L.A. Care s Medicare Advantage Special Needs Plan

Transcription

1 L.A. Care s Medicare Advantage Special Needs Plan Summary of Benefits 2008 for people with Medicare and Medi-Cal

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3 Thank you for your interest in L.A. Care Health Plan. Our plan is offered by L.A. CARE HEALTH PLAN, a Medicare Advantage Health Maintenance Organization (HMO) Special Needs Plan. This plan is designed for people who meet specific enrollment criteria. This includes anyone who receives medical assistance from the state and Medicare. All cost sharing in this summary of benefits is based on your level of Medicaid eligibility. Please call L.A. Care to find out if you are eligible to join. Our number is listed at the end of this introduction. This Summary of Benefits tells you some features of our plan. It doesn t list every service we cover or list every limitation or exclusion. To get a complete list of our benefits, please call L.A. Care and ask for the Evidence of Coverage.

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5 Section 1 Introduction For assistance call L.A. Care Health Plan at LA-CARE ( ) TTY

6 You have choices in your health care As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (fee-for-service) Medicare Plan. Another option is a Medicare health plan, like L.A. Care. You may have other options too. You make the choice. No matter what you decide, you are still in the Medicare Program. You may join or leave a plan only at certain times. Please call L.A. Care at the telephone number listed at the end of this introduction or MEDICARE ( ) for more information. TTY users should call You can call this number 24 hours a day, 7 days a week. How can I compare my options? You can compare L.A. Care and the Original Medicare Plan using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what our plan covers and what the Original Medicare Plan covers. Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, which may change from year to year. Where is L.A. Care available? The service area for this plan includes: Los Angeles County, CA. You must live in one of these places to join the plan. Who is eligible to join L.A. Care? You can join L.A. Care if you are enrolled in Medicare Part B and entitled to Medicare Part A and live in the service area. You must also be enrolled in the Medi-Cal program, but not have Medi-Cal share-of-cost, or be in a Medi-Cal Long-Term Care aid code to join this plan. Please call L.A. Care Health Plan to see if you are eligible to join. 4 L.A. Care s Medicare Advantage Special Needs Plan for people with Medicare and Medi-Cal

7 2008 Medicare Advantage Summary of Benefits Can I choose my doctors? L.A. Care has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time. You can ask for a current Provider Directory for an up-to-date list or visit us at Our customer service number is listed at the end of this introduction. What happens if I go to a doctor who s not in your network? If you choose to go to a doctor outside of our network, you must pay for these services yourself. Neither L.A. Care Health Plan nor the Original Medicare Plan will pay for these services. Does my plan cover Medicare Part B or Part D drugs? L.A. Care does cover both Medicare Part B prescription drugs and Medicare Part D prescription drugs. For assistance call LA-CARE ( ). TTY a.m. to 5 p.m. Where can I get my prescriptions if I join this plan? L.A. Care has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. The pharmacies in our network can change at any time. You can ask for a current Pharmacy Network List or visit us at Our customer service number is listed at the end of this introduction. L.A. Care has a list of preferred pharmacies. At these pharmacies, you may get your drugs at a lower copay or co-insurance. You may go to a non-preferred pharmacy, but you may have to pay more for your prescription drugs. For assistance call L.A. Care Health Plan at LA-CARE ( ) TTY

8 What is a Prescription Drug Formulary? L.A. Care uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members ability to fill their prescriptions, we will notify the affected enrollees before the change is made. We will send a formulary to you and you can see our complete formulary on our Web site at If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician s help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy. How can I get extra help with Prescription Drug Plan costs? If you qualify for extra help with your Medicare prescription drug plan costs, your premium and costs at the pharmacy will be lower. When you join L.A. Care, Medicare will tell us how much extra help you are getting. Then we will let you know the amount you will pay. If you are not getting this extra help you can see if you qualify by calling MEDICARE ( ). TTY users should call You can call this number 24 hours a day, 7 days a week. Please call L.A. Care Health Plan for more information about this plan. 6 L.A. Care s Medicare Advantage Special Needs Plan for people with Medicare and Medi-Cal

9 2008 Medicare Advantage Summary of Benefits What are my protections in this Plan? All Medicare Advantage Plans agree to stay in the program for a full year at a time. Each year, the plans decide whether to continue for another year. Even if a Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area. As a member of L.A. Care, you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. What is a Medication Therapy Management (MTM) Program? A Medication Therapy Management (MTM) Program is a free service we may offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Contact L.A. Care for more details. For assistance call L.A. Care Health Plan at LA-CARE ( ) TTY

10 Please call L.A. Care Health Plan for more information about this plan. Visit us at or, call us: Current members should call for questions related to the Medicare Advantage program. (TTY ) Prospective members should call for questions related to the Medicare Advantage program. (TTY ) Current and prospective members should call for questions related to the Medicare Part D Prescription Drug program. (TTY ) For more information about Medicare, please call Medicare at MEDICARE ( ). TTY users should call You can call 24 hours a day, 7 days a week. Or, visit on the Web. If you have special needs, this document may be available in other formats. 8 L.A. Care s Medicare Advantage Special Needs Plan for people with Medicare and Medi-Cal

11 Section 2 Summary of Benefits For assistance call L.A. Care Health Plan at LA-CARE ( ) TTY

12 MEDICAL BENEFITs Important Information Premium and Other Important Information Doctor and Hospital Choice For more information, see Emergency Care and Urgently Needed Care Inpatient Care Inpatient Hospital Care includes substance abuse and rehabilitation services original medicare $96.40 monthly Medicare Part B Premium $135 yearly Medicare Part B deductible If a doctor or supplier does not accept assignment, their costs are often higher, which means that you pay more. You may go to any doctor, specialist or hospital that accepts Medicare. For each benefit period: Days 1 60: $1,024 deductible Days 61 90: $256 per day Days : $512 per lifetime reserve day Please call MEDICARE ( ) for information about lifetime reserve days. Lifetime reserve days can only be used once. A benefit period begins the day you go into a hospital or a skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. l.a. care s medicare advantage SPECIAL NEEDS plan General: All cost sharing in this summary of benefits is based on your level of Medi-Cal eligibility. $19.80 plan premium in addition to your $96.40 monthly Medicare Part B premium. Because you qualify for extra help from Medi-Cal, the extra help pays the $19.80 on your behalf. $0 yearly deductible. * Contact plan for services that apply. Out-of-Network: Unless otherwise noted, out-of-network services not covered. You must go to network doctors, specialists, and hospitals. Referral required for network hospitals and specialists (for certain benefits). $0 yearly deductible For Medicare-covered hospital stays $0 or: Days 1-60: $0 copay per day* Days 61-90: $0 copay per day* Plan covers 60 lifetime reserve days. Cost per lifetime reserve day, $0 or: Days 1-60: $0 copay per day* Plan covers 90 days each benefit period. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. 10 L.A. Care s Medicare Advantage Special Needs Plan for people with Medicare and Medi-Cal

13 2008 Medicare Advantage Summary of Benefits MEDICAL BENEFITs Inpatient Mental Health Care Skilled Nursing Facility in a Medicare-certified skilled nursing facility Home Health Care includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc. original medicare Same deductible and copay as inpatient hospital care (see Inpatient Hospital Care on previous page). 190-day limit in a psychiatric hospital. For each benefit period after at least a 3-day covered hospital stay: Days 1 20: $0 per day Days : $128 per day 100 days for each benefit period. A benefit period begins the day you go to a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. l.a. care s medicare advantage SPECIAL NEEDS plan $0 yearly deductible For Medicare-covered hospital stays $0 or: Days 1-60: $0 copay per day* Days 61-90: $0 copay per day* Plan covers 60 lifetime reserve days. Cost per lifetime reserve day, $0 or: Days 1-60: $0 copay per day* You get up to 190 days in a psychiatric hospital in a lifetime. Except in an emergency, your doctor must tell the Plan that you are going to be admitted to the hospital. General: Prior authorization required. For Medicare-covered SNF stays, $0 or: Days 1-20: $0 copay per day* Days : $0 copay per day* 100 days covered for each benefit period. 3-day prior hospital stay is required. $0 copay General: Authorization rules may apply. $0 copay for Medicare-covered home health visits. For assistance call L.A. Care Health Plan at LA-CARE ( ) TTY

14 MEDICAL BENEFITs Hospice original medicare You pay part of the cost for outpatient drugs and inpatient respite care. You must get care from a Medicarecertified hospice. l.a. care s medicare advantage SPECIAL NEEDS plan You must get care from a Medicare-certified hospice. Outpatient Care Doctor Office Visits Chiropractic Services Podiatry Services Outpatient Mental Health Care Outpatient Substance Abuse Care 20% coinsurance General: Authorization rules may apply. 0% of the cost for each primary care doctor visit for Medicare-covered benefits.* 0% of the cost for each specialist visit for Medicare-covered benefits.* 20% coinsurance Routine care not covered. 20% coinsurance for manual manipulation of the spine to correct subluxation if you get it from a chiropractor or other qualified provider. 20% coinsurance Routine care not covered. 20% coinsurance for medically necessary foot care, including care for medical conditions affecting the lower limbs. 50% coinsurance for most outpatient mental health services. 0% of the cost for Medicare-covered visits.* 0% of the cost for each routine visit. Medicare-covered chiropractic visits are for manual manipulation of the spine to correct a displacement or misalignment of a joint or body part. 0% of the cost for each Medicare-covered visit.* Medicare-covered podiatry benefits are for medically-necessary foot care. General: Authorization rules may apply. 0% of the cost for each Medicare-covered individual or group therapy visit.* 20% coinsurance General: Authorization rules may apply. 0% of the cost for Medicare-covered individual or group visits.* 12 L.A. Care s Medicare Advantage Special Needs Plan for people with Medicare and Medi-Cal

15 2008 Medicare Advantage Summary of Benefits MEDICAL BENEFITs Outpatient Services/ Surgery Ambulance Services medically necessary ambulance services Emergency Care You may go to any emergency room if you reasonably believe you need emergency care. Urgently Needed Care This is NOT emergency care and, in most cases, is out of the service area. Outpatient Rehabilitation Services Occupational Therapy, Physical Therapy, Speech and Language Therapy original medicare 20% coinsurance for the doctor 20% of outpatient facility l.a. care s medicare advantage SPECIAL NEEDS plan 0% of the cost for each Medicare-covered ambulatory surgical center visit.* 0% of the cost for each Medicare-covered outpatient hospital facility visit.* 20% coinsurance General: Authorization rules may apply. 0% of the cost for Medicare-covered ambulance benefits.* 20% coinsurance for the doctor 20% of facility charge, or a set copay per emergency room visit You don t have to pay the emergency room copay if you are admitted to the hospital for the same condition within 3 days of the emergency room visit. NOT covered outside the U.S. except under limited circumstances. 20% coinsurance, or a set copay NOT covered outside the U.S. except under limited circumstances. 0% of the cost (up to $50) for Medicarecovered emergency room visits.* Out-of-Network: Not covered outside the U.S. except under limited circumstances. Contact the plan for more details. In and Out-of-Network: If you are admitted to the hospital within 3-day(s) for the same condition, you pay $0 for the emergency room visit. General: 0% of the cost for Medicare-covered urgently needed care visits.* 20% coinsurance General: Authorization rules may apply. 0% of the cost for Medicare-covered occupational therapy visits.* 0% of the cost for Medicare-covered physical and/or speech/language therapy visits.* For assistance call L.A. Care Health Plan at LA-CARE ( ) TTY

16 MEDICAL BENEFITs original medicare l.a. care s medicare advantage SPECIAL NEEDS plan Outpatient Medical Services and Supplies Durable Medical Equipment includes wheelchairs, oxygen, etc. Prosthetic Devices includes braces, artificial limbs and eyes, etc. Diabetes Self- Monitoring Training, Nutrition Therapy, and Supplies includes coverage for glucose monitors, test strips, lancets, screening tests, and self-management training Diagnostic Tests, X-Rays, and Lab Services 20% coinsurance General: Authorization rules may apply. 0% of the cost for Medicare-covered items.* 20% coinsurance General: Authorization rules may apply. 0% of the cost for Medicare-covered items.* 20% coinsurance 0% of the cost for diabetes self-monitoring training*. 0% of the cost for nutritional therapy for diabetes.* 0% of the cost for diabetes supplies.* 20% coinsurance for diagnostic tests and x-rays. $0 copay for Medicare-covered lab services. Lab services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most routine screening tests, like checking your cholesterol. 0% of the cost for Medicare-covered lab services.* 0% of the cost for Medicare-covered diagnostic procedures and tests.* 0% of the cost for Medicare-covered X-rays.* 0% of the cost for Medicare-covered diagnostic radiology procedures.* 0% of the cost for Medicare-covered therapeutic radiology procedures.* 14 L.A. Care s Medicare Advantage Special Needs Plan for people with Medicare and Medi-Cal

17 2008 Medicare Advantage Summary of Benefits MEDICAL BENEFITs original medicare l.a. care s medicare advantage SPECIAL NEEDS plan Preventive Services Bone Mass Measurements for people with Medicare who are at risk Colorectal Screening Exams for people with Medicare age 50 and older Immunizations Flu vaccine, Hepatitis B vaccine for people with Medicare who are at risk, pneumonia vaccine Mammograms (Annual Screening) for women with Medicare age 40 and older Pap Smears and Pelvic Exams for women with Medicare Prostate Cancer Screening Exams for men with Medicare age 50 and older ESRD 20% coinsurance Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions. 20% coinsurance Covered when you are high risk or when you are age 50 or older. $0 copay for flu and pneumonia vaccines 20% coinsurance for Hepatitis B vaccine You may only need the pneumonia vaccine once in your lifetime. Call your doctor for more information. 20% coinsurance No referral needed Covered one a year for all women with Medicare age 40 and older. One baseline mammogram covered for women with Medicare between age 35 and 39. $0 copay for Pap smears Covered once every two years. Covered one a year for women with Medicare at high risk. 20% coinsurance for pelvic exams. 20% coinsurance for the digital rectal exam. $0 for the PSA test; 20% coinsurance for other related services. Covered once a year for all men with Medicare over age 50. 0% of the cost for Medicare-covered bone mass measurement.* 0% of the cost for Medicare-covered colorectal screenings.* $0 copay for flu and pneumonia vaccines. No referral needed for flu and pneumonia vaccines. 0% of the cost for Hepatitis B vaccine.* 0% of the cost for Medicare-covered screening mammograms.* 0% of the cost for Medicare-covered pap smears and pelvic exams.* 0% of the cost for Medicare-covered prostate cancer screening.* 20% coinsurance for dialysis 0% of the cost for in and out-of-area dialysis.* 0% of the cost for nutritional therapy for renal disease.* For assistance call L.A. Care Health Plan at LA-CARE ( ) TTY

18 MEDICAL BENEFITs Preventive Services (cont d) original medicare l.a. care s medicare advantage SPECIAL NEEDS plan Prescription Drugs Most drugs not covered. (You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan.) Drugs Covered under Medicare Part B Drugs Covered under Medicare Part D In-Network General: 0% of the cost for Part B-covered drugs (not including Part B-covered chemotherapy drugs).* 0% of the cost for Part B-covered chemotherapy drugs. * General: This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at on the Web. The plan offers national in-network prescription coverage. This means that you will pay the same amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan s service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by both you and the plan. The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from L.A. Care for certain drugs. If the actual cost of a drug is less than the normal copay amount for that drug, you will pay the actual cost, not the higher copay amount. $0 deductible on all drugs except generic drugs. You pay $0 copay for generic drugs until you reach the deductible. 16 L.A. Care s Medicare Advantage Special Needs Plan for people with Medicare and Medi-Cal

19 2008 Medicare Advantage Summary of Benefits MEDICAL BENEFITs Initial Coverage Retail Pharmacy Long-Term Care Pharmacy Mail Order original medicare l.a. care s medicare advantage SPECIAL NEEDS plan After you pay your yearly deductible, you pay the following until total yearly drug costs reach $2,270. Tier 1 Preferred Generic $0 copay for a three-month (90-day) supply of drugs from a preferred pharmacy $0 copay for a one-month (30-day) supply of drugs from a non-preferred pharmacy Tier 2 Other $3.15 for a three-month (90-day) supply of multi-source drugs, or $9.30 for a three-month (90-day) supply of single-source drugs from a preferred pharmacy $1.05 for a one-month (30-day) supply of multi-source drugs, or $3.10 for a one-month (30-day) supply of singlesource drugs from a non-preferred pharmacy Tier 1 Preferred Generic $0 copay for a one-month (30-day) supply of drugs Tier 2 - Other $1.05 for a one-month (30-day) supply of multi-source drugs, or $3.10 for a one-month (30-day) supply of singlesource drugs Tier 1 Preferred Generic $0 copay for a three-month (90-day) supply of drugs Tier 2 - Other $3.15 for a three-month (90-day) supply of multi-source drugs, or $9.30 for a three-month (90-day) supply of single-source drugs For assistance call L.A. Care Health Plan at LA-CARE ( ) TTY

20 MEDICAL BENEFITs Coverage Gap Castrophic Coverage Out-of-Network Out-of-Network Initial Coverage Out-of-Network Pharmacy original medicare l.a. care s medicare advantage SPECIAL NEEDS plan After your total yearly drug costs reach $2,270, and until your yearly out-of-pocket drug costs reach $4,050 you pay: Tier 1 Preferred Generic $3.15 copay for a three-month (90-day) supply of drugs $1.05 copay for a one-month (30-day) supply of drugs Tier 2 Other $3.15 for a three-month (90-day) supply of multi-source drugs, or $9.30 for a three-month (90-day) supply of single-source drugs $1.05 for a one-month (30-day) supply of multi-source drugs, or $3.10 for a one-month (30-day) supply of singlesource drugs After your yearly out-of-pocket costs reach $4,050, you pay $0 for all drugs. Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan s service area where there is no network pharmacy. You may pay more than the copay if you get your drugs at an out-of-network pharmacy. After you pay your yearly deductible, you pay the following until total yearly drug costs reach $2,270. Tier 1 Preferred Generic $0 copay for a one-month (30-day) supply of drugs Tier 2 - Other $1.05 for a one-month (30-day) supply of multi-source drugs, or $3.10 for a one-month (30-day) supply of singlesource drugs 18 L.A. Care s Medicare Advantage Special Needs Plan for people with Medicare and Medi-Cal

21 2008 Medicare Advantage Summary of Benefits MEDICAL BENEFITs Out-of-Network Coverage Gap Out-of-Network Catastrophic Gap Dental Services Hearing Services Vision Services original medicare Preventive dental services (such as cleaning) not covered. Routine hearing exams and hearing aids not covered. 20% coinsurance for diagnostic hearing exams. 20% coinsurance for diagnosis and treatment of diseases and conditions of the eye. Routine eye exams and glasses not covered. Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery. Annual glaucoma screenings covered for people at risk. l.a. care s medicare advantage SPECIAL NEEDS plan After your total yearly drug costs reach $2,270, and until your yearly out-of-pocket drug costs reach $4,050 you pay: Tier 1 Preferred Generic $1.05 copay for a one-month (30-day) supply of drugs Tier 2 Other $1.05 for a one-month (30-day) supply of multi-source drugs, or $3.10 for a one-month (30-day) supply of singlesource drugs After your yearly out-of-pocket costs reach $4,050, you pay $0 copay for preferred generic and $0 copay for all other drugs. In general, preventive dental benefits (such as cleaning) not covered. 0% of the cost for Medicare-covered dental benefits.* In general, routine hearing exams and hearing aids not covered. 0% of the cost for diagnostic hearing exams.* General: Authorization rules may apply. 0% of the cost for one pair of eyeglasses or contact lenses after each cataract surgery.* 0% of the cost for exams to diagnose and treat diseases and conditions of the eye.* 0% of the cost for up to 1 routine eye exam(s) every year. 0% of the cost for up to 1 pair(s) of glasses every two years 0% of the cost for up to 2 pair(s) of contacts every two years $75 limit for eye wear every two years For assistance call L.A. Care Health Plan at LA-CARE ( ) TTY

22 MEDICAL BENEFITs Physical Exams Health/Wellness Education Transportation Routine original medicare 20% coinsurance for one exam within the first 6 months of your new Medicare Part B coverage. When you get Medicare Part B, you can get a one-time physical exam within the first 6 months of your new Part B coverage. The coverage does not include lab tests. Not covered. Not covered. l.a. care s medicare advantage SPECIAL NEEDS plan When you get Medicare Part B, you can get a one-time physical within the first 6 months of your new Part B coverage. The coverage does not include lab tests. Routine exams not covered. 0% of the cost for Medicare-covered benefits.* General: Authorization rules may apply. $0 copay for up to 12 one-way trip(s) to plan-approved location every year. *All cost sharing in this Summary of Benefits is based on your level of Medi-Cal eligibility. 20 L.A. Care s Medicare Advantage Special Needs Plan for people with Medicare and Medi-Cal

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24 Medicare and Medi-Cal Together in One Plan Thank you for looking at L.A. Care s Medicare Advantage SPECIAL NEEDS Plan for people with both Medicare and Medi-Cal. We know you have many choices when it comes to choosing your Medicare and Medi-Cal health plan, so we appreciate that you are considering us. For more than 10 years, L.A. Care Health Plan has been providing no-cost and low-cost, quality health coverage to Los Angeles County residents who qualify. We work with over 2,000 doctors and specialists throughout the neighborhoods of Los Angeles. We already serve nearly 800,000 members through our Medi-Cal, Healthy Kids, and Healthy Families Programs. Now, L.A. Care is offering a plan that combines both Medi-Cal and Medicare coverage, plus prescription drugs. Here are some highlights of what L.A. Care s Medicare Advantage Special Needs Plan covers.

25 2008 Medicare Advantage Summary of Benefits Section 3 Important Plan Information For assistance call L.A. Care Health Plan at LA-CARE ( ) TTY

26 All L.A. Care Medicare Advantage Special Needs Plan members receive the following additional benefits over and above what Original Medicare alone covers: MEDICAL BENEFITs Prescription Drug Coverage Routine Chiropractic Services original medicare Most drugs not covered. (You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan.) 20% coinsurance Routine care not covered. 20% coinsurance for manual manipulation of the spine to correct subluxation if you get it from a chiropractor or other qualified provider. l.a. care s medicare advantage SPECIAL NEEDS plan $0 yearly deductible Before your total yearly drug costs reach $2,270, you pay: $0 for formulary generic drugs; and $1.05 for multi-source or $3.10 for single-source formulary brand drugs. After your total yearly drug costs reach $2,270, you pay: $1.05 for formulary generic drugs; and $1.05 for multi-source or $3.10 for single-source formulary brand drugs. After your yearly out-of-pocket drug costs reach $4,050, you pay a $0 copay. You pay $0 for the cost of routine chiropractic care visits. You can receive an unlimited number of routine chiropractic visits during a benefit year. 24 L.A. Care s Medicare Advantage Special Needs Plan for people with Medicare and Medi-Cal

27 2008 Medicare Advantage Summary of Benefits MEDICAL BENEFITs Routine Eye Exams and Eyewear Non-Emergency Transportation Routine original medicare 20% coinsurance for diagnosis and treatment of diseases and conditions of the eye. Routine eye exams and glasses not covered. Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery. Annual glaucoma screenings covered for people at risk. Not covered. l.a. care s medicare advantage SPECIAL NEEDS plan You pay $0 for up to one routine eye exam per year You pay $0 for up to one pair of glasses or two pairs of contacts every two years. You are covered up to $75 for eyewear every two years. See following table for additional Medi- Cal coverage of vision services. You pay $0 for: Non-emergency transportation to and from covered health care services Transportation must be provided by an L.A. Care contracted transportation provider. Coverage is limited to 12 one-way trips per year. Services must be approved in advance by L.A. Care staff. Please call L.A. Care Health Plan for more information about this plan. For assistance call L.A. Care Health Plan at LA-CARE ( ) TTY

28 And because you have full Medi-Cal coverage, you will have access to the following benefits that are not covered under Original Medicare: MEDICAL BENEFITs Part B Premium Inpatient Hospital Care Doctors Office Visits Skilled Nursing Facility Stays Vision Services Hearing Aids Acupuncture Podiatry Services Incontinence Supplies Dental Services Excluded Medicare Part D Drugs l.a. care s Medicare Advantage Special Needs PLAN Your monthly Medicare Part B premium is $ Because you qualify for extra help from Medi-Cal, the extra help pays this amount on your behalf. You pay $0 for unlimited number of days for inpatient coverage in the hospital as long as your stay is medically necessary and authorized. You pay $0 for each visit to your Primary Care Provider (PCP) or Specialist, including annual routine physical exams/checkups and mental health visits. You pay $0 for skilled nursing facility stays. Medi-Cal covers additional days beyond the Medicare limit if extra days are authorized and medically necessary. You pay $0 for glasses or contact lenses every two years if medically necessary. You pay $0 for an office visit every other year, unless there is a medical need for additional visits. You pay $0 for hearing aids that are provided by an in-network specialist. You pay $0 for acupuncture services from the Medi-Cal fee-for-service program. You pay $0 for up to 12 additional routine/maintenance visits per year (24 total per year, including nail trimmings, cutting and removal of calluses, etc). You pay $0 for medically necessary incontinence supplies. You pay $0 for dental services from Denti-Cal. You pay $0 for certain excluded drugs covered by Medi-Cal, including prescribed over-the-counter drugs. 26 L.A. Care s Medicare Advantage Special Needs Plan for people with Medicare and Medi-Cal

29 2008 Medicare Advantage Summary of Benefits More Advantages to Becoming an L.A. Care Health Plan Member! Health Navigator You pay $0. As a member of L.A. Care s Medicare Advantage Special Needs Plan, you receive the services of a Health Navigator. A Health Navigator is a Member Services Representative who acts as your personal health plan assistant. Your Health Navigator will help you with any questions, concerns or problems you may have. Your Health Navigator will: Inform you about your benefits Help if you have difficulty scheduling appointments or obtaining your prescriptions Connect you with community resources as needed, and Be your guide within L.A. Care Health Plan. Family Resource Center You pay $0. The Family Resource Center provides friendly, helpful customer service and health information for L.A. Care members and the local community. The center is open six days a week and offers: Health education classes and workshops on topics like parenting, weight and diabetes management, and how to manage asthma Health screenings like blood pressure and vision checks Personal assistance with understanding and getting the most from your current health care coverage like application assistance and help re-qualifying for Medi-Cal or other programs Child care is available, as well, when you attend classes and workshops and for individuals applying for health care coverage. An L.A. Care representative is always available during the center s business hours to assist you and your family in both English and Spanish. Interpreter services are available upon request to assist you if you speak another language. Remember, you automatically receive the advantages of The Health Care Navigator and Family Resource Center when you become a member of L.A. Care s Medicare Advantage Special Needs Plan all for no extra cost or charge. An L.A. Care representative is always available during business hours to assist you and your family. For assistance call L.A. Care Health Plan at LA-CARE ( ) TTY

30 Next steps to becoming an L.A. Care Medicare Advantage Plan member. Now that you ve had an opportunity to learn about the benefits, services and unique advantages to being an L.A. Care member, we encourage you to take the next step and enroll with us today. It s easy to enroll. Simply: Complete the L.A. Care Medicare Advantage Plan Individual Enrollment Form Keep a copy for yourself and mail the other copies to L.A. Care in the envelope provided. Or you can Call us at the number below and an L.A. Care representative will assist you. How to contact L.A. Care Health Plan. If you have any questions about L.A. Care or our Medicare Advantage Special Needs Plan, call us at LA-CARE ( ); TTY LACARE1 ( ). From November 15, 2007 to March 1, 2008, L.A. Care representatives are available from 8 a.m. to 8 p.m. daily; from March 2, 2008 to November 14, 2008, L.A. Care representatives are available from 8 a.m. to 5 p.m., Monday Friday. A representative will be available to answer any questions you may have and can even assist you with completing the Medicare Advantage Special Needs Enrollment Form. (See page 8 in this brochure for all the ways to contact L.A. Care Health Plan and to learn how to get more information on Medicare.) 28 L.A. Care s Medicare Advantage Special Needs Plan for people with Medicare and Medi-Cal

31 2008 Medicare Advantage Summary of Benefits Notes For assistance call L.A. Care Health Plan at LA-CARE ( ) TTY

32 Notes 30 L.A. Care s Medicare Advantage Special Needs Plan for people with Medicare and Medi-Cal

33 2008 Medicare Advantage Summary of Benefits Notes For assistance call L.A. Care Health Plan at LA-CARE ( ) TTY

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35 555 West Fifth Street Los Angeles, CA Toll Free: LA-CARE ( ) LA /07 H2643_LA0448_11/06/2007