MA Plan (HMO) Plan 006. Summary of Benefits. Offered by. H5826_MA_194_2015_v_01_SB006 Accepted

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1 MA Plan (HMO) Plan Summary of Benefits Offered by H5826_MA_194_2015_v_01_SB006 Accepted

2 Blank Inside Front Cover

3 Section I Introduction to the Summary of Benefits for Community HealthFirst MA Plan (HMO) A Medicare Advantage plan offered by Community Health Plan of Washington with a Medicare contract. January 1, December 31, 2015 This booklet gives you a summary of what we cover and what we pay. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of service 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-for-service Medicare). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Community HealthFirst TM MA Plan). Tips for comparing your Medicare choices. This Summary of Benefits booklet gives you a summary of what Community HealthFirst MA Plan 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 Community HealthFirst MA Plan Monthly Premium, Deductible, and limits on how much you pay for covered services. Covered Medical and Hospital Benefits This document is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call our Customer Service Department toll-free at , between 8:00 a.m. to 8:00 p.m., 7 days a week. TTY users should call (TTY Relay: Dial 7-1-1). Things to know about Community HealthFirst MA Plan Hours of Operation You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Pacific time. Community HealthFirst MA Plan If you are a member of this plan, call toll-free , TTY users should call (TTY Relay: Dial 7-1-1). If you are not a member of this plan call toll-free , TTY users should call (TTY Relay: Dial 7-1-1). For more information visit our website at Who can join? To join Community HealthFirst MA Plan, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our service area includes the following counties in Washington: Clark, King, Kitsap, Pierce, Skagit, Snohomish, Spokane, and Thurston. Which doctors and hospitals can I use? Community HealthFirst MA Plan has a network of doctors, hospitals, and other providers. If you use the providers that are not in the network, the plan may not pay for these services. You can see our plan s provider directory on our website at Or call us and we will send you a copy of the provider directory. 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. Community HealthFirst MA Plan covers Part B drugs including chemotherapy and some drugs administered by your provider. However, this plan does not cover Part D prescription drugs. 1

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5 Section II Summary of Benefits Contract - H5826 Community HealthFirst MA Plan 3

6 Section II: Summary of Benefits Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the monthly premium? $15.00 per month. In addition, you must keep paying your Medicare Part B premium. How much is the deductible? This plan does not have a deductible. Is there any limit on how much I will pay for my covered services? Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. In this plan, you will pay nothing for Medicare-covered services from in-network providers. Your yearly limit(s) in this plan: $3,400 for services you receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums. 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. Community Health Plan of Washington is a Corrdinated Care plan with a Medicare Advantage contract. Enrollment in Community Health Plan of Washington depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. 4

7 Section II: Summary of Benefits Covered Medical and Hospital Benefits Acupuncture and Other Alternative Therapies There is a limit to how much our plan will pay: You pay nothing Alternative Medicine Benefit includes: Acupuncture and Naturopathy, benefit includes up to $250 per person, all services combined. These services must be performed by a State certified practitioner. Ambulance 1 Chiropractic Care 2 $250 copay Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 copay Dental Services Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): 20% of the cost Preventive dental services: Cleaning: You pay nothing Dental x-ray(s): You pay nothing Fluoride treatment: You pay nothing Oral exam: You pay nothing Our plan pays up to $500 every year for most supplemental dental services. Diabetes Supplies and Services 2 Diabetes monitoring supplies: You pay nothing Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: You pay nothing 5 Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor.

8 Section II: Summary of Benefits Covered Medical and Hospital Benefits Diagnostic Tests, Lab and Radiology Services, and X- Rays 1 Diagnostic radiology services (such as MRIs, CT scans): 0% or 20% of the cost Diagnostic tests and procedures: 20% of the cost Lab services: You pay nothing Outpatient x-rays: 20% of the cost Therapeutic radiology services (such as radiation treatment for cancer): 20% of the cost Doctor s Offce Visits 2 Primary care physician visit: 0-20% of the cost, depending on the service Specialist visit: $40 copay or 0-20% of the cost, depending on the service Copayment applies for E&M services. Coinsurance applies for all other services. Coinsurance applies for facility-based services where a facility may bill separately Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 Emergency Care 20% of the cost $65 copay or 0-20% of the cost, depending on the service If you are admitted to the hospital within 24 hours, 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. $65 copayment applies for each separate Medicare- covered emergency room visit. 20% of the cost for all other Medicare covered services and facility-based services Foot Care (podiatry services) 2 Foot exams and treatment if you have diabetes-related nerve damage and/ or meet certain conditions: $20 copay or 0-20% of the cost, depending on the service Routine foot care (for up to 4 visit(s) every year): You pay nothing Hearing Services 1 Home Health Care 1 Exam to diagnose and treat hearing and balance issues: $20 copay You pay nothing 6

9 Section II: Summary of Benefits Covered Medical and Hospital Benefits Mental Health Care 1 There is a Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit applies to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 lifetime reserve days. These are extra days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days. $185 copay per day for days 1 through 10 You pay nothing per day for days 11 through 90 Outpatient group therapy visit: $20 copay or 0-20% of the cost, depending on the service Outpatient individual therapy visit: $20 copay or 0-20% of the cost, depending on the service Coinsurance also applies for facility-based services where a facility may bill separately 7 Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor.

10 Section II: Summary of Benefits Covered Medical and Hospital Benefits Outpatient Rehabilitation 1 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): 20% of the cost Occupational therapy visit: $20 copay or 0-20% of the cost, depending on the service Physical therapy and speech and language therapy visit: $20 copay or 0-20% of the cost, depending on the service Coinsurance also applies for facility-based services where a facility may bill separately Outpatient Substance Abuse 1 Group therapy visit: 20% of the cost Individual therapy visit: 20% of the cost Outpatient Surgery 1 Ambulatory surgical center: 20% of the cost Outpatient hospital: 20% of the cost Over-the-Counter Items Not Covered Prosthetic Devices (braces, artificial limbs, etc.) 1 Prosthetic devices: 20% of the cost Related medical supplies: 20% of the cost 8

11 Section II: Summary of Benefits Covered Medical and Hospital Benefits Renal Dialysis 1 20% of the cost Transportation Not covered Urgent Care $30 copay or 0-20% of the cost, depending on the service Coinsurance also applies for facility-based services where a facility may bill separately Vision Services 2 Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $20 copay Routine eye exam (for up to 1 every year): You pay nothing Contact lenses: You pay nothing Eyeglasses (frames and lenses): You pay nothing Eyeglasses frames: You pay nothing Eyeglasses lenses: You pay nothing Eyeglasses or contact lenses after cataract surgery: 20% of the cost Our plan pays up to $100 every two years for supplemental eyewear. Our relationship with VSP allows a number of options to receive frames and basic lenses within this benefit amount. 9 Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor.

12 Section II: Summary of Benefits Covered Medical and Hospital Benefits Preventative Care You pay nothing Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA) 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. 10

13 Section II: Summary of Benefits Covered Medical and Hospital Benefits Hospice You pay nothing for hospice care from a Medicare- certified hospice. You may have to pay part of the cost for drugs and respite care. Inpatient Hospital Care 1 Our plan covers an unlimited number of days for an inpatient hospital stay. $425 copay per day for days 1 through 5 You pay nothing per day for days 6 through 90 You pay nothing per day for days 91 and beyond 11 Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor.

14 Section II: Summary of Benefits Covered Medical and Hospital Benefits Inpatient Mental Health Care For inpatient mental health care, see the Mental Health Care section of this booklet. Skilled Nursing Facility (SNF) Our plan covers up to 100 days in a SNF. $40 copay per day for days 1 through 20 $155 copay per day for days 21 through 35 You pay nothing per day for days 36 through

15 Section II: Summary of Benefits Prescription Drug Benefits How much do I pay? For Part B drugs such as chemotherapy drugs 1 : 20% of the cost Other Part B drugs 1 : 20% of the cost Our plan does not cover Part D prescription drugs. 13 Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor.

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17 Section III Additional Information Section Contract - H5826 Community HealthFirst MA Plan 15

18 Section III: Additional Information Section Community HealthFirst is offered by Community Health Plan of Washington History We made a commitment more than 20 years ago: To improve the health of our communities by making quality health care accessible to all Washington State residents. We continue that pledge today by providing affordable comprehensive coverage. We are the only health plan in the state founded by local community health centers. This network brought together shared values for equal access to health care, years of experience in community organizing, and effective health care administration. This means our members have access to first-class medical care and it s just down the street. Mission Our mission is to deliver accessible managed care services that meet the needs and improve the health of our members and make managed care participation beneficial for community-responsive providers. Populations Served We serve more than 300,000 individuals and families throughout Washington State. We are proud to be a recognized leader in creating health care products that meet the needs of low-income individuals and families, diverse groups, and people with complex health conditions. Health Care Policy From Main Street to Olympia to Washington, D.C., we organize at the grassroots level while working closely with legislators and regulators to create effective policy. Our Core Values 1. Excellence in service to our members, providers, and each other is our highest priority. 2. Every person, every idea counts. 3. We expect individual accountability for behavior. We share team accountability for performance. 4. Resource management & productivity are everyone s responsibility 16

19 If you have any questions about this plan s benefits or costs, please contact Community HealthFirst Medicare Advantage Plan for details. MA Plan (HMO) 006 San Juan Island Whatcom Skagit Okanogan Ferry Stevens Pend Oreille Clallam Snohomish Chelan Kitsap King Douglas Lincoln Spokane Grays Harbor Mason Thurston Pierce Kittitas Grant Adams Whitman Wahkiakum Cowlitz Lewis Skamania Yakima Benton Franklin Walla Walla Columbia Asotin Clark Klickitat 17

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23 How do you enroll? Apply by Phone Call today and a licensed Community HealthFirst Medicare Advantage expert will be happy to help you enroll over the phone. Call (TTY Relay: dial 7-1-1) between the hours of 8:00 a.m. and 8:00 p.m., 7 days a week. Apply in Person Medicare can be diffcult to tackle alone. If you prefer to meet faceto-face with one of our Medicare Advantage experts please call us to schedule a free appointment. Apply by Mail Simply complete the enrollment application and return it using the postage-paid orange envelope. If you do not already have an enrollment application, call us and we will be happy to help you complete your application. Contact Information Web: Mailing Address: Community Health Plan of Washington ATTN: Community HealthFirst 720 Olive Way, Suite 300 Seattle, WA Prospective Members: Current Members: TTY Relay: Dial :00 a.m. to 8:00 p.m. 7 days a week Apply Online Visit to apply online. We will receive your application electronically. You may also apply to enroll in a Community HealthFirst plan through the Centers for Medicare and Medicare Services Online Enrollment Center, at

24 Offered by Prospective Members: Current Members: (TTY Relay: Dial 7-1-1) 8:00 a.m. to 8:00 p.m., 7 days a week 720 Olive Way, Suite 300 Seattle, WA

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