tests and lab services, sometimes separate cost sharing of $0 or $15 may apply. Assured Diamond SM There is no copayment for Medicare-approved clinical/diagnostic lab services. Depending on the type of physician/professional service provided, a separate cost share may apply. Doctor's Office Visits Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Primary care physician visit: $0 or $15 copay Specialist visit: $0 or $30 copay There is no authorization if service is from the Gateway Health SM specialist network. 0% or 20% of the cost Authorization from Gateway Health SM is required for DME services $ or greater for a single item or multiple quantities of a single item. Emergency Care $0 or $65 copay You pay nothing Foot Care (podiatry services) Hearing Services Foot exams and treatment if you have diabetesrelated nerve damage and/or meet certain conditions: $0 or $30 copay Routine foot care: $30 copay There is no authorization if service is from the Gateway Health SM specialist network. Exam to diagnose and treat hearing and balance issues: You pay nothing Routine hearing exam: You pay nothing Primary care physician visit: You pay nothing Specialist visit: You pay nothing There is no authorization if service is from the Gateway Health SM specialist network. You pay nothing Authorization from Gateway Health SM is required for DME services $ or greater for a single item or multiple quantities of a single item. Foot exams and treatment if you have diabetesrelated nerve damage and/or meet certain conditions: You pay nothing Routine foot care: 20% of the cost There is no authorization if service is from the Gateway Health SM specialist network. Exam to diagnose and treat hearing and balance issues: You pay nothing Routine hearing exam: You pay nothing 9

12 Hearing Services (continued) SECTION II - SUMMARY OF BENEFITS Assured Ruby SM Hearing aid fitting/evaluation: You pay nothing Hearing aid: You pay nothing Our plan pays up to $1,000 every two years for hearing aids. Home Health Care 1 You pay nothing You pay nothing Mental Health Care 1 Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Assured Diamond SM Hearing aid fitting/evaluation: You pay nothing Hearing aid: You pay nothing Our plan pays up to $1,000 every two years for hearing aids. Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. $0 or $225 copay per day for days 1 through 6 You pay nothing per day for days 7 through 90 Outpatient group therapy visit: $0 or $30 copay Outpatient individual therapy visit: $0 or $30 copay Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. You pay nothing Outpatient group therapy visit: You pay nothing Outpatient individual therapy visit: You pay nothing 10

13 SECTION II - SUMMARY OF BENEFITS Mental Health Care 1 (continued) Assured Ruby SM Medicare beneficiaries may only receive 190 days in a freestanding Psychiatric Hospital in a lifetime. Except in an emergency, authorization by Gateway Health SM is required before service is received. Assured Diamond SM Medicare beneficiaries may only receive 190 days in a freestanding Psychiatric Hospital in a lifetime. Except in an emergency, authorization by Gateway Health SM is required before service is received. Cardiac (heart) rehab services (for a maximum of 2 Outpatient Rehabilitation 1 one-hour sessions per day for up to 36 sessions up to 36 weeks): $0 or $30 copay Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): You pay nothing. Outpatient Substance Abuse 1 Outpatient Surgery Over-the-Counter Items Occupational therapy visit: $0 or $30 copay Physical therapy and speech and language therapy visit: $0 or $30 copay Group therapy visit: $0 or $30 copay Individual therapy visit: $0 or $30 copay Ambulatory surgical center: $0 or $175 copay Outpatient hospital: $0 or $175 copay Other cost sharing may apply to non-surgery services. Please visit our website to see our list of covered over-the-counter items. Members receive $10 every 3 months for purchasing Medicare-approved non-prescription over-the-counter medication and health-related items through catalog purchasing. 11 Occupational therapy visit: You pay nothing Physical therapy and speech and language therapy visit: You pay nothing The Medicare-defined Part B deductible and facility cost share amount of 20% will apply for all occupational therapy services. Group therapy visit: You pay nothing Individual therapy visit: You pay nothing Ambulatory surgical center: You pay nothing Outpatient hospital: You pay nothing Please visit our website to see our list of covered over-the-counter items. Members receive $10 every 3 months for purchasing Medicare-approved non-prescription over-the-counter medication and health-related items through catalog purchasing.

14 SECTION II - SUMMARY OF BENEFITS Prosthetic Devices (braces, artificial limbs, etc.) 1 Assured Ruby SM Prosthetic devices: 0% or 20% of the cost Related medical supplies: 0% or 20% of the cost Authorization from Gateway Health SM is required for DME services $ or greater for a single item or multiple quantities of a single item. Assured Diamond SM Prosthetic devices: You pay nothing Related medical supplies: You pay nothing Authorization from Gateway Health SM is required for DME services $ or greater for a single item or multiple quantities of a single item. Renal Dialysis 0% or 20% of the cost You pay nothing Transportation 1 You pay nothing 24 one-way trips per year. Authorization and scheduling rules apply. You pay nothing 24 one-way trips per year. Authorization and scheduling rules apply. Urgent Care $0 or $30 copay You pay nothing Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0 or $30 Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing Routine eye exam (for up to 1 every three months): You pay nothing Contact lenses (for up to 1 every year): You pay nothing Eyeglasses (frames and lenses) (for up to 1 every year): You pay nothing Eyeglasses or contact lenses after cataract surgery: You pay nothing Routine eye exam (for up to 1 every three months): You pay nothing Contact lenses (for up to 1 every year): You pay nothing Eyeglasses (frames and lenses) (for up to 1 every year): You pay nothing Eyeglasses or contact lenses after cataract surgery: You pay nothing 12

15 SECTION II - SUMMARY OF BENEFITS Vision Services (continued) Preventive Care Assured Ruby SM Our plan pays up to $150 every year for contact lenses and eyeglasses (frames and lenses). Vendor frames and standard lenses or standard contact lenses at no cost per calendar year. $90 toward non-vendor frames or $150 toward specialty contact lenses per calendar year. You pay nothing Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) Assured Diamond SM Our plan pays up to $150 every year for contact lenses and eyeglasses (frames and lenses). Vendor frames and standard lenses or standard contact lenses at no cost per calendar year. $90 toward non-vendor frames or $150 toward specialty contact lenses per calendar year. You pay nothing Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) 13

16 SECTION II - SUMMARY OF BENEFITS Preventive Care (continued) Assured Ruby SM Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" preventive visit (onetime) Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. Annual physical exam: You pay nothing Assured Diamond SM Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease) Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots "Welcome to Medicare" preventive visit (onetime) Yearly "Wellness" visit Any additional preventive services approved by Medicare during the contract year will be covered. Annual physical exam: You pay nothing Hospice You pay nothing for hospice care from a Medicarecertified hospice. You may have to pay part of the cost for drugs and respite care. You pay nothing for hospice care from a Medicarecertified hospice. You may have to pay part of the cost for drugs and respite care. 14

17 SECTION II - SUMMARY OF BENEFITS INPATIENT CARE Inpatient Hospital Care 1 Inpatient Mental Health Care Skilled Nursing Facility (SNF) 1 Assured Ruby SM Our plan covers an unlimited number of days for an inpatient hospital stay. $0 or $225 copay per day for days 1 through 6 You pay nothing per day for days 7 through 90 You pay nothing per day for days 91 and beyond For inpatient mental health care, see the "Mental Health Care" section of this booklet. Our plan covers up to 100 days in a SNF. You pay nothing per day for days 1 through 20 $0 or $ copay per day for days 21 through 100 Assured Diamond SM Our plan covers an unlimited number of days for an inpatient hospital stay. You pay nothing 10% of the cost per day for days 91 and beyond For inpatient mental health care, see the "Mental Health Care" section of this booklet. Our plan covers up to 100 days in a SNF. You pay nothing PRESCRIPTION DRUG BENEFITS How much do I pay? For Part B drugs such as chemotherapy drugs 1 : 0% or 20% of the cost Other Part B drugs 1 : 0% or 20% of the cost Pre-authorization is required by Gateway Health SM for certain prescription drugs. For Part B drugs such as chemotherapy drugs 1 : You pay nothing Other Part B drugs 1 : You pay nothing Pre-authorization is required by Gateway Health SM for certain prescription drugs. 15

18 SECTION II - SUMMARY OF BENEFITS Initial Coverage Assured Ruby SM Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: $0 copay; or $1.20 copay; or $2.65 copay For all other drugs, either: $0 copay; or $3.60 copay; or $6.60 copay You may get your drugs at network retail pharmacies. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. Assured Diamond SM Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: $0 copay; or $1.20 copay; or $2.65 copay For all other drugs, either: $0 copay; or $3.60 copay; or $6.60 copay You may get your drugs at network retail pharmacies. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay nothing for all drugs. Or, you may pay the greater of $2.65 for generic or a preferred multi-source drug, and $6.60 for all other drugs, or 5%. You pay nothing. 16

19 Additional Information About Assured Ruby SM and Gateway Medicare Assured Diamond SM Bathroom Safety Products Dental Services Assured Ruby SM Bathroom Safety benefit provides up to $ per calendar year for bathroom safety products such as bath/shower chairs, bathtub rails and bathtub stools or bench. In addition to those items described in Section II: 1 dental bite-wing x-ray per side, every 6 months. 1 panoramic x-ray every 5 years. Assured Diamond SM Bathroom Safety benefit provides up to $ per calendar year for bathroom safety products such as bath/shower chairs, bathtub rails and bathtub stools or bench. In addition to those items described in Section II: 1 dental bite-wing x-ray per side, every 6 months. 1 panoramic x-ray every 5 years. Comprehensive dental coverage is $500 every 2 years, limited to fillings, simple extractions and denture repair. Dental services, such as root canals, crowns, surgical extractions & gum treatments, not covered. Dentures, up to 1 complete set every 5 years. Partial dentures are not a covered benefit. Health Club Membership / Fitness Classes Provides membership at participating network fitness centers at no cost, including: o Basic fitness membership to one Plan approved fitness facility per month o Orientation to the fitness center and instructions about how to use equipment and services o Pak per year for those members with limited access to a network fitness center. Provides membership at participating network fitness centers at no cost, including: o Basic fitness membership to one Plan approved fitness facility per month o Orientation to the fitness center and instructions about how to use equipment and services o Pak per year for those members with limited access to a network fitness center. 17

20 SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H5932, PLANS 001 AND 009 The benefits described below are covered by Medicaid. The benefits described in the Covered Medical and Hospital s section of the Summary of s are covered by Medicare. For each benefit listed below, you can see what the Pennsylvania Department of Public Welfare (DPW) Medical Assistance Program (Medicaid) covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. The services listed below are available only to those SNP members eligible under Title XIX Medicaid for medical services. Medically-necessary, Medicaid-covered services must be obtained through the Pennsylvania Department of Public Welfare, fee-forservice Medicaid Program Assured Ruby and Assured Diamond cannot provide Medicaid-covered services for our Medicare members. Medicaid is usually the payer of last resort this means, as a member of our plan, you must access benefits that are covered by both programs through Medicare ( Assured Ruby SM or Assured Diamond SM ) first and Medicaid (DPW) last. As applicable, for services that are reimbursed by both Medicare and Medicaid for dual eligible members, providers will bill Assured Ruby or Assured Diamond for the Medicare portion of the bill. Providers may not seek additional payments for the Medicare Cost Sharing Obligations. Providers will bill the Pennsylvania Department of Public Welfare for the Medicaid portion of the bill. If you have questions about how your benefits are coordinated between programs, contact - Medicare - Assured Ruby SM and Assured Diamond SM Member Services at 1-(800) , 8am - 8pm, 7 days a week. TTY users call 711. Medicaid , TTY users call

21 S SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H5932, PLANS 001 AND 009 Medicaid State Plan Limits Assured Ruby SM *** Assured Diamond SM ** Inpatient Acute Hospital N/A Unlimited number of days for an inpatient hospital stay $0 or $225 copayment per days 1 through 6 $0 for days 7 and beyond Unlimited number of days for an inpatient hospital stay $0 coinsurance- days % of the cost per day for days 91 and beyond copayment Inpatient Rehab Hospital N/A Unlimited number of days for an inpatient hospital stay $0 or $225 copayment for days 1 through 6 $0 for days 7 and beyond Unlimited number of days for an inpatient hospital stay $0 coinsurance- days % of the cost per day for days 91 and beyond copayment Inpatient Psych 30 Days per Fiscal Year Up to 190 days in a lifetime for inpatient mental healthcare in a psychiatric hospital. The inpatient psychiatric hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. $0 or $225 copayment for days 1 through 6 $0 for days 7 through 90 Up to 190 days in a lifetime for inpatient mental healthcare in a psychiatric hospital. The inpatient psychiatric hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. $0 copayment 19

22 SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H5932, PLANS 001 AND 009 Inpatient Drug & Alcohol Medicaid State Plan Limits Assured Ruby SM *** 30 Days per Fiscal Year Unlimited number of days for inpatient stay $$0 or 225 copayment for days 1 through 6 $0 for days 7 through 90 Assured Diamond SM ** Unlimited number of days for an inpatient hospital stay $0 coinsurance- days % of the cost per day for days 91 and beyond Emergency Room N/A $0 or $65 copayment $0 copayment Outpatient Hospital Short Procedure Unit and Ambulatory Surgical Center Outpatient Hospital Clinic N/A Outpatient Hospital: $0 or $175 copayment Ambulatory surgical center: $0 or $175 copayment 18 visits per Fiscal Year* Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $0 or $30 copayment Outpatient therapy visit, physical therapy and speech and language visit: $0 or $30 copayment $0 copayment Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $0 copayment Outpatient therapy visit, physical therapy and speech and language visit: $0 copayment Outpatient Psych Clinic 5 hours psychotherapy per 30 days $0 or $30 copayment $0 copayment Psych Partial 540 hours per Fiscal Year Partial Hospitalization $0 or $55 per day copayment Partial Hospitalization $0 per day copayment 20