An ANALYSIS of Medicare Benefits per the 2016 Medicare and You Handbook & The State of Delaware's Special Medicfill Plan Benefits

Transcription

1 An ANALYSIS of Medicare Benefits per the 2016 Medicare and You Handbook & The State of Delaware's Special Medicfill Plan Benefits The chart below presents the list of benefits covered by Medicare, and categorized as Part A and Part B services as described in the 2016 Medicare and You handbook. For each service, the chart includes coverage provided by Medicare, the coverage provided by the State of Delaware's Special Medicfill plan and the net cost to the subscriber. For more information about the benefits covered by Medicare, the subscriber should refer to Section 3 Find Out if Medicare Covers Your Test, Service or Item of the 2016 Medicare and You handbook. Medicare subscribers also may use: to help determine what Medicare pays for specific MEDICARE PART A / SPECIAL MEDIFILL BENEFITS TABLE Service: Medicare Special Medicfill Subscriber Inpatient Hospital Care Days 1-60 Days All but the Part A. All but a fixed coinsurance amount The Part A. The fixed coinsurance amount Days All covered inpatient costs. Pays the coinsurance amount if lifetime reserve days are used. Days All covered inpatient costs. Pays the coinsurance amount if lifetime reserve days are used. Inpatient Skilled Nursing Facility (SNF) Care Days 1-20 charges Days All but a fixed coinsurance amount The fixed coinsurance amount. Hospice Hospice Home Care (or I/P or SNF care when medically necessary) I/P Respite Care 5 days maximum charges All but 5% of the Medicare approved amount. 5% of the Medicare approved amount. Home Health Care charges Blood charges First 3 pints of blood 1

2 Service: Medicare Special Medicfill Subscriber after first 3 pints in any benefit year. in any benefit year. PART B & SPECIAL MEDICFILL TABLE Note: There's a for Part B services that is separate from the Part A. Service: Medicare Special Medicfill Preventive Services Subscriber Note: Services identified with this symbol services, and are listed together, below. Abdominal aortic aneurysm screening (One-time, as part of the "Welcome to Medicare" preventive visit. Alcohol Misuse Counseling (One screening, and up to 4 brief counseling sessions per year.) Bone Density Screening (every 24 mos.) Breast Cancer Screening (Mammograms - women age 40 & older; one baseline b/w ages years.) Cardiovascular disease (behavioral therapy) One visit per year with primary doctor in the Medicare and You handbook are preventive 2

3 Service: Medicare Special Medicfill Cardiovascular Screenings (lab tests every 5 years) Cervical and Vaginal Cancer Screening (every 24 mos. except for high risk - annually) Lung Cancer Screening (Annually for adults age years with 30 pack/year smoking history and currently smokes or quit within the past 15 years. Colorectal Cancer Screening Occult Blood (50+: annually) Sigmoidoscopy (50+: every 48 mos., or 120 after mos. screening colonoscopy) Colonoscopy (once every 120 months unless at high risk for colon cancer; then once every 24 months.) Barium Enema (50+: once every 48 mos. instead of colonoscopy or sigmoidoscopy) Depression Screening (annual in a primary care setting) Diabetes Screening (up to twice per year) Routine: 100% of allowed charges, no Non-Routine: 80% of allowed charges, no, if polyp or other tissue is removed.. Nothing Routine: Non-Routine: Subscriber Nothing Diabetes Self- Nothing for covered 3

4 Service: Medicare Special Medicfill Subscriber Management Training for covered Flu Shots (annual) Glaucoma Tests (annual for high risk) charges after Hepatitis B Shots HIV Screening (annually) Medical Nutrition Therapy Services Obesity Screening and Counseling Pneumococcal Shot (once per lifetime) Prostate Cancer Screenings Tobacco Cessation (without diagnosis of tobacco related illness) Welcome to Medicare Preventive Visit (within 12 mos. of enrollment) PSA test: 100% of allowed charges, no Digital rectal exam:. Yearly Wellness Visits PSA: Nothing DRE: Part B, then Other Part B Services Ambulance Ambulatory Surgical 4

5 Service: Medicare Special Medicfill Centers Blood charges after first 3 pints in any benefit year. Cardiac Rehabilitation Chemotherapy Chiropractic Services (limited to correction of subluxation of the spine) Clinical Research Studies Defibrilator (Implantable Automatic) charges; the may apply Diabetes Supplies for covered Doctor and Other Health Care Provider Services Durable Medical Equipment EKG (once for screening; otherwise diagnostic) Emergency Department Services Eyeglasses (limited to one pair glasses or contacts after cataract surgery with implanted for covered for covered 80% of the allowed Subscriber First 3 pints of blood in any benefit year. If applicable, the Part B, then Nothing for covered Nothing for covered Nothing for covered 5

6 Service: Medicare Special Medicfill lens) Federally-Qualified Health Center Services Foot Exams and Treatment Hearing and Balance Exams Home Health Services (doctor ordered care with a Medicarecertified provider) Kidney Dialysis Services and Supplies Kidney Disease Education Services charges 100% of allowed charges, no for most preventive services Laboratory Services Mental Health Care (Outpatient) Diagnosis: 80% of allowed charges after the or nothing for preventive : Subscriber Occupational Therapy Outpatient Hospital Services Outpatient Medical and Surgical Services and Supplies Physical Therapy (limits may apply) 6

7 Service: Medicare Special Medicfill Prescription Drugs (limited) for certain drugs. Prosthetic/Orthotic Items Pulmonary Rehabilitation Rural Health Clinic Services Second Surgical Opinions Speech-Language Pathology Services Surgical Dressing Services in a doctor's office. A copayment applies in a hospital setting. ; Preventive Care: 100% of allowed charges, no in a doctor's office. A copayment applies in a hospital setting. Teleheath Tests (other than lab tests) Tobacco Use Cessation Counseling (with for x-rays, MRIs, CT scans, EKGs and some other diagnostic tests. A copayment may apply in hospital setting. ; Preventive Care: Nothing Subscriber 7

8 Service: Medicare Special Medicfill diagnosis of tobaccorelated illness) Transplants and Immunosuppressive Drugs Travel (health care needed when traveling outside the United States) for eligible transplants in a Medicare-certified facility Medicare generally doesn't cover medical care while you're traveling outside the U.S. or its territories and possessions. If emergency care is needed and covered, payment is 80% of allowed charges after the Urgently-Needed Care. A copayment applies in a hospital setting. Out of country Surgical medical benefits: For services outside the U.S. which are covered by Medicare BCBSD will pay the Medicare Part B and coinsurance. Benefits for services outside the U.S. not paid by Medicare are covered at of the BCBSDE traditional RBRVS allowable, if these services are defined as coverable under Medicare policy guidelines. Subscriber Nothing for services covered by Medicare. 80% for services not covered by Medicare but defined as coverable under Medicare policy guidelines. 8