2015 Summary of Benefits

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1 2015 Summary of Benefits Senior Advantage Medicare Medicaid Plan (HMO SNP) Atlanta Metro Area Kaiser Foundation Health Plan of Georgia, Inc. Georgia Region A nonprofit corporation Health Maintenance Organization (HMO) January 1, 2015, through December 31, 2015 Plan 008 H1170_014_45 accepted /14

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3 Senior Advantage Medicare Medicaid Plan (HMO SNP) (a Medicare Advantage Health Maintenance Organization (HMO) offered by KAISER FOUNDATION HP OF GA, INC. with a Medicare contract). Summary of Benefits January 1, 2015 December 31, 2015 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the Evidence of Coverage. You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-forservice 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 Senior Advantage Medicare Medicaid Plan (HMO SNP)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what Senior Advantage Medicare Medicaid Plan (HMO SNP) 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 Benefits 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 Senior Advantage Medicare Medicaid Plan (HMO SNP) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits Kaiser Permanente 2015 Summary of Benefits 1

4 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 Things to Know About Senior Advantage Medicare Medicaid Plan (HMO SNP) 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. Senior Advantage Medicare Medicaid Plan (HMO SNP) Phone Numbers and Website If you are a member of this plan, call toll-free If you are not a member of this plan, call toll-free Our website: kp.org/medicare Who can join? To join Senior Advantage Medicare Medicaid Plan (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and Medicaid, and live in our service area. Our service area includes the following counties in Georgia: Cherokee, Clayton, Cobb, Coweta, DeKalb, Douglas, Fayette, Forsyth, Fulton, Gwinnett, Henry, and Paulding*. * denotes partial county Paulding County: 30127, 30134, Which doctors, hospitals, and pharmacies can I use? Senior Advantage Medicare Medicaid Plan (HMO SNP) has 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. 2 Kaiser Permanente 2015 Summary of Benefits

5 Some of our network pharmacies have preferred cost-sharing. You may pay less if you use these pharmacies. You can see our plan s provider directory at our website (kp.org/medicare). You can see our plan s pharmacy directory at our website (http://www.kp.org/seniorrx). Or, call us and we will send you a copy of the provider and pharmacy directories. 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? Our plan groups each medication into one of six tiers. You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. 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: Initial Coverage, Coverage Gap, and Catastrophic Coverage. Kaiser Permanente 2015 Summary of Benefits 3

6 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the premium? How much is the deductible? Is there any limit on how much I will pay for my covered services? $26 per month. In addition, you must keep paying your monthly Medicare Part B premium. This plan does not have a deductible. 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 some services, depending on your level of Medicaid eligibility. Your yearly limit(s) in this plan: $1,000 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. Kaiser Permanente is an HMO SNP plan with a Medicare contract and a contract with the state Medicaid program. Enrollment in Kaiser Permanente depends on contract renewal. 4 Kaiser Permanente 2015 Summary of Benefits

7 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 Ambulance 1 $0 or $40 copay Chiropractic Care 2 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $0 or $3 copay Dental Services Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $0 or $3 copay Diabetes Supplies and Services Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts: Diagnostic Tests, Lab and Radiology Services, and X-Rays 1 Diagnostic radiology services (such as MRIs, CT scans): $0 or $3 copay Diagnostic tests and procedures: $0 or $0-3 copay, depending on the service Lab services: $0 or $0-3 copay, depending on the service Kaiser Permanente 2015 Summary of Benefits 5

8 Outpatient Care and Services Outpatient x-rays: $0 or $0-3 copay, depending on the service Therapeutic radiology services (such as radiation treatment for cancer): $0 or $3 copay Doctor s Office Visits 2 Primary care physician visit: Specialist visit: $0 or $3 copay Visits to your primary care physician and some specified specialty care do not require a referral. Please refer to the Evidence of Coverage (EOC) for details. Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Emergency Care $0 or $35 copay If you are immediately admitted to the hospital, you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section of this booklet for other costs. Our plan covers emergency care anywhere in the world. Foot Care (podiatry services)2 Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $0 or $3 copay Hearing Services Exam to diagnose and treat hearing and balance issues: $0 or $3 copay Routine hearing exam: Home Health Care 1 We do not cover custodial care, homemaker services, meals delivered to your home, or full-time nursing care in your home. 6 Kaiser Permanente 2015 Summary of Benefits

9 Outpatient Care and Services Mental Health Care 1 Inpatient visit: Our plan covers an unlimited number of days for an inpatient hospital stay. $0 or $12 copay per stay per day for days 91 and beyond Outpatient group therapy visit: Outpatient individual therapy visit: $0 or $3 copay Day limits do not apply to inpatient mental health stays in a general hospital. Outpatient Rehabilitation 1,2 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 $3 copay Occupational therapy visit: $0 or $3 copay Physical therapy and speech and language therapy visit: $0 or $3 copay Outpatient Substance Abuse Group therapy visit: $0 or $3 copay Individual therapy visit: $0 or $3 copay Outpatient Surgery 1 Ambulatory surgical center: $0 or $3 copay Outpatient hospital: $0 or $3 copay Over-the-Counter Items Not covered Prosthetic Devices (braces, artificial limbs, etc.) 1 Prosthetic devices: Related medical supplies: Kaiser Permanente 2015 Summary of Benefits 7

10 Outpatient Care and Services Renal Dialysis Transportation Not covered Urgent Care $0 or $3-35 copay, depending on the service Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0 or $3 copay Routine eye exam (for up to 1 every year): $3 copay Contact lenses (for up to 1 every two years): Eyeglasses (frames and lenses) (for up to 1 every two years): Eyeglasses or contact lenses after cataract surgery: You pay nothing Our plan pays up to $75 every two years for contact lenses and eyeglasses (frames and lenses). Following cataract surgery, you pay any amounts that exceed what Medicare covers. For all other eyewear, you pay amounts that exceed $75 every two years. Preventive Care 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 8 Kaiser Permanente 2015 Summary of Benefits

11 Outpatient Care and Services Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) 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 (one-time) Yearly Wellness visit Any additional preventive services approved by Medicare during the contract year will be covered. Annual physical exam: The applicable cost-sharing listed elsewhere in this Summary of Benefits will apply to any non-preventive services you receive during or subsequent to preventive care. Hospice for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. When you are enrolled in a Medicare certified hospice program, your hospice services and your Part A and Part B services related to your terminal condition are paid for by Original Medicare, not our plan. Kaiser Permanente 2015 Summary of Benefits 9

12 Inpatient Care Inpatient Hospital Care 1 Our plan covers an unlimited number of days for an inpatient hospital stay. $0 or $12 copay per stay per day for days 91 and beyond Inpatient Mental Health Care For inpatient mental health care, see the Mental Health Care section of this booklet. Skilled Nursing Facility (SNF) 1 Our plan covers up to 100 days in a SNF. We cover up to 100 days per benefit period. A benefit period begins on the first day you go to a Medicare-covered inpatient hospital or skilled nursing facility (SNF). The benefit period ends when you have not been an inpatient at any hospital or SNF for 60 calendar days in a row. 10 Kaiser Permanente 2015 Summary of Benefits

13 Prescription Drug Benefits How much do I pay? Initial Coverage For Part B drugs such as chemotherapy drugs: $0 or $0-45 copay depending on the drug Other Part B drugs: $0 or $0-45 copay depending on the drug Our plan does not have a deductible for Part D prescription drugs. You pay the following: You may get your drugs at network retail pharmacies and mail order pharmacies. Preferred Retail Cost-Sharing Tier One or three-month supply Tier 1 (Preferred Generic) Tier 2 (Non-Preferred Generic) Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier) 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. Tier 6 (Vaccines) $0 for one-month supply Not offered for three-month supply Kaiser Permanente 2015 Summary of Benefits 11

14 Standard Retail Cost-Sharing Tier One or three-month supply Tier 1 (Preferred Generic) Tier 2 (Non-Preferred Generic) Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier) 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. Tier 6 (Vaccines) $0 for one-month supply Not offered for three-month supply 12 Kaiser Permanente 2015 Summary of Benefits

15 Preferred Mail Order Cost-Sharing Tier One or three-month supply Tier 1 (Preferred Generic) Tier 2 (Non-Preferred Generic) Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier) 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. Standard Mail Order Cost-Sharing Tier One or three-month supply Tier 1 (Preferred Generic) Tier 2 (Non-Preferred Generic) Tier 3 (Preferred Brand) Tier 4 (Non-Preferred Brand) Tier 5 (Specialty Tier) 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. 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 innetwork pharmacy. Kaiser Permanente 2015 Summary of Benefits 13

16 A three-month supply is not available for all drugs. Not all drugs can be mailed. Mail order drugs are only available from our mail order pharmacy that offers preferred mail order cost sharing. The prescription drug cost-sharing applies to persons who get Extra Help to pay for prescription drugs. Other cost-sharing applies if you lose eligibility for Extra Help (see the EOC for details). 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. 14 Kaiser Permanente 2015 Summary of Benefits

17 Additional information about Senior Advantage Medicare Medicaid Plan (HMO SNP) Covered services are provided in accord with Medicare coverage guidelines. Please see the Evidence of Coverage (EOC) for complete details, including other coverage limitations and exclusions. Getting care You must get covered services from plan providers except for authorized referrals, emergency care, and out-of-area urgent or dialysis care or as otherwise described in the EOC. Case management We have case management programs if you are managing many chronic conditions. Nurses, social workers, and your physician partner to meet your needs. They educate and teach self-care skills to help you manage your health. Please ask your physician for details. Grievances & appeals You can ask us to provide or pay for an item or service you think should be covered. If we deny your request, you can ask us to reconsider. You may ask for a fast decision if you think waiting could put your health at risk. If your doctor makes or supports the fast request, we will expedite our decision. If you have an issue unrelated to coverage, you can file a grievance with us. Please see the EOC for details. Privacy We protect the privacy of protected health information. Please see the EOC or view our Notice of Privacy Practices on kp.org to learn more. Kaiser Permanente 2015 Summary of Benefits 15

18 Summary of Medicaid-Covered Benefits The benefits described below are covered by Medicaid. The benefits described in the Covered Medical and Hospital Benefits section of the Summary of Benefits are covered by Medicare. For each benefit listed below, you can see what Medicaid covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. Note: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. Benefit Medicaid State Plan Senior Advantage Medicare Medicaid Plan (HMO SNP) Acupuncture and Other Alternative Therapies Ambulance 1 Not covered $0 per visit if emergent $3 per visit will be imposed if the condition is not an emergent medical condition. Not covered $0 or $40 copay Chiropractic Care 2 Not covered Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $0 or $3 copay 16 Kaiser Permanente 2015 Summary of Benefits

19 Benefit Medicaid State Plan Senior Advantage Medicare Medicaid Plan (HMO SNP) Dental Services Diabetes Supplies and Services The following Dental Services are a benefit of Georgia Medicaid: *Preventive, diagnostic and treatment services provided to Members under age 21. Emergency Services only for Members age 21 and older. Children < 21: $0 per visit Services include exams, cleanings, X-rays, fillings, dentures, oral surgery and orthodontic treatment. Adults 21+ (emergency only): $0 co-pay Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $0 or $3 copay Diabetes monitoring supplies: Diabetes self-management training: Therapeutic shoes or inserts: Diagnostic Tests, Lab and Radiology Services, and X- Rays 1 $3 co-pay if outpatient based *Not covered: portable X-ray services; services provided in facilities not meeting the definition of an independent Diagnostic radiology services (such as MRIs, CT scans): $0 or $3 copay Diagnostic tests and procedures: $0 or $0-3 copay, depending on the service Lab services: $0 or $0-3 copay, depending on the service Kaiser Permanente 2015 Summary of Benefits 17

20 Benefit Medicaid State Plan Senior Advantage Medicare Medicaid Plan (HMO SNP) Doctor s Office Visits 2 Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Emergency Care laboratory or X-ray facility; services or procedures referred to another testing facility; services furnished by a State or public laboratory; services or procedures performed by a facility not certified to perform them. Cost-based: $10.00 or less $0.50 $10.01-$25.00 $1.00 $25.01-$50.00 $2.00 $50.01 or more $3.00 FQHC or RHC $2.00 $1.00 or $3.00 co-pay (service based) Outpatient x-rays: $0 or $0-3 copay, depending on the service Therapeutic radiology services (such as radiation treatment for cancer): $0 or $3 copay Primary care physician visit: You pay nothing Specialist visit: $0 or $3 copay Visits to your primary care physician and some specified specialty care do not require a referral. Please refer to the Evidence of Coverage (EOC) for details. $0 or $35 copay If you are immediately admitted to the hospital, you do not have to pay your share of the cost for emergency care. See the 18 Kaiser Permanente 2015 Summary of Benefits

21 Benefit Medicaid State Plan Senior Advantage Medicare Medicaid Plan (HMO SNP) Foot Care (podiatry services) 2 Hearing Services Home Health Care 1 $0 co-pay for Medicaid-covered services. *Not covered outside the U.S. except under limited circumstances. Contact the plan for more details. Cost-based: $10.00 or less $0.50 $10.01-$25.00 $1.00 $25.01-$50.00 $2.00 $50.01 or more $3.00 *Not covered: services for flatfoot; subluxation; routine foot care, supportive devices; vitamin B-12 injections. *Not covered for members age 21 and older. Available under EPSDT as part of a written service plan. "Inpatient Hospital Care" section of this booklet for other costs. Our plan covers emergency care anywhere in the world. Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $0 or $3 copay Exam to diagnose and treat hearing and balance issues: $0 or $3 copay Routine hearing exam: You pay nothing Kaiser Permanente 2015 Summary of Benefits 19

22 Benefit Medicaid State Plan Senior Advantage Medicare Medicaid Plan (HMO SNP) We do not cover custodial care, homemaker services, meals delivered to your home, or fulltime nursing care in your home. Mental Health Care 1 *Not covered: social services, chore services, meals on wheels, audiology services. Inpatient visit: $12.50 per admission for members over age. *(This is dependent upon the member s demographic location). Outpatient visit: $3.00 member co-payment is required on all non-emergency outpatient hospital visits. *Community Mental Health Rehabilitation services are only available as part of a written service plan. Inpatient visit: Our plan covers an unlimited number of days for an inpatient hospital stay. $0 or $12 copay per stay per day for days 91 and beyond Outpatient group therapy visit: Outpatient individual therapy visit: $0 or $3 copay Our plan does not limit the amount of days covered in an acute inpatient hospital stay. All the references to limits do not apply to inpatient mental health services provided in a general hospital. 20 Kaiser Permanente 2015 Summary of Benefits

23 Benefit Medicaid State Plan Senior Advantage Medicare Medicaid Plan (HMO SNP) Pregnant women, members under twenty-one (21) years of age, nursing facility members, community care participants, Qualified Medicare Beneficiary (QMB), and hospice care participants are not subject to the co-payment. When the outpatient cost-based settlements are made for hospital services, the copayment plus Medicaid payment will be compared to the allowable cost to determine the amount of final settlement. Outpatient Rehabilitation 1,2 Outpatient Substance Abuse $3 per visit *Not covered for Members age 21and older. Available under EPSDT as part of a written service plan. 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 $3 copay Occupational therapy visit: $0 or $3 copay Physical therapy and speech and language therapy visit: $0 or $3 copay Group therapy visit: $0 or $3 copay Individual therapy visit: $0 or $3 copay Kaiser Permanente 2015 Summary of Benefits 21

24 Benefit Medicaid State Plan Senior Advantage Medicare Medicaid Plan (HMO SNP) $3 co-pay *Substance abuse treatment, inpatient and rehabilitative, are covered as part of a written service plan. Outpatient Surgery 1 Over-the-Counter Items Prescription Drugs Not covered Cost-based: $10.00 or less $0.50 $ $25.00 $1.00 $ $50.00 $2.00 $50.01 or more $3.00 *Not covered: certain outpatient drugs pursuant to Section 1927(d) of the Social Security Act. Additionally, certain over the counter (OTC) drugs must be included, pursuant to the Georgia State Policies and Procedures Manual. Ambulatory surgical center: $0 or $3 copay Outpatient hospital: $0 or $3 copay Not covered For Part B drugs such as chemotherapy drugs: $0 or $0-45 copay depending on the drug Other Part B drugs: $0 or $0-45 copay depending on the drug Home Infusion Drugs, Supplies and Services: for home infusion drugs that would normally be covered under Part D. If you are eligible for extra help, see Prescription Drug Benefits, page 11 for information about Medicare Part D prescription drug cost sharing. If you are not 22 Kaiser Permanente 2015 Summary of Benefits

25 Benefit Medicaid State Plan Senior Advantage Medicare Medicaid Plan (HMO SNP) eligible for extra help, refer to the Evidence of Coverage (EOC), for cost-sharing information. Prosthetic Devices (braces, artificial limbs, etc.) 1 Renal Dialysis Transportation $3 co-pay *Not covered for Members age 21and older: orthopedic shoes and supportive devices for the feet which are not an integral part of a leg brace; hearing aids and accessories. The following Transportation Services are a benefit of Georgia Medicaid: Non-emergency transportation NET services are defined as medically necessary transportation for any member (and escort, if required,) who has no other means of transportation available to any Medicaid Prosthetic devices: You pay nothing Related medical supplies: You pay nothing Not covered Kaiser Permanente 2015 Summary of Benefits 23

26 Benefit Medicaid State Plan Senior Advantage Medicare Medicaid Plan (HMO SNP) reimbursable service for the purpose of receiving treatment, medical evaluation, obtaining prescription drugs or medical equipment. Urgent Care Vision Services The following Vision Services are a benefit of Georgia Medicaid: Medically necessary diagnostic services may be covered. Services may only be covered if performed for medical reasons and not for refractive purposes for members twenty-one (21) years of age or older. Cost-based: $10.00 or less $0.50 $ $25.00 $1.00 $ $50.00 $2.00 $50.01 or more $3.00 $0 or $3-35 copay, depending on the service Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0 or $3 copay Routine eye exam (for up to 1 every year): $3 copay Contact lenses (for up to 1 every two years): Eyeglasses (frames and lenses) (for up to 1 every two years): Eyeglasses or contact lenses after cataract surgery: You pay nothing 24 Kaiser Permanente 2015 Summary of Benefits

27 Benefit Medicaid State Plan Senior Advantage Medicare Medicaid Plan (HMO SNP) *Not covered for members age 21 and older: routine refractive services and optical devices. Our plan pays up to $75 every two years for contact lenses and eyeglasses (frames and lenses). Following cataract surgery, you pay any amounts that exceed what Medicare covers. For all other eyewear, you pay amounts that exceed $75 every two years. Annual Physical Exam Bone Mass Measurement Breast Cancer Screening (Mammogram) Colorectal Cancer Screenings $3.00 co-pay if outpatient based $0 Co-Pay Kaiser Permanente 2015 Summary of Benefits 25

28 Benefit Medicaid State Plan Senior Advantage Medicare Medicaid Plan (HMO SNP) If part of an E&M visit, costbased: $10.00 or less $0.50 $ $25.00 $1.00 $ $50.00 $2.00 $50.01 or more $3.00 Immunizations Pap Smears and Pelvic Exams Prostate Cancer Screening Exams Welcome to Medicare and Annual Wellness Visit Hospice Not covered $3 co-pay for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. When you are enrolled in a Medicare certified hospice 26 Kaiser Permanente 2015 Summary of Benefits

29 Benefit Medicaid State Plan Senior Advantage Medicare Medicaid Plan (HMO SNP) *Available to Members certified as being terminally ill and having a medical prognosis of life expectancy of six (6) months or less. program, your hospice services and your Part A and Part B services related to your terminal condition are paid for by Original Medicare, not our plan. Inpatient Hospital Care 1 $12.50 per admission for members over age. Our plan covers an unlimited number of days for an inpatient hospital stay. $0 or $12 copay per stay per day for day 91 and beyond. Inpatient Mental Health Care For inpatient mental health care, see the Mental Health Care section of this booklet. For inpatient mental health care, see the Mental Health Care section of this booklet. Skilled Nursing Facility (SNF) 1 Our plan covers up to 100 days in a SNF. We cover up to 100 days per benefit period. A benefit period begins on the first day you go to a Medicare-covered inpatient hospital or skilled nursing facility (SNF). The benefit period ends when you have not been an inpatient at any hospital or SNF for 60 calendar days in a row. Family Planning The following Family Planning Services are a benefit of Georgia Medicaid: Medicaid Kaiser Permanente 2015 Summary of Benefits 27

30 Benefit Medicaid State Plan Senior Advantage Medicare Medicaid Plan (HMO SNP) covers some Family planning services and supplies. For dual-eligible members coverage for services and supplies for the purpose of family planning are covered regardless of sex or marital status. $0 co-pay for Medicaid-covered services. Federal Qualified Health Care Center Services *Ambulatory services such as dental services are subject to any limitations applicable to the specific ambulatory service. $2 Co-Pay $0 or $3-35 copay, depending on the service Private Duty Nursing Not covered Rural Health Clinic Services $2 Co-Pay $0 or $35 copay 28 Kaiser Permanente 2015 Summary of Benefits

31 Benefit Medicaid State Plan Senior Advantage Medicare Medicaid Plan (HMO SNP) Swing Bed Services 1 Our plan covers up to 100 days each benefit period. Targeted Case Management * Covered for pregnant women under age 21 and other pregnant women at risk for adverse outcomes; infants and toddlers with established risk for developmental delay. Transplants *Not covered for Members age 21and older: heart, lung and heart/lung transplants. Under certain conditions, the following types of transplants are covered: corneal, kidney, kidney-pancreatic, heart, liver, lung, heart/lung, bone marrow, stem cell, and intestinal/ multivisceral. Our plan covers an unlimited number of days for an inpatient hospital stay. $0 or $12 copay per stay per day for day 91 and beyond. Kaiser Permanente 2015 Summary of Benefits 29

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