Health Partners Plans Provider Manual Health Partners Plans Medicare Benefits Summary

Size: px
Start display at page:

Download "Health Partners Plans Provider Manual Health Partners Plans Medicare Benefits Summary"

Transcription

1 5 Health Partners Plans Provider Manual Health Partners Plans Medicare Benefits Summary Purpose: This chapter provides a benefit summary for Health Partners Plans Medicare members, by plan. Topics: Health Partners Plans Medicare Benefit Summary Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-1

2 Module Contents Overview 5-3 Summary of Benefits 5-4 Health Partners Plans Medicare Basic Benefits 5-5 Health Partners Plans Medicare Prime Benefits 5-8 Health Partners Plans Medicare Prime Plus Benefits 5-11 Health Partners Plans Medicare Special Benefits 5-14 Health Partners Plans Medicare n-covered Services 5-18 Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-2

3 Overview This chapter provides an overview of the benefits that Health Partners Plans Medicare members are entitled to and guidelines for appropriately utilizing authorizations. Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-3

4 Summary of Benefits Health Partners Plans Medicare The following charts summarize Health Partners Plans Medicare benefits and services, providing key information about cost sharing, benefit limits and prior authorization. te that referrals are not required for plan specialists in any Health Partners Plans Medicare Plan. Separate charts are provided for each of our Medicare plans: Health Partners Plans Basic (HMO) Health Partners Plans Prime (HMO) Health Partners Plans Prime Plus (HMO) Health Partners Plans Special (HMO SNP) (Enrollment requires both Medicare and Medicaid eligibility) Prior authorization is ALWAYS REQUIRED for out-of-network services, except emergency/urgent care. te: Generally, DME services or items that are under $500 per claim line and with specific HCPCS coding (NOT Code E1399) do not need prior authorization. Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-4

5 Health Partners Plans Medicare Basic (HMO) Benefit/Service Cost-sharing/Limits Prior Authorization Acupuncture t covered N/A Ambulance Services $200 copay for non-emergent ambulance services Audiology Services $45 copay for routine hearing exam every year; hearing aid coverage Cardiac and Pulmonary Rehabilitation Services $45 copay for each service Chiropractic Services $20 copay for each Medicarecovered visit Dental Services $45 copay for Medicare-covered dental benefits; Preventive dental services not covered Diabetes Programs and Supplies $0 copay for test strips and monitors; 20% for other diabetes supplies; $0 copay for diabetes selfmanagement training Diagnostic Radiology $30 copay for each X-Ray; $195 copay for other diagnostic radiology services, for CT/PET/MRI services contact Landmark Doctor Office Visits $0 copay for each primary care visit; $45 copay for each specialist visit; referral required for plan specialists Durable Medical Equipment 20% Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-5

6 Emergency Care $65 copay per visit; $0 copay if admitted to the hospital within 24 hours for the same condition (if member reasonably believes emergency care is needed) Home Health Care $0 copay per visit Hospice $0 copay Hospital Care (Inpatient) limit to the number of days of hospital stay; Days 1-7: $235 copay per day; Days 8-90: $0 copay per day Kidney Disease and Conditions 20% Laboratory Services $20 copay per lab service/test Mental Health Care (Inpatient) up to 190 days in a lifetime; Days 1-7: $200 copay per day; Days 8-90: $0 copay per day - contact Magellan Behavioral Health Mental Health Care (Outpatient) $40 copay per visit Outpatient Services $215 copay for each ambulatory surgical center visit and outpatient hospital facility visit Physical/Occupational/Speech Therapy Services (Outpatient) $45 copay per visit Podiatry Services $45 copay per visit Prescription Drugs (Outpatient) Part D drugs not covered N/A Preventive Services $0 copay per visit Prosthetic Devices 20% Radiation Therapy 20% Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-6

7 Skilled Nursing Facility (SNF) Up to 100 days each benefit period; Days 1-5: $0 copay per day; Days 6-20: $25 copay per day; Days : $140 copay per day ( prior hospital stay required) Substance Abuse Treatment (Outpatient) $45 copay per visit Transportation (Routine) t covered N/A Urgently Needed Care $45 copay per visit; $0 copay if admitted to the hospital within 24 hours for the same condition Vision Services $45 copay for routine eye exam every year; $0 copay for one pair of eyeglasses or contact lenses after cataract surgery Weight Watchers $2 copay per weekly visit Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-7

8 Health Partners Plans Medicare Prime (HMO) Benefit/Service Cost-sharing/Limits Prior Authorization Acupuncture t covered N/A Ambulance Services Audiology Services Cardiac and Pulmonary Rehabilitations Services Chiropractic Services Dental Services Diabetes Programs and Supplies Diagnostic Radiology Doctor Office Visits $200 copay for non-emergent ambulance services $45 copay for routine hearing exam every year; hearing aid coverage $45 copay for each service $20 copay for each Medicarecovered visit $45 copay for Medicare-covered dental benefits; Preventive dental services not covered $0 copay for test strips and monitors; 20% for other diabetes supplies; $0 copay for diabetes selfmanagement training $30 copay for each X-Ray; $195 copay for other diagnostic radiology services $0 copay for each primary care visit; $45 copay for each specialist visit; referral required for plan specialists, for CT/PET/MRI services contact Landmark Durable Medical Equipment 20% Emergency Care $65 copay per visit; $0 copay if admitted to the hospital within 24 hours for the same condition (if member reasonably believes emergency care is needed) Home Health Care $0 copay per visit Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-8

9 Hospice $0 copay Hospital Care (Inpatient) limit to the number of days of hospital stay; Days 1-7: $235 copay per day; Days 8-90: $0 copay per day Kidney Disease and Conditions 20% Laboratory Services $25 copay per lab service/test Mental Health Care (Inpatient) Up to 190 days in a lifetime; Days 1-7: $200 copay per day; Days 8-90: $0 copay per day - contact Magellan Behavioral Health Mental Health Care (Outpatient) $40 copay per visit Outpatient Services $240 copay for each ambulatory surgical center visit and outpatient hospital facility visit Physical/Occupational/Speech Therapy Services (Outpatient) $50 copay per visit Podiatry Services $45 copay per visit Prescription Drugs (Outpatient) $0 copay for generic, $45 copay for brand for 30-day supply and $90 copay for 60-day or 90-day supply; and 33% coinsurance for specialty tier, until total yearly drug costs reach $2,850. Then no more than 47.5% for brand drugs and 72% for generic drugs until reaching $4,550. After that, the member pays the greater of 5% coinsurance or $2.55 copay for generic and brand and $6.35 copay for all other drugs. Quantity limits may apply. Required for certain drugs see Formulary Preventive Services $0 copay per visit Prosthetic Devices 20% Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-9

10 Radiation Therapy 20% Skilled Nursing Facility (SNF) Up to 100 days each benefit period; Days 1-5: $0 copay per day; Days 6-20: $25 copay per day; Days : $140 copay per day ( prior hospital stay required) Substance Abuse Treatment (Outpatient) $45 copay per visit Transportation (Routine) t covered N/A Urgently Needed Care Vision Services $45 copay per visit; $0 copay if admitted to the hospital within 24 hours for the same condition $45 copay for routine eye exam every year; $0 copay for one pair of eyeglasses or contact lenses after cataract surgery Weight Watchers $2 copay per weekly visit Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-10

11 Acupuncture Health Partners Plans Medicare Prime Plus (HMO) Benefit/Service Cost-sharing/Limits Prior Authorization Ambulance Services Audiology Services Cardiac and Pulmonary Rehabilitations Services Chiropractic Services Dental Services Diabetes Programs and Supplies Diagnostic Radiology Doctor Office Visits $5 copay per visit up to 20 visits $175 copay for non-emergent ambulance services $35 copay for routine hearing exam every year; $0 copay for 1 hearing aid every three years, up to $1,000 limit $35 copay for each service $20 copay for each Medicarecovered visit; $20 copay per visit for up to 20 routine visits $35 copay for Medicare-covered dental benefits; $0 copay for up to 2 dental exams/cleanings and one fluoride treatment and dental X-ray yearly; Additional supplemental coverage limited to $500, with $50 deductible $0 copay for test strips and monitors; 20% for other diabetes supplies; $0 copay for diabetes selfmanagement training $30 copay for each X-Ray; $195 copay for other diagnostic radiology services $0 copay for each primary care visit; $35 copay for each specialist visit; referral required for plan specialists, for CT/PET/MRI services contact Landmark Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-11

12 Durable Medical Equipment 20% Emergency Care $65 copay per visit; $0 copay if admitted to the hospital within 24 hours for the same condition (if member reasonably believes emergency care is needed) Home Health Care $0 copay per visit Hospice $0 Hospital Care (Inpatient) Kidney Disease and Conditions limit to the number of days of hospital stay; Days 1-5: $175 copay per day; Days 6-90: $0 copay per day 20% Laboratory Services $0 copay per lab service/test Mental Health Care (Inpatient) Up to 190 days in a lifetime; Days 1-5: $175 copay per day; Days 6-90: $0 copay per day - contact Magellan Behavioral Health Mental Health Care (Outpatient) $35 copay per visit Outpatient Services Physical/Occupational/Speech Therapy Services (Outpatient) $165 copay for each ambulatory surgical center visit and outpatient hospital facility visit $35 copay per visit Podiatry Services $35 copay per visit Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-12

13 Prescription Drugs (Outpatient) $0 copay for generic, $45 copay for brand for 30-day supply and $90 copay for 60-day and 90-day supply; and 33% coinsurance for specialty tier, until total yearly drug costs reach $2,850. Then no more than 47.5% for brand drugs and 72% for generic drugs until reaching $4,550. After that, the member pays the greater of 5% coinsurance or $2.55 copay for generic and brand and $6.35 copay for all other drugs. Quantity limits may apply. Required for certain drugs see Formulary Preventive Services $0 copay per visit Prosthetic Devices 20% Radiation Therapy 20% Skilled Nursing Facility (SNF) Up to 100 days each benefit period; Days 1-5: $0 copay per day; Days 6-20: $25 copay per day; Days : $140 copay per day ( prior hospital stay required) Substance Abuse Treatment (Outpatient) $35 copay per visit Transportation (Routine) t covered N/A Urgently Needed Care Vision Services $35 copay per visit; $0 copay if admitted to the hospital within 24 hours for the same condition $35 copay for Medicare-covered exams; $35 copay for one routine eye exam yearly; $0 copay for one pair of eyeglasses or contact lenses after cataract surgery; $0 copay for one pair of eyeglasses or contact lenses every two years, up to $150 limit Weight Watchers $2 copay per weekly visit Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-13

14 Health Partners Plans Medicare Special (HMO SNP) Cost sharing in this plan depends on the member s Medicaid eligibility level. Benefit/Service Cost-sharing/Limits Prior Authorization Acupuncture $5 copay per visit up to 20 visits Ambulance Services $0 or 20% for non-emergent ambulance benefits Audiology Services $0 or 20% for Medicare-covered services; $0 copay for one routine hearing exam yearly; $0 copay for one hearing aid every three years, up to $1,000 limit Cardiac and Pulmonary Rehabilitation Services $0 or 20% Chiropractic Services $0 or 20% for each Medicarecovered chiropractic visit; $0 copay for up to 20 routine visits every year Dental Services $0 or 20% for Medicare-covered dental services; $0 copay for up to 2 dental exams/cleanings and one fluoride treatment and dental X-ray yearly; Additional supplemental coverage limited to $500 every two years Diabetes Programs and Supplies $0 or 20% Diagnostic Radiology $0 or 20%, for CT/PET/MRI services - contact Landmark Doctor Office Visits $0 or 20% for each primary care visit and specialist visit; referral required for Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-14

15 plan specialists Durable Medical Equipment $0 or 20% Emergency Care $0 or 20% of the cost (up to $65) for each visit; $0 copay if admitted to the hospital within 24 hours for the same condition (if a member reasonably believe emergency care is needed) Home Health Care $0 copay per visit Hospice $0 Hospital Care (Inpatient) limit to the number of days of hospital stay; Days 1-60: $1,184 deductible; Days 61-90: $296 copay per day; Days : $592 copay per lifetime reserve day Kidney Disease and Conditions $0 or 20% Laboratory Services $0 or 20% Mental Health Care (Inpatient) Up to 190 days in a lifetime; Days 1-60: $1,184 deductible; Days 61-90: $296 copay per day; Days : $592 copay per lifetime reserve day - contact Magellan Behavioral Health Mental Health Care (Outpatient) $0 or 20% Outpatient Services $0 or 20% for each ambulatory surgical center visit and outpatient hospital facility visit Physical/ Occupational/ Speech Therapy Services $0 or 20% Podiatry Services $0 or 20% for each Medicarecovered podiatry visit; $15 copay for one routine visit Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-15

16 every three months Prescription Drugs (Outpatient) $0 annual deductible; Depending on income, pay either $0 copay or $1.15 copay or $2.55 copay for generic and brand drugs; for all other drugs, pay either $0 copay or $3.50 copay or $6.35 copay. After yearly out-of-pocket drug costs reach $4,550, members pay $0 copay. Some drugs have quantity limits. Required for certain drugs see Formulary Preventive Services $0 copay per visit Prosthetic Devices $0 or 20% Radiation Therapy $0 or 20% Skilled Nursing Facility (SNF) Up to 100 days each benefit period; Days 1-20: $0 copay per day; Days : $148 copay per day ( prior hospital stay required) Substance Abuse Treatment (Outpatient) $0 or 20% Transportation (Routine) 10 one-way trips to plan-approved locations per quarter Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-16

17 Urgently Needed Care $0 or 20% for each Medicarecovered visit; $0 copay if admitted to the hospital within 24 hours for the same condition Vision Services $0 or 20% for Medicare-covered exams; $0 copay for one routine eye exam yearly; $0 copay for one pair of eyeglasses or contact lenses after cataract surgery; $0 copay for one pair of eyeglasses or contact lenses every two years, up to $150 limit Weight Watchers $2 copay per weekly visit Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-17

18 n-covered Services The following services and benefits are excluded or limited under Health Partners Plans Medicare plans. Services considered not reasonable and necessary, according to the standards of Original Medicare, unless these services are listed by our plan as covered services. Experimental medical and surgical procedures, equipment and medications, unless covered by Original Medicare or under a Medicare-approved clinical research study or by our plan. Experimental procedures and items are those items and procedures determined by our plan and Original Medicare to not be generally accepted by the medical community. Surgical treatment for morbid obesity, except when it is considered medically necessary and covered under Original Medicare. Private room in a hospital, except when it is considered medically necessary. Private duty nurses. Personal items in your room at a hospital or a skilled nursing facility, such as a telephone or a television. Full-time nursing care in your home. Custodial care, including care provided in a nursing home, hospice, or other facility setting when you do not require skilled medical care or skilled nursing care. Custodial care is personal care that does not require the continuing attention of trained medical or paramedical personnel, such as care that helps you with activities of daily living, such as bathing or dressing. Homemaker services including basic household assistance, such as light housekeeping or light meal preparation. Fees charged by your immediate relatives or members of your household. Meals delivered to your home. Elective or voluntary enhancement procedures or services (including weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance), except when medically necessary. Cosmetic surgery or procedures, unless because of an accidental injury or to improve a malformed part of the body. However, all stages of reconstruction are covered for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance. Routine dental care, such as cleanings, fillings or dentures, except for services specifically covered in the Health Partners Plans Medicare Prime Plus and Special plans, as shown in the charts in this chapter. However, non-routine dental care required to treat illness or injury may be covered as inpatient or outpatient care. Chiropractic care, other than manual manipulation of the spine consistent with Medicare coverage guidelines, except for services specifically covered in the Health Partners Plans Medicare Prime Plus and Special plans, as shown in the charts in this chapter. Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-18

19 Routine foot care, except for the limited coverage provided according to Medicare guidelines, except for services specifically covered in the Health Partners Plans Medicare Prime Plus and Special plans, as shown in the charts in this chapter. Orthopedic shoes, unless the shoes are part of a leg brace and are included in the cost of the brace or the shoes are for a person with diabetic foot disease. Supportive devices for the feet, except for orthopedic or therapeutic shoes for people with diabetic foot disease. Hearing aids or exams to fit hearing aids, except for services specifically covered in the Health Partners Plans Medicare Prime Plus and Special plans, as shown in the charts in this chapter. Eyeglasses, except as specifically covered in the Health Partners Plans Medicare Prime Plus and Special plans, as shown in the charts in this chapter. (However, eyeglasses are covered for people after cataract surgery.) Radial keratotomy, LASIK surgery, vision therapy and other low vision aids. Reversal of sterilization procedures, sex change operations, and non-prescription contraceptive supplies. Acupuncture, except for services specifically covered in the Health Partners Plans Medicare Prime Plus and Special plans, as shown in the charts in this chapter. Naturopath services (uses natural or alternative treatments). Services provided to veterans in Veterans Affairs (VA) facilities. However, when emergency services are received at VA hospital and the VA cost sharing is more than the cost sharing under our plan, we will reimburse veterans for the difference. Members are still responsible for our cost-sharing amounts. The plan will not cover the excluded services listed above. Even if received at an emergency facility, the excluded services are still not covered. Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-19

Health Partners Plans Provider Manual Health Partners Medicare Benefits Summary

Health Partners Plans Provider Manual Health Partners Medicare Benefits Summary 5 Health Partners Plans Provider Manual Health Partners Medicare Benefits Summary Purpose: This chapter provides a benefit summary for Health Partners Medicare members, by plan. Topics: Health Partners

More information

Privacy Information Services Not Covered by UPMC for Life Review and Approval of Medical Procedures

Privacy Information Services Not Covered by UPMC for Life Review and Approval of Medical Procedures 2016 Privacy Information Services Not Covered by UPMC for Life Review and Approval of Medical Procedures Y0069_16_1075 Accepted Review this important information about your health care coverage. This

More information

Gateway Health Medicare Assured RubySM (HMO SNP) $6,700 out-of-pocket limit for Medicare-covered services. No No No No. Days 1-6: $0 or $225 copay per

Gateway Health Medicare Assured RubySM (HMO SNP) $6,700 out-of-pocket limit for Medicare-covered services. No No No No. Days 1-6: $0 or $225 copay per Assured RubySM (HMO Premium $0 monthly plan $0 - $33.90 monthly plan Assured GoldSM (HMO $12.40 - $46.30 monthly plan $43.90 - $77.80 monthly plan In Network Maximum Out-of-Pocket $3,400 out-of-pocket

More information

Y0069_15_3006 Approved

Y0069_15_3006 Approved 2015 Privacy Information Services Not Covered by UPMC for You Advantage (HMO SNP), UPMC for Life Options (HMO SNP), and UPMC Community Care (HMO SNP) Review and Approval of Medical Procedures Y0069_15_3006

More information

Summary of Benefits Community Advantage (HMO)

Summary of Benefits Community Advantage (HMO) Summary of Benefits Community Advantage (HMO) 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

More information

Independent Health s Medicare Passport Advantage (PPO)

Independent Health s Medicare Passport Advantage (PPO) Independent Health s Medicare Passport Advantage (PPO) (a Medicare Advantage Preferred Provider Organization Option (PPO) offered by INDEPENDENT HEALTH BENEFITS CORPORATION with a Medicare contract) Summary

More information

January 1, 2015 December 31, 2015 Summary of Benefits. Altius Advantra (HMO) H8649-003 80.06.361.1-UTWY A

January 1, 2015 December 31, 2015 Summary of Benefits. Altius Advantra (HMO) H8649-003 80.06.361.1-UTWY A January, 205 December 3, 205 Summary of Benefits H8649-003 80.06.36.-UTWY A Y0022_205_H8649_003_UT_WYa Accepted /204 Summary of Benefits January, 205 December 3, 205 This booklet gives you a summary of

More information

[2015] SUMMARY OF BENEFITS H1189_2015SB

[2015] SUMMARY OF BENEFITS H1189_2015SB [2015] SUMMARY OF BENEFITS H1189_2015SB Section I You have choices in your health care One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare

More information

HNE Premier 1 (HMO) and HNE Premier 2 (HMO)

HNE Premier 1 (HMO) and HNE Premier 2 (HMO) 2016 Medicare Advantage Summary of Benefits HNE Premier 1 (HMO) and HNE Premier 2 (HMO) January 1, 2016 - December 31, 2016 H8578_2016_429 Accepted HNE MEDICARE ADVANTAGE ENROLLMENT KIT 2016 SECTION I

More information

Summary of Benefits. Health Partners Medicare Special (HMO SNP) 153967 HPM-415-15 SNP Benefits Book.indd 1

Summary of Benefits. Health Partners Medicare Special (HMO SNP) 153967 HPM-415-15 SNP Benefits Book.indd 1 2016 Health Partners Medicare 901 Market Street, Suite 500 Philadelphia, PA 19107 Visit us at HPPMedicare.com Summary of Benefits Health Partners Medicare Special (HMO SNP) H9207_HPM-415-16 Accepted 9/2015

More information

January 1, 2015 December 31, 2015 Summary of Benefits. Advantra (HMO) H3928-001 80.06.360.1-LA1

January 1, 2015 December 31, 2015 Summary of Benefits. Advantra (HMO) H3928-001 80.06.360.1-LA1 January, 205 December 3, 205 Summary of Benefits H3928-00 80.06.360.-LA Y0022_205_H3928_00_LA Accepted 9/204 Summary of Benefits January, 205 December 3, 205 This booklet gives you a summary of what we

More information

FIRSTCAROLINACARE INSURANCE COMPANY 2015 Summary of Benefits. FirstMedicare Direct PPO Plus (PPO)

FIRSTCAROLINACARE INSURANCE COMPANY 2015 Summary of Benefits. FirstMedicare Direct PPO Plus (PPO) FIRSTCAROLINACARE INSURANCE COMPANY 2015 Summary of Benefits FirstMedicare Direct PPO Plus (PPO) Chatham, Hoke, Lee, Montgomery, Moore, Richmond, Scotland Counties 1 P age SECTION I - INTRODUCTION TO SUMMARY

More information

L.A. Care s Medicare Advantage Special Needs Plan

L.A. Care s Medicare Advantage Special Needs Plan L.A. Care s Medicare Advantage Special Needs Plan Summary of Benefits 2008 for people with Medicare and Medi-Cal Thank you for your interest in L.A. Care Health Plan. Our plan is offered by L.A. CARE

More information

2016 Summary of Benefits

2016 Summary of Benefits 2016 Summary of Benefits Health Net Violet Option 3 (PPO) Douglas and Josephine counties, OR Benefits effective January 1, 2016 H5520 Health Net Life Insurance Company H5520_2016_0202 CMS Accepted 09162015

More information

Tribute. 2015 Summary of Benefits. Health Plan of Oklahoma. Tribute Health Plan of Oklahoma HMO SNP

Tribute. 2015 Summary of Benefits. Health Plan of Oklahoma. Tribute Health Plan of Oklahoma HMO SNP Tribute Health Plan of Oklahoma Tribute Health Plan of Oklahoma HMO SNP 2015 Summary of Benefits This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we

More information

2015 Summary of Benefits

2015 Summary of Benefits 2015 Summary of Benefits January 1, 2015 December 31, 2015 City of Houston Y0067_PRE_COH_SB_1014 IA 11/06/2014 HMO-COH-SB 2015 Section I Introduction to Summary of Benefits You have choices about how to

More information

January 1, 2016 December 31, 2016. Summary of Benefits. Aetna Medicare Value Plan (HMO) H3312-060 H3312.060.1

January 1, 2016 December 31, 2016. Summary of Benefits. Aetna Medicare Value Plan (HMO) H3312-060 H3312.060.1 January 1, 2016 December 31, 2016 Summary of Benefits H3312-060 H3312.060.1 Y0001_2016_H3312_060 Accepted 9/2015 Summary of Benefits January 1, 2016 December 31, 2016 This booklet gives you a summary of

More information

SCAN Classic (HMO) San Joaquin County 2016 Summary of Benefits. Y0057_SCAN_9240_2015F File & Use Accepted

SCAN Classic (HMO) San Joaquin County 2016 Summary of Benefits. Y0057_SCAN_9240_2015F File & Use Accepted SCAN Classic (HMO) San Joaquin County 2016 Summary of Benefits Y0057_SCAN_9240_2015F File & Use Accepted SCAN Classic (HMO) (a Medicare Advantage Health Maintenance Organization (HMO) offered by SCAN Health

More information

2015 Summary of Benefits

2015 Summary of Benefits 2015 Summary of Benefits Effective January 1, 2015, through December 31, 2015 H3952 Y0041_H3952_KS_15_18734 Accepted 09/01/2014 Section I: Introduction to Summary of Benefits You have choices about how

More information

SCAN Health Plan. 2015 Summary of Benefits

SCAN Health Plan. 2015 Summary of Benefits SCAN Health Plan 2015 Summary of Benefits Y0057_SCAN_8713_2014F File & Use Accepted 09032014 SCAN Classic (HMO) (a Medicare Advantage Health Maintenance Organization (HMO) offered by SCAN Health Plan with

More information

2015 Medicare Advantage Summary of Benefits

2015 Medicare Advantage Summary of Benefits 2015 Medicare Advantage Summary of Benefits HNE Medicare Premium No Rx and HNE Medicare Basic No Rx January 1, 2015 - December 31, 2015 H8578_2015_034 Accepted HNE MEDICARE ADVANTAGE ENROLLMENT KIT 2015

More information

Summary of Benefits January 1, 2016 December 31, 2016. FirstMedicare Direct PPO Plus (PPO)

Summary of Benefits January 1, 2016 December 31, 2016. FirstMedicare Direct PPO Plus (PPO) Summary of Benefits January 1, 2016 December 31, 2016 FIRSTCAROLINACARE INSURANCE COMPANY FirstMedicare Direct PPO Plus (PPO) Chatham, Hoke, Lee, Montgomery, Moore, Richmond, Scotland Counties This booklet

More information

Your Plan: Anthem Silver HMO 1500/30%/6550 Your Network: California Care HMO

Your Plan: Anthem Silver HMO 1500/30%/6550 Your Network: California Care HMO Your Plan: Anthem Silver HMO 1500/30%/6550 Your Network: California Care HMO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does

More information

SCAN Health Plan. 2015 Summary of Benefits

SCAN Health Plan. 2015 Summary of Benefits SCAN Health Plan 2015 Summary of Benefits Y0057_SCAN_8712_2014F File & Use Accepted 09032014 ( a Medicare Advantage Health Maintenance Organization (HMO) offered by SCAN Health Plan with a Medicare contract)

More information

Summary of Benefits. King, Pierce, Snohomish, Spokane and Thurston Counties. premera.com/ma

Summary of Benefits. King, Pierce, Snohomish, Spokane and Thurston Counties. premera.com/ma Summary of Benefits 2016 HMO King, Pierce, Snohomish, Spokane and Thurston Counties premera.com/ma Plus Section 1 Introduction to the and Plus This booklet gives you a summary of what we cover and what

More information

H9412_14238_8 File and Use 8/31/14

H9412_14238_8 File and Use 8/31/14 Introduction to Summary of s 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

More information

Service AvMed Cigna Leon Cares Humana HMO Humana PPO UnitedHealthcare. Out-of- Network

Service AvMed Cigna Leon Cares Humana HMO Humana PPO UnitedHealthcare. Out-of- Network 2016 Medicare Advantage Plans Comparison Chart This comparison chart is a side-by-side representation of services offered through the AvMed, Cigna, UHC, and Humana Medicare Advantage Plans for both in-network

More information

SUMMARY OF BENEFITS CARE1ST HEALTH PLAN. Care1st AdvantageOptimum Plan (HMO) California: Fresno, Merced, Stanislaus and San Joaquin Counties

SUMMARY OF BENEFITS CARE1ST HEALTH PLAN. Care1st AdvantageOptimum Plan (HMO) California: Fresno, Merced, Stanislaus and San Joaquin Counties SUMMARY OF BENEFITS January 1, 2016 - December 31, 2016 CARE1ST HEALTH PLAN 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

More information

2015 Summary of Benefits

2015 Summary of Benefits 2015 Summary of Benefits Plans 003 and 004 H6298_14_027 accepted 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

More information

January 1, 2016 December 31, 2016. Summary of Benefits. Aetna Medicare Prime Plan (HMO) H3931-087 H3931.087.1

January 1, 2016 December 31, 2016. Summary of Benefits. Aetna Medicare Prime Plan (HMO) H3931-087 H3931.087.1 January 1, 2016 December 31, 2016 Summary of Benefits H3931-087 H3931.087.1 Y0001_2016_H3931_087 Accepted 9/2015 Summary of Benefits January 1, 2016 December 31, 2016 This booklet gives you a summary of

More information

2015 Summary of Benefits

2015 Summary of Benefits 2015 Summary of Benefits January 1, 2015 December 31, 2015 Houston/Beaumont Area Y0067_PRE_H4506_SETX_SB41_0814 CMS Accepted 09/13/2014 HMO-SETX-SB K41 2015 Section I Introduction to Summary of Benefits

More information

2015 Summary of Benefits

2015 Summary of Benefits 2015 Summary of Benefits Effective January 1, 2015, through December 31, 2015 H3909 Y0041_H3909_PC_15_18889 Accepted 09/01/2014 Section I: Introduction to Summary of Benefits You have choices about how

More information

H3954_14238_3 File and Use 8/31/14

H3954_14238_3 File and Use 8/31/14 Introduction to Summary Of s 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

More information

2015 SUMMARY OF BENEFITS MICHIGAN: H5926 PLAN 001

2015 SUMMARY OF BENEFITS MICHIGAN: H5926 PLAN 001 2015 SUMMARY OF BENEFITS MICHIGAN: H5926 PLAN 001 MOLINA MEDICARE OPTIONS PLUS (HMO SNP) Genesee, Kent, Lapeer, Macomb, Montcalm, Oakland, Saginaw, and Wayne H5926_15_1061_0001_MISB Accepted 43005MED0714

More information

D-SNP Benefits. A Quick Guide to Understanding the AmeriHealth VIP Care D-SNP Benefits

D-SNP Benefits. A Quick Guide to Understanding the AmeriHealth VIP Care D-SNP Benefits D-SNP Benefits A Quick Guide to Understanding the AmeriHealth VIP Care D-SNP Benefits Benefits Why AmeriHealth VIP Care Was Created The dual-eligible special needs Medicare Advantage plan, AmeriHealth

More information

2015 Summary of Benefits

2015 Summary of Benefits 2015 Summary of Benefits Value (HMO-POS) Essentials Rx (HMO-POS) (H4270) January 1, 2015 - December 31, 2015 Western Wisconsin (26 Counties) H4270_082914_1 CMS Accepted (09032014) SECTION I INTRODUCTION

More information

CDPHP CLASSIC (PPO) CDPHP CORE RX (PPO) CDPHP CLASSIC RX (PPO) CDPHP PRIME RX (PPO)

CDPHP CLASSIC (PPO) CDPHP CORE RX (PPO) CDPHP CLASSIC RX (PPO) CDPHP PRIME RX (PPO) Introduction to the Summary of Benefits Report for CDPHP CLASSIC (PPO) CDPHP CORE RX (PPO) CDPHP CLASSIC RX (PPO) CDPHP PRIME RX (PPO) January 1, 2015 December 31, 2015 CAPITAL, CENTRAL, SOUTHERN TIER,

More information

2015 Summary of Benefits

2015 Summary of Benefits 2015 Summary of Benefits Health Net Ruby Select (HMO) Placer and Sacramento counties, CA Benefits effective January 1, 2015 H0562 Health Net of California, Inc. Material ID # H0562_2015_0285_B_CMS Accepted

More information

2016 Medicare Advantage Special Needs Plans (SNP) Full Dual Medicare & Medicaid Maricopa County

2016 Medicare Advantage Special Needs Plans (SNP) Full Dual Medicare & Medicaid Maricopa County 2016 Medicare Advantage Special Needs Plans (SNP) Full Dual Medicare & Medicaid Maricopa County Special Needs Plans for Dual Eligible beneficiaries are an HMO plan that limits their membership to people

More information

January 1, 2015 December 31, 2015. Summary of Benefits. Aetna Medicare Select Plan (HMO) H3623-018 58.06.360.1-OH3 B

January 1, 2015 December 31, 2015. Summary of Benefits. Aetna Medicare Select Plan (HMO) H3623-018 58.06.360.1-OH3 B January, 205 December 3, 205 Summary of Benefits H3623-08 58.06.360.-OH3 B Y000_205_H3623_08_OH Accepted 9/204 Summary of Benefits January, 205 December 3, 205 This booklet gives you a summary of what

More information

Summary of Benefits. Prime (HMO-POS) and Value (HMO) January 1, 2015 December 31, 2015 G ENERATIONS A DVANTAGE 1-888-408-8285 (TTY: 711)

Summary of Benefits. Prime (HMO-POS) and Value (HMO) January 1, 2015 December 31, 2015 G ENERATIONS A DVANTAGE 1-888-408-8285 (TTY: 711) Summary of s and January 1, 2015 December 31, 2015 G ENERATIONS A DVANTAGE For more information about benefits or enrollment, call us or visit our website at www.martinspoint.org/medicare. 1-888-408-8285

More information

2015 Summary of Benefits

2015 Summary of Benefits 2015 Summary of Benefits Health Net Healthy Heart (HMO) Placer and Sacramento counties, CA Benefits effective January 1, 2015 H0562 Health Net of California, Inc. Material ID # H0562_2015_0273 CMS Accepted

More information

Annual Notice of Changes for 2014

Annual Notice of Changes for 2014 True Blue Rx Option II (HMO) offered by Blue Cross of Idaho Health Service, Inc. (Blue Cross of Idaho) Annual Notice of Changes for 2014 You are currently enrolled as a member of True Blue Freedom (HMO).

More information

INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 SUMMARY OF BENEFITS

INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 SUMMARY OF BENEFITS INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 SUMMARY OF BENEFITS January 1, 2015 - December 31, 2015 CARE1ST HEALTH PLAN Care1st AdvantageOptimum Plan (HMO) Texas: El Paso County H5928_15_029_SB_EP INTRODUCTION

More information

January 1, 2015 December 31, 2015

January 1, 2015 December 31, 2015 BLUESHIELD FOREVER BLUE MEDICARE PPO VALUE AND BLUESHIELD MEDICARE PPO 750 (PPO) (a Medicare Advantage Preferred Provider Organization (PPO) offered by HEALTHNOW NEW YORK INC. with a Medicare contract)

More information

2014 Summary of Benefits

2014 Summary of Benefits 2014 Summary of Benefits An Independent Licensee of the Blue Cross and Blue Shield Association SM P.O. BOX 15349 Tallahassee, Florida 32317-5349 H5938_DP 471 CMS Accepted 08312013 SECTION I INTRODUCTION

More information

2014 Medicare Advantage Summary of Benefits HNE MEDICARE PREMIUM NO RX (HMO) HNE MEDICARE BASIC NO RX (HMO)

2014 Medicare Advantage Summary of Benefits HNE MEDICARE PREMIUM NO RX (HMO) HNE MEDICARE BASIC NO RX (HMO) 2014 Medicare Advantage Summary of Benefits HNE MEDICARE PREMIUM NO RX (HMO) HNE MEDICARE BASIC NO RX (HMO) HNE MEDIC ARE ADV ANTAGE ENROLLMENT KIT 2014 H8578_2014_034 Accepted SECTION I - INTRODUCTION

More information

2015 Summary of Benefits

2015 Summary of Benefits 2015 Summary of Benefits Health Net Ruby Select (HMO) Maricopa and Pinal counties Benefits effective January 1, 2015 H0351 Health Net of Arizona, Inc. Material ID # H0351_2015_0258 CMS Accepted 08302014

More information

2015 Summary of Benefits

2015 Summary of Benefits 2015 Summary of Benefits Health Net Ruby (HMO) Benton, Clackamas, Lane, Linn, Marion, Multnomah, Polk, Washington and Yamhill counties, OR Benefits effective January 1, 2015 H6815 Health Net Health Plan

More information

of BenefitS Cigna-HealthSpring Preferred (Hmo) H4513-024 - 2 2014 Cigna H4513_15_19942 Accepted

of BenefitS Cigna-HealthSpring Preferred (Hmo) H4513-024 - 2 2014 Cigna H4513_15_19942 Accepted agesummary of BenefitS Cover erage Cigna-HealthSpring Preferred (Hmo) H4513-024 - 2 2014 Cigna H4513_15_19942 Accepted SeCtion i - introduction to Summary of BenefitS you have choices about how to get

More information

Your Plan: Anthem Bronze PPO 5500/30%/6450 w/hsa Your Network: Prudent Buyer PPO

Your Plan: Anthem Bronze PPO 5500/30%/6450 w/hsa Your Network: Prudent Buyer PPO Your Plan: Anthem Bronze PPO 5500/30%/6450 w/hsa Your Network: Prudent Buyer PPO This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does

More information

2015 Summary of Benefits

2015 Summary of Benefits 2015 Summary of Benefits Colorado Access Advantage Summit Plan (HMO SNP) COLORADO ACCESS ADVANTAGE SUMMIT PLAN (HMO SNP) Summary of Benefits January 1, 2015 - December 31, 2015 This booklet gives you a

More information

Health Alliance Plan. Coverage Period: 01/01/2014-12/31/2014. document at www.hap.org or by calling 1-800-759-3436.

Health Alliance Plan. Coverage Period: 01/01/2014-12/31/2014. document at www.hap.org or by calling 1-800-759-3436. Health Alliance Plan Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 01/01/2014-12/31/2014 Coverage for: Individual Family Plan Type: HMO This is only a summary.

More information

Introduction to Summary of Benefits

Introduction to Summary of Benefits Introduction to Summary of Benefits Section I CENTRAL HEALTH MEDICARE PLAN (HMO), CENTRAL HEALTH MEDI-MEDI PLAN (HMO SNP), CENTRAL HEALTH PREMIER PLAN (HMO), and CENTRAL HEALTH FOCUS PLAN (HMO SNP) (a

More information

Summary of Benefits. Service To Seniors (HMO) and OC Preferred (HMO) It s Personal. Medicare Specialist Scott Pratt Se Habla Español.

Summary of Benefits. Service To Seniors (HMO) and OC Preferred (HMO) It s Personal. Medicare Specialist Scott Pratt Se Habla Español. 2015 Summary of Benefits Service To Seniors (HMO) and OC Preferred (HMO) Medicare Specialist Scott Pratt Se Habla Español. It s Personal. H0545_RAY2012_xxx CMS Approved: xx/xx/2012 H0545_FUY2015_18 Accepted

More information

ROCHESTER INSTITUTE OF TECHNOLOGY 2014 Medical Benefits Comparison Chart Medicare-Eligible Retirees in the Rochester Area

ROCHESTER INSTITUTE OF TECHNOLOGY 2014 Medical Benefits Comparison Chart Medicare-Eligible Retirees in the Rochester Area Contacting the Carrier Voice: (877) 883-9577 TTY: (585) 454-2845 Website: Voice: (800) 665-7924 TTY: (800) 252-2452 Website: www.excellusbcbs.com www.mvphealthcare.com Deductible Carry Over None None Deductible,

More information

Summary of Benefits JANUARY 1 THROUGH DECEMBER 31, 2015. HealthPlus MedicarePlus Essential HealthPlus MedicarePlus Classic CMS Contract #H1595

Summary of Benefits JANUARY 1 THROUGH DECEMBER 31, 2015. HealthPlus MedicarePlus Essential HealthPlus MedicarePlus Classic CMS Contract #H1595 Summary of Benefits JANUARY 1 THROUGH DECEMBER 31, 2015 HealthPlus MedicarePlus Essential HealthPlus MedicarePlus Classic CMS Contract #H1595 For Medicare-eligible beneficiaries residing in Arenac, Bay,

More information

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services?

Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.etf.wi.gov or by calling 1-877-533-5020. Important Questions

More information

What is the overall deductible? $250 per person/$500 per family. Are there other deductibles for specific services? No.

What is the overall deductible? $250 per person/$500 per family. Are there other deductibles for specific services? No. This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.etf.wi.gov or by calling 1-877-533-5020. Important Questions

More information

January 1, 2016 December 31, 2016. Summary of Benefits. Coventry Medicare Advantage Total Care (HMO) H2672-009 H2672.009.1

January 1, 2016 December 31, 2016. Summary of Benefits. Coventry Medicare Advantage Total Care (HMO) H2672-009 H2672.009.1 January 1, 2016 December 31, 2016 Summary of Benefits H2672-009 H2672.009.1 Y0001_2016_H2672_009 Accepted 9/2015 Summary of Benefits January 1, 2016 December 31, 2016 This booklet gives you a summary of

More information

January 1, 2016 December 31, 2016. Summary of Benefits. Aetna Medicare Connect Plus (HMO) H3931-088 H3931.088.1

January 1, 2016 December 31, 2016. Summary of Benefits. Aetna Medicare Connect Plus (HMO) H3931-088 H3931.088.1 January 1, 2016 December 31, 2016 Summary of Benefits H3931-088 H3931.088.1 Y0001_2016_H3931_088 Accepted 9/2015 Summary of Benefits January 1, 2016 December 31, 2016 This booklet gives you a summary of

More information

SUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. Laramie County School District 2 Open Access Plus Base - Effective 7/1/2015

SUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. Laramie County School District 2 Open Access Plus Base - Effective 7/1/2015 SUMMARY OF BENEFITS Cigna Health and Life Insurance Co. Laramie County School District 2 Open Access Plus Base - Effective General Services In-Network Out-of-Network Physician office visit Urgent care

More information

Cost Sharing Definitions

Cost Sharing Definitions SU Pro ( and ) Annual Deductible 1 Coinsurance Cost Sharing Definitions $200 per individual with a maximum of $400 for a family 5% of allowable amount for inpatient hospitalization - or - 50% of allowable

More information

INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 SUMMARY OF BENEFITS

INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 SUMMARY OF BENEFITS INTRODUCTION TO SUMMARY OF BENEFITS SECTION 1 SUMMARY OF BENEFITS January 1, 2015 - December 31, 2015 CARE1ST HEALTH PLAN California:,, San Bernardino and Counties Coordinated Choice California: Alameda,

More information

Section IV - Information for People with Medicare and Medicaid

Section IV - Information for People with Medicare and Medicaid TM Section IV - Information for People with Medicare and People who qualify for Medicare and are known as dual eligibles. As a dual eligible, you are eligible for benefits under both the federal Medicare

More information

Blue Shield 65 Plus Choice Plan (HMO) Blue Shield 65 Plus (HMO) summary of benefits

Blue Shield 65 Plus Choice Plan (HMO) Blue Shield 65 Plus (HMO) summary of benefits summary of benefits Los Angeles (partial) & Orange Counties January 1, 2015 to 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

More information

Providence Health Plan is an HMO and HMO-POS health plan with a Medicare contract. Enrollment in Providence Health Plan depends on contract renewal.

Providence Health Plan is an HMO and HMO-POS health plan with a Medicare contract. Enrollment in Providence Health Plan depends on contract renewal. Providence Health Plan is an HMO and HMO-POS health plan with a Medicare contract. Enrollment in Providence Health Plan depends on contract renewal. Section 1 Introduction to the Summary of Benefits for

More information

Summary of Services and Cost Shares

Summary of Services and Cost Shares Summary of Services and Cost Shares This summary does not describe benefits. For the description of a benefit, including any limitations or exclusions, please refer to the identical heading in the Benefits

More information

SUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. Grand County Open Access Plus Effective 1/1/2015

SUMMARY OF BENEFITS. Cigna Health and Life Insurance Co. Grand County Open Access Plus Effective 1/1/2015 SUMMARY OF BENEFITS Cigna Health and Life Insurance Co. Grand County Open Access Plus Effective General Services In-Network Out-of-Network Primary care physician You pay $25 copay per visit Physician office

More information

2015 Summary of Benefits Aultimate Plan (HMO-POS) E00060

2015 Summary of Benefits Aultimate Plan (HMO-POS) E00060 2015 Summary of Benefits Aultimate Plan (HMO-POS) E00060 H3664_E00060SB_15 Accepted 08312014 SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS You have choices about how to get your Medicare benefits One

More information

Essentials Choice Rx 24 (HMO-POS) offered by PacificSource Medicare

Essentials Choice Rx 24 (HMO-POS) offered by PacificSource Medicare Essentials Choice Rx 24 (HMO-POS) offered by PacificSource Medicare Annual Notice of Changes for 2016 You are currently enrolled as a member of Essentials Choice Rx 24 (HMO-POS). Next year, there will

More information

Essentials Choice Rx 25 (HMO-POS) offered by PacificSource Medicare

Essentials Choice Rx 25 (HMO-POS) offered by PacificSource Medicare Essentials Choice Rx 25 (HMO-POS) offered by PacificSource Medicare Annual Notice of Changes for 2016 You are currently enrolled as a member of Essentials Choice Rx 25 (HMO-POS). Next year, there will

More information

Annual Notice of Changes for 2015

Annual Notice of Changes for 2015 Cigna HealthSpring Premier (HMO POS) offered by Cigna HealthSpring Annual Notice of Changes for 2015 You are currently enrolled as a member of Cigna HealthSpring Premier (HMO POS). Next year, there will

More information

2015 Summary of Benefits

2015 Summary of Benefits 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

More information

Aetna Medicare Advantage HMO SHBP Summary of Benefits and Coverage: What this Plan Covers & What it Costs

Aetna Medicare Advantage HMO SHBP Summary of Benefits and Coverage: What this Plan Covers & What it Costs This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.state.nj.us/treasury/pensions/health-benefits.shtml or

More information

Greater Tompkins County Municipal Health Insurance Consortium

Greater Tompkins County Municipal Health Insurance Consortium WHO IS COVERED Requires both Medicare A & B enrollment. Type of Coverage Offered Single only Single only MEDICAL NECESSITY Pre-Certification Requirement None None Medical Benefit Management Program Not

More information

2016 SUMMARY OF BENEFITS MEDICARE ADVANTAGE PLANS

2016 SUMMARY OF BENEFITS MEDICARE ADVANTAGE PLANS 2016 SUMMARY OF BENEFITS MEDICARE ADVANTAGE PLANS California Santa Clara County H5087 January 1, 2016 - December 31, 2016 Easy Choice Best Plan (HMO) Plan 014 H5087_CA030093_WCM_SOB_ENG CMS Accepted WellCare

More information

Important Questions Answers Why this Matters: What is the overall deductible?

Important Questions Answers Why this Matters: What is the overall deductible? Molina Healthcare of Ohio, Inc.: Molina Gold Plan Coverage Period: 01/01/2016-12/31/2016 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual + Family ǀ Plan

More information

Greater Tompkins County Municipal Health Insurance Consortium

Greater Tompkins County Municipal Health Insurance Consortium WHO IS COVERED Requires Covered Member to be Enrolled in Both Medicare Parts A & B Type of Coverage Offered Single only Single only MEDICAL NECESSITY Pre-Certification Requirement Not Applicable Not Applicable

More information

SUMMARY OF BENEFITS 2016 EmblemHealth PPO I and EmblemHealth Advantage (PPO) Bronx, Kings, New York, Nassau, Queens Richmond, Suffolk and Westchester

SUMMARY OF BENEFITS 2016 EmblemHealth PPO I and EmblemHealth Advantage (PPO) Bronx, Kings, New York, Nassau, Queens Richmond, Suffolk and Westchester SUMMARY OF BENEFITS 2016 and Bronx, Kings, New York, Nassau, Queens Richmond, Suffolk and Westchester January 1, 2016 December 31, 2016 H5528_125910 Accepted 9/13/2015 SECTION I - INTRODUCTION TO SUMMARY

More information

What is the overall deductible? Are there other deductibles for specific services?

What is the overall deductible? Are there other deductibles for specific services? This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.anthem.com/cuhealthplan or by calling 1-800-735-6072.

More information

January 1, 2015 December 31, 2015. Summary of Benefits. Aetna Medicare Premier Plan (PPO) H5521-081 58.06.362.1-NC1

January 1, 2015 December 31, 2015. Summary of Benefits. Aetna Medicare Premier Plan (PPO) H5521-081 58.06.362.1-NC1 January, 205 December 3, 205 Summary of Benefits H552-08 58.06.362.-NC Y000_205_H552_08_NC Accepted 9/20 Summary of Benefits January, 205 December 3, 205 This booklet gives you a summary of what we cover

More information

January 1, 2015 December 31, 2015. Summary of Benefits. Aetna Medicare Premier Plan (PPO) H5521-081 58.06.362.1-NC1

January 1, 2015 December 31, 2015. Summary of Benefits. Aetna Medicare Premier Plan (PPO) H5521-081 58.06.362.1-NC1 January 1, 2015 December 31, 2015 Summary of Benefits H5521-081 58.06.362.1-NC1 Y0001_2015_H5521_081_NC Accepted 9/2014 Summary of Benefits January 1, 2015 December 31, 2015 This booklet gives you a summary

More information

SUMMARY OF BENEFITS. Cigna-HealthSpring Traditions (HMO SNP) H2108-020. January 1, 2016 - December 31, 2016. 2015 Cigna H2108_16_32732 Accepted

SUMMARY OF BENEFITS. Cigna-HealthSpring Traditions (HMO SNP) H2108-020. January 1, 2016 - December 31, 2016. 2015 Cigna H2108_16_32732 Accepted SUMMARY OF BENEFITS January 1, 2016 - December 31, 2016 Cigna-HealthSpring Traditions (HMO SNP) H2108-020 2015 Cigna H2108_16_32732 Accepted SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS This booklet

More information

2016 Summary of Benefits

2016 Summary of Benefits 2016 Summary of Benefits Health Net Healthy Heart (HMO) Alameda and Stanislaus counties, CA Benefits effective January 1, 2016 H0562 Health Net of California, Inc. H0562_2016_0171 CMS Accepted 09172015

More information

SUMMARY OF BENEFITS. Cigna-HealthSpring. Preferred (HMO) H9725-001. January 1, 2016 - December 31, 2016. 2015 Cigna H9725_16_32700 Accepted

SUMMARY OF BENEFITS. Cigna-HealthSpring. Preferred (HMO) H9725-001. January 1, 2016 - December 31, 2016. 2015 Cigna H9725_16_32700 Accepted SUMMARY OF BENEFITS January 1, 2016 - December 31, 2016 Cigna-HealthSpring Preferred (HMO) H9725-001 2015 Cigna H9725_16_32700 Accepted SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS This booklet gives

More information

BlueCHiP for Medicare Group Plus (HMO) Summary of Benefits. January 1, 2015 - December 31, 2015

BlueCHiP for Medicare Group Plus (HMO) Summary of Benefits. January 1, 2015 - December 31, 2015 BlueCHiP for Medicare Group Plus (HMO) 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

More information

Effective January 1, 2014 through December 31, 2014

Effective January 1, 2014 through December 31, 2014 Summary of Benefits Effective January 1, 2014 through December 31, 2014 The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.

More information

Senate Bill 91 (2011) Standard Plan - EHB and Cost Share Matrix - Updated for 2016 ***NOT INTENDED AS A STATEMENT OF COVERAGE***

Senate Bill 91 (2011) Standard Plan - EHB and Cost Share Matrix - Updated for 2016 ***NOT INTENDED AS A STATEMENT OF COVERAGE*** Deductible Medical: $1,250; Medical: $2,500; Integrated Medical/Rx: Rx: $0 Rx: $0 $5,000 Maximum OOP Combined Medical Combined Medical Combined Medical and and Drug: $6,350 and Drug: $6,350 Drug: $6,350

More information

SUMMARY OF BENEFITS. Cigna-HealthSpring. Preferred (HMO) H2108-022. January 1, 2016 - December 31, 2016. 2015 Cigna H2108_16_32731 Accepted

SUMMARY OF BENEFITS. Cigna-HealthSpring. Preferred (HMO) H2108-022. January 1, 2016 - December 31, 2016. 2015 Cigna H2108_16_32731 Accepted SUMMARY OF BENEFITS January 1, 2016 - December 31, 2016 Cigna-HealthSpring Preferred (HMO) H2108-022 2015 Cigna H2108_16_32731 Accepted SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS This booklet gives

More information

Coventry Advantra (HMO) Teachers Retiree Insurance Program January 1, 2015 - December 31, 2015 (a Medicare Advantage Health Maintenance Organization

Coventry Advantra (HMO) Teachers Retiree Insurance Program January 1, 2015 - December 31, 2015 (a Medicare Advantage Health Maintenance Organization Coventry Advantra (HMO) Teachers Retiree Insurance Program January 1, 2015 - December 31, 2015 (a Medicare Advantage Health Maintenance Organization (HMO) offered by Coventry Health Care with a Medicare

More information

ANNUAL NOTICE OF CHANGES FOR 2016

ANNUAL NOTICE OF CHANGES FOR 2016 Cigna-HealthSpring Preferred (HMO) offered by Cigna-HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna-HealthSpring Preferred (HMO). Next year, there will be

More information

Blue Cross Premier Bronze Extra

Blue Cross Premier Bronze Extra An individual PPO health plan from Blue Cross Blue Shield of Michigan. You will have a broad choice of doctors and hospitals within Blue Cross Blue Shield of Michigan s unsurpassed statewide PPO network

More information

Important Questions Answers Why this Matters: What is the overall deductible?

Important Questions Answers Why this Matters: What is the overall deductible? This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.uhs.wisc.edu/ship or by calling 1-866-796-7899. Important

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com or by calling 1-800-756-3702.

More information

Covered 100% No deductible Not Applicable (exam, related tests and x-rays, immunizations, pap smears, mammography and screening tests)

Covered 100% No deductible Not Applicable (exam, related tests and x-rays, immunizations, pap smears, mammography and screening tests) A AmeriHealth EPO Individual Summary of Benefits Value Network IHC EPO $30/50% Benefit Network Non network Benefit Period+ Calendar year Individual deductible $2,500 Family deductible $5,000 50% Individual

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.studentplanscenter.com or by calling 1-800-756-3702.

More information

Important Questions Answers Why this Matters: What is the overall deductible?

Important Questions Answers Why this Matters: What is the overall deductible? Important Questions Answers Why this Matters: What is the overall deductible? Are there other deductibles for specific services? Is there an out of pocket limit on my expenses? What is not included in

More information

Lesser of $200 or 20% (surgery) $10 per visit. $35 $100/trip $50/trip $75/trip $50/trip

Lesser of $200 or 20% (surgery) $10 per visit. $35 $100/trip $50/trip $75/trip $50/trip HOSPITAL SERVICES Hospital Inpatient : Paid in full, Non-network: Hospital charges subject to 10% of billed charges up to coinsurance maximum. Non-participating provider charges subject to Basic Medical

More information

Important Questions Answers Why this Matters:

Important Questions Answers Why this Matters: UnitedHealthcare Life Ins Co: Platinum Copay Select Coverage Period: Beginning on or after 01/01/2015 Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage for: Individual/Family

More information