Summary of Benefits. Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care Plan

Transcription

1 Summary f Benefits Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Cmmnwealth Crdinated Care Plan Virginia Virginia mss.anthem.cm/ccc Member Services: (TTY 711) Mnday thrugh Friday 8 a.m. t 8 p.m. lcal time H0147_16_24595_T CMS Apprved 09/11/2015

2 H0147_16_24595_T CMS Apprved 09/11/2015 This is a summary f health services cvered by Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Cmmnwealth Crdinated Care plan, fr This is nly a summary. Please read the Member Handbk fr the full list f benefits. HealthKeepers, Inc. is a health plan that cntracts with bth Medicare and the Virginia Department f Medical Assistance Services t prvide benefits f bth prgrams t enrllees. It is fr peple with bth Medicare and Medicaid. Under Anthem HealthKeepers MMP, a Cmmnwealth Crdinated Care plan, yu can get yur Medicare and Medicaid services in ne health plan. An Anthem HealthKeepers MMP care manager 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 Anthem HealthKeepers MMP Member Services r read the Anthem HealthKeepers 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 c-payments 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 (TTY 711). The call is free. Yu can get this infrmatin fr free in ther languages. Call (TTY 711). The call is free. Puede recibir esta infrmación sin carg en trs idimas. Llame al (TTY 711). La llamada es gratuita. HealthKeepers, Inc. is an independent licensee f the Blue Crss and Blue Shield Assciatin. ANTHEM is a registered trademark f Anthem Insurance Cmpanies, Inc. The Blue Crss and Blue Shield names and symbls are registered marks f the Blue Crss and Blue Shield Assciatin. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 1

3 The fllwing chart lists frequently asked questins. Frequently Asked Questins (FAQ) Answers What is a Medicare- Medicaid Plan A Medicare- Medicaid Plan is an rganizatin made up f dctrs, hspitals, pharmacies, prviders f lng-term services, and ther prviders. It als has care managers t help yu manage all yur prviders and services. They all wrk tgether t prvide the care yu need. What is an Anthem HealthKeepers MMP care manager An Anthem HealthKeepers MMP care manager 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. What are lng-term services and supprts Lng-term services and supprts (LTSS) are a variety f services and supprts that help elderly individuals and individuals with disabilities meet their daily needs fr assistance and imprve the quality f their lives. Examples include assistance with bathing, dressing, and ther basic activities f daily life and self-care, as well as supprt fr everyday tasks such as laundry, shpping, and transprtatin. LTSS are prvided ver a lng perid f time, usually in hmes and cmmunities, but als in facility-based settings such as nursing facilities. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 2

4 Frequently Asked Questins (FAQ) Answers Will yu get the same Medicare and Medicaid benefits in Anthem HealthKeepers MMP that yu get nw Yu will get yur cvered Medicare and Medicaid benefits directly frm HealthKeepers, Inc. 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 Anthem HealthKeepers MMP, yu and yur care team will wrk tgether t develp an Individualized Care Plan t address yur health and supprt needs. During this time, yu can keep yur current prviders (including ut f netwrk prviders) fr 180 days after yu first enrll. Yu can als keep getting yur prir authrized services fr the duratin f the prir authrizatin r fr 180 days after yu first enrll, whichever is sner. If yu are in a nursing facility at the time f prgram implementatin, yu may remain in the facility as lng as yu cntinue t meet the criteria fr nursing facility care, unless yu r yur family prefers t mve t a different nursing facility r return t the cmmunity. Nursing hme criteria are established by the Virginia Department f Medical Assistance Services. When yu jin ur plan, if yu are taking any Medicare Part D prescriptin drugs that Anthem HealthKeepers MMP des nt nrmally cver, yu can get a temprary supply. We will help yu get anther drug r get an exceptin fr Anthem HealthKeepers MMP t cver yur drug, if medically necessary. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 3

5 Frequently Asked Questins (FAQ) Answers Can yu g t the same dctrs yu see nw Often that is the case. If yur prviders (including dctrs, therapists, and pharmacies) wrk with HealthKeepers, Inc. 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 Anthem HealthKeepers MMP s netwrk. If yu need urgent r emergency care r ut-f-area dialysis services, yu can use prviders utside f Anthem HealthKeepers MMP's netwrk. T find ut if yur dctrs are in the plan s netwrk, call Member Services r read Anthem HealthKeepers MMP s Prvider and Pharmacy Directry. If Anthem HealthKeepers MMP is new fr yu, yu can cntinue seeing the dctrs yu g t nw (including ut f netwrk prviders) fr 180 days after yu first enrll. If yu are transferring frm anther Virginia Cmmnwealth Crdinated Care health plan, yu can cntinue seeing the dctrs and ther prviders yu currently g t fr 30 days after yu enrll. What happens if yu need a service but n ne in Anthem HealthKeepers MMP s netwrk can prvide it Mst services will be prvided by ur netwrk prviders. If yu need a service that cannt be prvided within ur netwrk, HealthKeepers, Inc. will pay fr the cst f an ut-f-netwrk prvider. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 4

6 Frequently Asked Questins (FAQ) Answers Where is Anthem HealthKeepers MMP available The service area fr this plan includes five regins in Virginia: Nrthern: Alexandria, Arlingtn, Culpeper, Falls Church, Fauquier, Ludun, Manassas, Manassas Park, Prince William Central: Amelia, Brunswick, Carline, Charles City, Chesterfield, Clnial Heights, Cumberland, Dinwiddie, Empria, Essex, Franklin, Fredericksburg, Gchland, Greensville, Hanver, Henric, Hpewell, King and Queen, King Gerge, King William, Lancaster, Lunenburg, Middlesex, New Kent, Nrthumberland, Nttway, Petersburg, Pwhatan, Prince Edward, Prince Gerge, Richmnd (city), Richmnd (cunty), Suthamptn, Sptsylvania, Staffrd, Surry, Sussex, Westmreland Tidewater: Glucester, Isle Of Wight, James City Cunty, Mathews, Nrthamptn, Yrk, Chesapeake, Hamptn, Newprt News, Nrflk, Pqusn, Prtsmuth, Sufflk, Virginia Beach, Williamsburg Western-Charlttesville: Albemarle, Augusta, Buckingham, Charlttesville, Fluvanna, Greene, Luisa, Madisn, Nelsn, Orange, Rckingham, Stauntn, Waynesbr Suthwest-Ranke: Alleghany, Bath, Bedfrd (city), Bedfrd (cunty), Bteturt, Buena Vista, Craig, Cvingtn, Flyd, Franklin Cunty, Giles, Highland, Lexingtn, Mntgmery, Patrick, Pulaski, Ranke (city), Radfrd (city),ranke (cunty), Rckbridge, Salem, Wythe Yu must live in ne f these areas t jin the plan. D yu pay a mnthly amunt (als called a premium) under Anthem HealthKeepers MMP Yu will nt pay any mnthly premiums t HealthKeepers, Inc. fr yur health cverage. What is prir authrizatin Prir authrizatin means that yu must get apprval frm HealthKeepers, Inc. befre yu can get a specific service r drug r see an ut-f-netwrk prvider. HealthKeepers, Inc. may nt cver the service r drug if yu dn t get apprval. If yu need urgent r emergency care r utf-area dialysis services, yu dn't need t get apprval first. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 5

7 Frequently Asked Questins (FAQ) Answers What is a referral 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, HealthKeepers, Inc. may nt cver the services, and yu may be billed fr these 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. What is Extra Help Extra Help is a Medicare prgram that helps reduce yur prescriptin drug prgram csts such as c-pays. Yur prescriptin drug c-pays under Anthem HealthKeepers 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 Wh shuld yu cntact if yu have questins r need help If yu have general questins r questins abut ur plan, services, service area, billing, r member cards, please call Anthem HealthKeepers MMP Member Services: CALL Calls t this number are free. Call us Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. Yu can als reach yur care manager 24/7 by calling the number given. Member Services als has free language interpreter services available fr peple wh d nt speak English. TTY 711 Calls t this number are free. Call us Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 6

8 Frequently Asked Questins (FAQ) Answers Wh shuld yu cntact if yu have questins r need help (cntinued) If yu have questins abut yur health, please call the Nurse Advice Call line: CALL Calls t this number are free. Call us 24 hurs a day, 7 days a week. TTY 711 Calls t this number are free. Call us 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. Call the Behaviral Health Crisis Line 24 hurs a day, 7 days a week. TTY 711 Calls t this number are free. TTY users can reach the Behaviral Health Crisis Line thrugh this number 24 hurs a day, 7 days a week at 711. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 7

9 The fllwing chart is a quick verview f what services yu may need, yur csts and rules abut the benefits. Yur csts fr Limitatins, exceptins, & benefit Health need r prblem Services yu may need in - netwrk prviders infrmatin (rules abut benefits) Yu want t see a dctr Visits t treat an injury r illness $0 $0 fr each cvered PCP visit. Wellness visits, such as a physical $0 $0 c-pay fr each cvered PCP visit. Transprtatin t a dctr s ffice $0 $0 c-pay fr each rund trip t planapprved lcatins. Nn-emergency transprtatin services must be arranged ahead f time. Specialist care $0 $0 c-pay fr each cvered specialist visit. Referral frm yur PCP may be required. Care t keep yu frm getting sick, such as flu shts Welcme t Medicare preventive visit (ne time nly) $0 $0 c-pay if administered by yur primary care practitiner r prvider. $0 $0 c-pay fr each cvered primary care practitiner r prvider visit. Yu need medical tests Lab tests, such as bld wrk $0 $0 c-pay fr each cvered lab service. May require prir authrizatin. X-rays r ther pictures, such as CAT scans Screening tests, such as tests t check fr cancer $0 These services may require a prir authrizatin. $0 These services may require a referral frm yur PCP, and may require prir authrizatin. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 8

10 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 r brand name drugs $0-$7.40 c-pay fr a 31-day supply, depending n the tier: Tier 1 - $0 c-pay; preferred Part D (Medicare) tier Tier 2 - $ c-pay; preferred and nnpreferred Part D (Medicare) tier Tier 3 - $0 c-pay; Medicaid (state) cvered prescriptin drugs Tier 4 - $0 c-pay; Medicaid (state) cvered ver-the-cunter (OTC) drugs with a prescriptin frm yur prvider C-pays fr prescriptin drugs may vary based n the level f Extra Help yu receive. Please cntact the plan fr mre details. There may be limitatins n the types f drugs cvered. Please see Anthem HealthKeepers MMP s List f Cvered Drugs (Drug List) fr mre infrmatin. Yu are als cvered fr a 93-day extended supply f prescriptin drugs frm retail r ur mail-rder pharmacy. The c-payment fr the 93-day extended supply is the same c-pay as the 31-day supply. Over-the-cunter (OTC) drugs $0 c-pay with a prescriptin frm yur prvider Anthem HealthKeepers MMP cvers sme OTC drugs when they are written as prescriptins by yur prvider. There may be limitatins n the types f drugs cvered. Please see Anthem HealthKeepers MMP s List f Cvered Drugs (Drug List) fr mre infrmatin. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 9

11 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) 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. Yu need therapy after a Occupatinal, physical, r speech $0 c-pay $0 c-pay fr cvered ccupatinal therapy strke r accident therapy (OT) visits Additinal acute and nn-acute OT services Cvered Physical Therapy (PT) and/r Speech and Language Pathlgy (SLP) visits Additinal acute and nn-acute PT and SLP services These services may require a referral frm yur primary care prvider, and may require prir authrizatin. Yu need emergency care Emergency rm services $0 c-pay $0 c-pay fr cvered emergency rm visits. N prir authrizatin required fr emergency services. Out-f-netwrk emergency 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 $0 c-pay fr cvered, medically necessary ambulance services. May require prir authrizatin fr nn-emergent ambulance services. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 10

12 Health need r prblem Yu need emergency care (cntinued) Services yu may need Yur csts fr in - netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Urgent care $0 c-pay $0 c-pay fr cvered urgently needed care visits. N prir authrizatin 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 $0 c-pay fr cvered hspital stays. N limit t the number f days cvered by the plan fr each hspital stay. Except in an emergency, yur dctr must tell the plan that yu are ging t be admitted t the hspital. Dctr r surgen care $0 c-pay $0 c-pay fr cvered hspital stays N limit t the number f days cvered by the plan fr each hspital stay. Except in an emergency, yur dctr must tell the plan that yu are ging t be admitted t the hspital. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 11

13 Health need r prblem Yu need help getting better r have special health needs Services yu may need Yur csts fr in - netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Rehabilitatin services $0 c-pay $0 c-pay fr: Cvered inpatient rehabilitatin services; n limit t number f days cvered fr each hspital stay Cvered and additinal PT, OT and SLP services Cvered and supplemental cardiac rehabilitatin services, including intensive services Cvered and supplementary pulmnary rehabilitatin services N limit n the number f supplemental cardiac r pulmnary rehabilitatin services. May require prir authrizatin. Medical equipment fr hme care $0 c-pay $0 c-pay fr cvered durable medical equipment May require prir authrizatin. Skilled nursing care $0 c-pay May require prir authrizatin. Yu need eye care Eye exams $0 c-pay $0 c-pay fr: Cvered diagnsis and treatment fr diseases and cnditins f the eye. One (1) eye exam a year. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 12

14 Health need r prblem Services yu may need Yur csts fr in - netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Glasses r cntact lenses $0 c-pay $0 c-pay fr: One pair f cvered eyeglasses (lenses and frames) r cntact lenses after cataract surgery Up t ne pair(s) f eyeglasses (lenses and frames) r cntact lenses every year; $100 plan cverage limit fr eyewear r cntact lenses every year. Yu need dental care Dental check-ups $0 c-pay $0 c-pay r cvered dental benefits Yu need hearing/auditry services $0 c-pay fr the fllwing preventive dental benefits: One ral exams every six mnths Up t tw cleanings every year Up t ne dental X-ray every year Hearing screenings $0 c-pay $0 c-pay fr: Cvered diagnstic hearing exams Up t ne rutine hearing exam every year May require prir authrizatin. Hearing aids $0 c-pay $0 c-pay fr up t ne hearing aid every year Unlimited visits fr hearing aid fitting $1,000 plan cverage limit fr hearing aids every year May require prir authrizatin. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 13

15 Health need r prblem Yu have a chrnic cnditin, such as diabetes r heart disease Services yu may need Services t help manage yur disease Yur csts fr in - netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) $0 c-pay $0 c-pay fr cvered diabetes selfmanagement training May require prir authrizatin. Diabetes supplies and services $0 c-pay $0 c-pay fr cvered: Diabetes mnitring supplies Therapeutic shes r inserts Diabetic supplies and services are limited t specific manufacturers, prducts and/r brands. Cntact the plan fr a list f cvered supplies. Yu have a mental health cnditin Mental r behaviral health services May require prir authrizatin. $0 c-pay $0 c-pay fr: Each cvered individual therapy visit Each cvered grup therapy visit Each cvered individual therapy visit with a psychiatrist Each cvered grup therapy visit with a psychiatrist Cvered partial hspitalizatin prgram services May require prir authrizatin. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 14

16 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 $0 c-pay fr: Each cvered individual substance abuse utpatient treatment visit Each cvered grup substance abuse utpatient treatment visit Yu need lng-term mental health services Yu need durable medical equipment (DME) Inpatient care fr peple wh need mental health care May require prir authrizatin. $0 c-pay $0 c-pay fr inpatient days in a psychiatric hspital except in an emergency, yur dctr must tell the plan that yu are ging t be admitted t the hspital Wheelchairs $0 c-pay May require prir authrizatin. Canes $0 c-pay May require prir authrizatin. Crutches $0 c-pay May require prir authrizatin. Walkers $0 c-pay May require prir authrizatin. Oxygen $0 c-pay May require prir authrizatin. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 15

17 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 Members may receive hme meal delivery after an inpatient stay in a facility fr up t 7 days and 14 meals. Persnal care assistant (Yu may be able t emply yur wn assistant. Call Member Services fr mre infrmatin.) $0 c-pay* Yu may receive persnal care assistant services if medically necessary and yu are in the state waiver prgram. Services are nly available t members n the EDCD waiver. State eligibility requirements may apply. Hme health care services $0 c-pay Yu may receive hme health services if medically necessary. Adult day services r ther supprt services Persnal emergency respnse system, r PERS (with and withut medicatin mnitring) $0 c-pay* Services are nly available t members n the EDCD waiver. State eligibility requirements may apply. $0 c-pay Services are nly available t members n the EDCD waiver. State eligibility requirements may apply. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 16

18 Health need r prblem Yu need help mving frm a facility back int yur hme and cmmunity Services yu may need Services may include security depsits fr rent r utilities, essential husehld furniture and appliances, services necessary fr yur health and ther reasnable expenses incurred as part f yur mve. Yur csts fr in - netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) $0 cpay These services are: Available t members transitining frm an institutin r licensed/certified prvider-perated living arrangement, t a living arrangement in a private residence where the member is directly respnsible fr his r her wn living expenses Cvered fr ne transitin per member and must be expended within nine mnths frm the date f authrizatin Limited t $5,000 per lifetime f the member Prir authrizatin is required. Please call Member Services fr mre infrmatin. Yu need a place t live with peple available t help yu Nursing facility care $0 c-pay* Services are available t members meeting specific level f care criteria. Yur caregiver needs sme time ff Respite care $0 c-pay* Yu may receive respite care up t 480 hurs per year if yu are enrlled in the state waiver prgram. Services are nly available t members n the EDCD waiver. State eligibility requirements may apply. Yearly maximum cap applies. * Yu must cntribute tward the cst f this service when yur incme exceeds an allwable amunt. This cntributin, knwn as the patient pay amunt, is required if yu live in a nursing facility r receive services thrugh the Elderly r Disabled with Cnsumer Directin (EDCD) Waiver. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 17

19 Other services that Anthem HealthKeepers 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 Anthem HealthKeepers MMP Tbacc cessatin cunseling fr pregnant wmen Respiratry care services Family planning services Case management (lng-term care) Case management Cmmunity mental health rehabilitatin services Outpatient mental health services Outpatient substance abuse treatment Pregnancy services (residential and day treatments) High-risk prenatal services HIV testing and treatment cunseling Federally Qualified Health Center access Temprary detentin/emergency custdy/curt-rdered services Additinal skilled nursing facility days Transprtatin fr nn-medical reasns Pdiatry services Pest cntrl Yur csts fr in-netwrk prviders $0 c-pay; cntact us fr mre details $0 c-pay; cntact us fr mre details $0 c-pay; cntact us fr mre details $0 c-pay; cntact us fr mre details $0 c-pay; cntact us fr mre details $0 c-pay; cntact us fr mre details $0 c-pay; cntact us fr mre details $0 c-pay; cntact us fr mre details $0 c-pay; cntact us fr mre details $0 c-pay; cntact us fr mre details $0 c-pay; cntact us fr mre details $0 c-pay; cntact us fr mre details $0 c-pay; cntact us fr mre details $0 c-pay; cntact us fr mre details $0 c-pay; cntact us fr mre details One (1) rutine ft care visit is cvered every three (3) mnths. Prir authrizatin and referral may be required. One treatment every three (3) mnth t eliminate rdents, raches and ther unsafe pests frm the hme in rder t prvide a healthier cmmunity-based envirnment fr members frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 18

20 Other services cvered by Anthem HealthKeepers MMP Acupuncture Membership in Health Club/Fitness Classes Yur csts fr in-netwrk prviders $0 c-pay Benefit is limited t six (6) treatments every year. Prir authrizatin and referral may be required. Cntact Member Services fr mre details. $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. Benefits cvered utside f Anthem HealthKeepers MMP This is nt a cmplete list. Call Member Services t find ut abut ther services nt cvered by Anthem HealthKeepers MMP but available thrugh Medicare r Cmmnwealth Crdinated Care. Other services cvered by Medicare r Cmmnwealth Crdinated Care Targeted Case Management Services Certain Dental Services (unless therwise nted) Case Management Services fr Participants f Auxiliary Grants Yur csts Includes bth referral/transitin management and clinical services such as mnitring, self-management supprt, medicatin review and adjustment fr enrllees with substance use disrders r develpmental disabilities. Anthem HealthKeepers MMP is respnsible fr sme medically necessary prcedures. Call Member Services fr mre infrmatin. An incme supplement fr individuals wh receive Supplemental Security Incme (SSI) and certain ther aged, blind, r disabled individuals wh reside in a licensed assisted living facility (ALF) r an apprved adult fster care (AFC) hme. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 19

21 Services that Anthem HealthKeepers MMP, Medicare, and Medicaid d nt cver This is nt a cmplete list. Call Member Services t find ut abut ther excluded services. Services nt cvered by Anthem HealthKeepers MMP, Medicare, r Cmmnwealth Crdinated Care Services cnsidered nt reasnable and necessary, accrding t the standards f Medicare and Medicaid, unless these services are listed by ur plan as cvered services. Experimental medical and surgical treatments, items, and drugs Surgical treatment fr mrbid besity A private rm in a hspital Private duty nurses Persnal items in yur rm at a hspital r a nursing facility Full-time nursing care in yur hme Hmemaker services Fees charged by yur immediate relatives r members f yur husehld Elective r vluntary enhancement prcedures r services Csmetic surgery r ther csmetic wrk Chirpractic care Additinal Infrmatin Unless cvered by Medicare r under a Medicare-apprved clinical research study r by ur plan. See yur Member Handbk fr mre infrmatin n clinical research studies. Experimental treatment and items are thse that are nt generally accepted by the medical cmmunity. Except when it is medically needed and Medicare pays fr it. Except when it is medically needed Such as a telephne r a televisin. Including basic husehld assistance, light cleaning r making meals. Including weight lss, hair grwth, sexual perfrmance, athletic perfrmance, csmetic purpses, anti-aging and mental perfrmance, except when medically needed. 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. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 20

22 Services nt cvered by Anthem HealthKeepers MMP, Medicare, r Cmmnwealth Crdinated Care Orthpedic shes Supprtive devices fr the feet Radial kerattmy, LASIK surgery, visin therapy, and ther lw visin aids Reversal f sterilizatin prcedures and nn-prescriptin cntraceptive supplies Medicatins fr erectile dysfunctin Naturpath services Services prvided t veterans in Veterans Affairs (VA) facilities Additinal Infrmatin Unless the shes are part f a leg brace and are included in the cst f the brace, r the shes are fr a persn with diabetic ft disease. Except fr rthpedic r therapeutic shes fr peple with diabetic ft disease. The plan will pay fr glasses after cataract surgery. The use f natural r alternative treatments. When a veteran gets emergency services at a VA hspital and the VA cstsharing is mre than the cst-sharing under ur plan, we will reimburse the veteran fr the difference. Members are still respnsible fr their cst-sharing amunts. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 21

23 Yur rights as a member f the plan As a member f Anthem HealthKeepers 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 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 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. Anthem HealthKeepers 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 make decisins abut yur care, including refusing treatment. This includes the right t: frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 22

24 Yu have the right t seek emergency and urgent care Yu have the right t make cmplaints abut yur when yu need it. This means yu have the right t: cvered services r care. This includes the right t: 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. Fr mre infrmatin abut yur rights, yu can read the Anthem HealthKeepers MMP Member Handbk. If yu have questins, yu can als call Anthem HealthKeepers MMP Member Services. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 23

25 If yu have a cmplaint r think we shuld cver smething we denied If yu have a cmplaint r think Anthem HealthKeepers MMP shuld cver smething we denied, call Anthem HealthKeepers MMP at (TTY 711). Yu are able t appeal ur decisin. Fr questins abut cmplaints and appeals, yu can read Chapter 9 f the Anthem HealthKeepers MMP Member Handbk. Yu can als call Anthem HealthKeepers MMP Member Services. Yu must file yur appeal within 60 days f the denial ntice. Call Member Services t file an appeal by phne r submit yur appeal in writing: By mail t: By fax t: Cmplaints, Appeals and Grievances HealthKeepers, Inc. P.O. Bx Virginia Beach, VA If yu have a cmplaint, als called a grievance, yu can call Member Services and tell us. Call (TTY 711). Or yu can send it t us in writing: By mail t: By fax t: Cmplaints, Appeals and Grievances HealthKeepers, Inc. P.O. Bx Virginia Beach, VA frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 24

26 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 Anthem HealthKeepers 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. frm 8 a.m. t 8 p.m. lcal time. The call is free. Fr mre infrmatin, visit mss.anthem.cm/ccc. 25

27 Have questins Call us tll free at (TTY 711) Mnday thrugh Friday frm 8 a.m. t 8 p.m. lcal time. Or visit mss.anthem.cm/ccc. 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, cpays, and restrictins may apply. Fr mre infrmatin, call Anthem HealthKeepers MMP Member Services r read the Anthem HealthKeepers MMP Member Handbk. Prvider Services 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 cpayments may change n January 1 f each year. HealthKeepers, Inc. is a health plan that cntracts with bth Medicare and the Virginia Department f Medical Assistance Services t prvide benefits f bth prgrams t enrllees. HealthKeepers, Inc. is an independent licensee f the Blue Crss and Blue Shield Assciatin. ANTHEM is a registered trademark f Anthem Insurance Cmpanies, Inc. The Blue Crss and Blue Shield names and symbls are registered marks f the Blue Crss and Blue Shield Assciatin. H0147_16_24595_T CMS Apprved 09/11/2015 AVADMKT SB