Information for Dual-Eligible Members with Secondary Coverage through Florida Medicaid (Fee-for-Service)

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1 Information for Dual-Eligible Members with Secondary Coverage through January 1, 2014 December 31, 2014 Broward and Miami-Dade Counties This publication is a supplement to the 2014 Evidence of Coverage and is for dual-eligible members who are enrolled in PHP and have (feefor-service). This publication explains which benefits are covered through PHP as primary Medicare payer, and which benefits are covered through (feefor-service) as secondary payer and how these benefits are coordinated. This information is available for free in other languages. Please contact our Member Services number at (888) for additional information. (TTY users should call 711). Hours are 8:00 a.m. to 8:00 p.m., seven days a week. Member Services also has free language interpreter services available for non-english speakers. Esta información está disponible gratis en otros idiomas. Por favor, póngase en contacto con el número de nuestro Departamento de servicios para miembros (888) para obtener información adicional. (Los usuarios de TTY deben llamar al 711). El horario es de 8:00 a.m. a 8:00 p.m., siete días a la semana. El Departamento de servicios para miembros también tiene servicios de intérprete gratis para personas que no hablan inglés. PHP is an HMO plan with a Medicare contract. Enrollment in PHP depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may Benefits, formulary, pharmacy network, premium, deductible and/or copyaments/coinsurance may change on January 1, H3132_ Approved

2 Introduction You have received this publication because you are dual-eligible. This means that you are eligible for health care coverage through Medicare and. You are enrolled in for your Medicare medical (Part C) and prescription drug (Part D) coverage and have (fee-for-service) that covers certain health care services that Medicare does not. also covers some of the costs of your Medicare coverage such as Medicare Part B premium and deductible. You and/or must continue to pay your Medicare Part B premium to be eligible for PHP. Generally, PHP is the primary, or first, payer for your health care and prescription drugs. (fee-for-service) is the secondary, or second, payer. If PHP does not cover a service or has limitations on a service you need that you have exhausted, Florida Medicaid (fee-for-service) will usually cover that service. For example, PHP does not cover long-term care, however, (fee-for-service) does. Please refer to the table on the following pages for all -covered services. If you have any questions about covered services through PHP or, please call Member Services at (888) , 8:00 a.m. to 8:00 p.m., seven days a week. TTY users call 711. Covered Services by Payer The table on the following pages describes which services are covered by PHP and which are covered by (fee-for-service). For more information about benefits covered through PHP and their cost sharing and limitations, if any, see Chapter 4 in the 2014 Evidence of Coverage. Limitations shown in the Florida Medicaid column do not apply to children and pregnant women

3 Inpatient Care Inpatient Hospital Care In network. $0 copay. Plan covers 90 days each benefit period. If more than 90 days are required, plan covers up to 60 additional days lifetime reserve days. Lifetime reserve days can only be used once. Includes substance abuse and rehabilitation services. If inpatient stay is greater than 90 days and lifetime reserve days are exhausted, covers additional medically necessary inpatient care up to 45 days per year (up to 365 days per year for emergency inpatient); $0 copay; requires prior authorization. Inpatient Mental Health Care Skilled Nursing Facility (SNF) Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. In network. $0 copay. 190-day lifetime limit in a psychiatric hospital. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. In network in a Medicarecertified SNF. $0 copay. Plan covers up to 100 days each benefit period. No prior hospital stay is required. If lifetime limit of 190 days is exhausted, Florida Medicaid covers additional medically necessary inpatient care up to 45 days per year (up to 365 days per year for emergency inpatient); $0 copay; requires prior authorization. If SNF stay is longer than 100 days, covers additional days; limits apply depending on type of SNF facility; $0 copay; requires prior authorization

4 Long-Term Care Not covered. Covered; no limits; $0 copay; requires prior authorization. Home Health Care (includes medically necessary intermittent skilled nursing care, home health aide services, rehabilitation services, etc.) Hospice Outpatient Care Doctor Office Visits Chiropractic Services home health visits. Authorization rules may Covered by Original Medicare at Medicarecertified hospice. Hospice consultation services covered by plan. each primary care doctor and specialist visit and urgent care visit for benefits. chiropractic visits. chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part)

5 Podiatry Services podiatry benefits. Authorization rules may podiatry visits are for medically necessary foot care. Outpatient Mental Health Care Outpatient Substance Abuse Care Outpatient Services Ambulance Services (medically necessary ambulance services) Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care.) mental health visits and partial hospitalization program services. Authorization rules may visits. each ambulatory surgical center and outpatient hospital facility visit. Authorization rules may ambulance benefits. $0 copay for each emergency room visit. Not covered outside the US except under limited circumstances

6 Urgently Needed Care (This is not emergency care, and in most cases, is out of the service area.) $0 copay for each urgentcare visit. Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy) occupational therapy, physical therapy, and speech and language therapy visits. Outpatient Medical Services and Supplies Durable Medical Equipment items. (includes wheelchairs, oxygen, etc.) Prosthetic Devices (includes braces, artificial limbs and eyes, etc.) prosthetic devices and medical supplies related prosthetics, splints and other devices. Diabetes Programs and Supplies diabetes self-management training, diabetes monitoring supplies and therapeutic shoes or inserts

7 Diagnostic Tests, X-Rays, Lab Services, and Radiology Services lab services, diagnostic procedures and tests, X- rays, diagnostic radiology services and therapeutic radiology services. Cardiac and Pulmonary Rehabilitation Services cardiac rehabilitation services, intensive cardiac rehabilitation services and pulmonary rehabilitation services. Authorization rules may Preventive Services Case Management and Disease Management Services $0 copay for case management and disease management services provided by plan s nurses. Not covered. Preventive Services all preventive services. preventive services are those covered under Original Medicare. $0 copay for annual physical exam. Authorization rules may apply for certain preventive services

8 Kidney Disease and Conditions renal dialysis and kidney disease education services. Outpatient Prescription Drugs $0 copay for Part B- covered drugs. Part D drugs are covered, but there may be cost sharing. Covers some drugs not on PHP formulary. Help for copays may be available. See Chapter 6 of the 2014 Evidence of Coverage for a complete description of Part D coverage and your Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs (also called Low Income Subsidy Rider or LIS Rider) for cost sharing information that applies to you. In most cases, your prescriptions are covered only if they are filled at the plan s network pharmacies Quantity limits and restrictions may - 7 -

9 Dental Services dental benefits. $0 copay for preventive dental benefits such as oral exams, cleanings, fluoride treatments and dental X- rays. Plan offers additional supplemental comprehensive dental benefits. $650 limit for supplemental dental benefits every year. Hearing Services diagnostic hearing exams. $0 copay for one (1) supplemental routine hearing exam every year and fitting-evaluation for a hearing aid. $0 copay each for up to two (2) supplemental hearing aids every year. $400 plan coverage limit for supplemental hearing aids every year. If cost of hearing aid(s) exceeds $400 in a year, will cover the difference up to the current yearly Medicaid limit for the type of hearing aid required. Annual limit computation includes $400 coverage through PHP; $0 copay; requires prior authorization

10 Vision Services diagnosis and treatment for diseases and conditions of the eye, including an annual glaucoma screening for people at risk. $0 copay for one (1) pair of eyeglasses (lenses and frames) or contact lenses after cataract surgery. $0 copay for one (1) pair of eyeglasses (lenses and frames), contact lenses, eyeglass lenses, and/or eyeglass frame every year. $100 plan coverage limit for supplemental eye wear every year

11 Health/Wellness Education and Other Supplemental Benefits & Services $0 copay for 24-hour nurse advice line, health education information and additional smoking and tobacco use cessation visits. Not covered. Transportation Members may choose either a gym membership or up to $200 worth of over-the-counter items, such as vitamins, fiber supplements, first aid supplies, sunscreen, tooth brushes and pastes, cold medication, antacids, etc., every year for $0 copay. up to 12 round trip(s) to plan-approved location every year. Authorization rules may If number of medically necessary round trips exceeds 12, Florida Medicaid will cover additional non-emergency medical transport when no other means of transportation to and from Medicaid-compensable services is available. No limits; $0 copay. Acupuncture and Other Alternative Therapies Not covered. Not covered. Benefit covered by both PHP and (fee-for-service); however, PHP is primary payer and services will be provided through PHP network providers. There is no copay for covered services through PHP and (fee-for-service). Most prescription drugs are covered through PHP for dual-eligible members. Some prescription drugs are not on PHP s list of drugs (formulary). (fee

12 for-service) will generally cover those drugs that are not on our formulary with no copay. Help to pay copays for certain drugs may be available through Florida s AIDS Drug Assistance Program (ADAP), but you must apply for it. Call Member Services for more information at (888) , Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711. PHP covers preventive dental care and other medically necessary dental services up to $650 per year. If the following medically necessary dental services exceed $650 in a year, Florid Medicaid will cover them. Comprehensive oral exam Denture-related procedures Full dentures and removable partial dentures (partial dentures require prior authorization) Incision and drainage of abscess Necessary radiographs to make a diagnosis Problem-focused oral evaluation Medicaid-covered dental services must be provided by a participating Medicaid dentist. Coordination of Covered Services PHP coordinates the covered services provided to you by PHP. If you require services covered by (fee-for-service), your primary care provider or specialist will refer you to the appropriate participating provider and get authorization from for that service, if required. Getting Covered Services from Network Providers PHP has its own provider networks. (fee-for-service) has participating providers who contract with Medicaid to provide services to Medicaid recipients. Most of the PHP providers accept (fee-for-service), but not all. If you need a referral for a service that is covered by (fee-for-service), your primary care provider will refer you to a participating Medicaid provider. For services you receive through PHP, you must generally receive your care from a network provider. In most cases, care you receive from a non-network provider (a provider who is not part of the PHP network) will not be covered. See Chapter 3 of your 2014 PHP Evidence of Coverage for more information

13 Which Member Identification Card to Use As a dual eligible member enrolled in PHP and eligible for (fee-forservice) you receive a PHP member identification (ID) card. When you get covered services or fill prescriptions, show your PHP member identification (ID) card and your gold Medicaid card. Do not use your red, white and blue Medicare ID card. Put it away for safe keeping in case you need to use it later if you change Medicare coverage to Original Medicare. If you lose your PHP member ID card, please call Member Services at (888) , 8:00 a.m. to 8:00 p.m., seven days a week. TTY users call 711. For More Information If you have questions about your covered services or their coordination, please call Member Services at (888) , 8:00 a.m. to 8:00 p.m., seven days a week. TTY users call