Medicare Summary of Benefits January 1, 2016 December 31, Front Range Colorado

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1 Medicare Summary of Benefits January 1, 2016 December 31, 2016 Front Range Colorado H0602_MC_SB_FR_ Accepted RMHP is a Medicare approved Cost plan. Enrollment in RMHP depends on contract renewal. SB FR 1015

2 Summary of Benefits January 1, December 31, 2016 This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the "Evidence of Coverage." You have choices about how to get your Medicare benefits One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Cost plan (such as Green Plan,,, or Rocky Mountain.) Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what, Rocky Mountain,, and cover 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,, Rocky Mountain, and Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Optional Benefits (you must pay an extra premium for these benefits) This document is available in other formats such as Braille, in large print, or other formation if you need it. This document may be available in a non-english language. For additional information, call us at (TTY dial 711). Este documento puede estar a disposición en otro idioma aparte del inglés. Para más información, por favor llámenos al (TTY dial 711). RMHP is a Medicare-approved Cost plan. Enrollment in RMHP depends on contract renewal. Benefits, premiums, copayments, and coinsurance may change on January 1, The provider network may change at any time. You will receive notice when necessary. 2

3 Things to Know About Health Plans (RMHP) Hours of operation From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Mountain time. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Mountain time. RMHP Phone Numbers and Website If you are a Member of these plans, call toll-free (TTY dial 711). If you are not a Member of these plans, call toll-free (TTY dial 711). Our website: Who can join? To join,, Standard Plan, or, you must be enrolled in Medicare Part B (or have both Medicare Part A and Medicare Part B), and live in our service area. Our service area includes the following counties in Colorado: Bent, Cheyenne, Clear Creek, Crowley, Custer, El Paso, Elbert, Fremont, Gilpin, Huerfano, Kiowa, Kit Carson, Larimer, Las Animas, Lincoln, Logan, Morgan, Otero, Park, Phillips, Prowers, Pueblo, Sedgwick, Teller, Washington, Weld, and Yuma. Which doctors and hospitals can I use? RMHP has a network of doctors, hospitals, and other providers. If you use the providers in our network, you may pay less for your covered services. But if you want to, you can also use providers that are not in our network. You can see our plan's provider at our website ( Or call us and we will send you a copy of the provider directory. What do we cover? 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. We cover Part B drugs including chemotherapy and some drugs administered by your provider. However, these plans do not cover Part D prescription drugs. You may also join a separate Medicare Prescription Drug Plan. 3

4 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is the monthly premium? $20 per month. $40 per month. $55 per month. $175 per month. In addition, you must keep paying your Medicare Part B premium. How much is the deductible? This plan has deductibles for some hospital and medical services. $600 per year for in-network services. This plan has deductibles for some hospital and medical services. $450 per year for in-network services. This plan has deductibles for some hospital and medical services. $200 per year for in-network services. Is there any limit on how much I will pay for my covered services? This plan has deductibles for some hospital and medical services. Yes. Our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers. $6,000 for services you receive from in-network providers. $4,500 for services you receive from in-network providers. $4,500 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? No. There are no limits on how much our plan will pay. 4

5 Covered Medical and Hospital Benefits Services with a 1 may require prior authorization. Outpatient Care and Services Acupuncture Not covered. Ambulance 1 $200 copay. $200 copay. $200 copay. $100 copay. Note: Medical deductible applies to non-emergency transportation 1 by ambulance. There is no deductible for. See deductible information on page 4. Chiropractic Care Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): 20% of the cost. Dental Services 1 Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): $25-$2,450 copay depending on the service, after you pay your deductible. $20-$1,250 copay, depending on the service, after you pay your deductible. See deductible information on page 4. Also see Optional Benefit Package 1: Dental Services. $20-$700 copay, depending on the service, after you pay your deductible. $15-$500 copay, depending on the service, after you pay your deductible. Note: Optional dental plan deductible applies to basic and major dental services provided under Optional Benefit Package 1: Dental Services. There is no deductible on Medicarecovered dental care. 5

6 Diabetes Supplies and Services Diabetes monitoring supplies: 20% of the cost. Diabetes self-management training: You pay nothing. Therapeutic shoes or inserts: 20% of the cost. Diagnostic Tests, Lab and Radiology Services, and X-rays 1 (Costs for these services may be different if received in an outpatient setting) Diagnostic radiology services (such as MRIs, CT scans): 20% of the cost. $150-$200 copay, Diagnostic tests and procedures: $75-$150 copay, $75-$150 copay, $0-$400 copay, $0-$400 copay, $0-$350 copay, $0-$300 copay, Lab services: You pay nothing. Outpatient x-rays: $25 copay. $20 copay. $20 copay. $15 copay. Therapeutic radiology services (such as radiation treatment for cancer): 20% of the cost. If your doctor provides additional services, a separate office visit copay may apply. Diagnostic radiology also includes: PET scans/ultrasounds/nuclear medicine. Deductible applies to therapeutic radiology and some outpatient services. There is no deductible for. See deductible information on page 4. Doctor's Office Visits 1 Primary care physician visit: $25 copay. $20 copay. $20 copay. $15 copay. Specialist visit: $55 copay. $50 copay. $45 copay. $40 copay. Note: Also see Preventive Care. 6

7 Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 20% of the cost. Medical deductible applies to Durable Medical Equipment. After medical deductible, you pay 20% of the cost for disposable medical supplies. There is no deductible for. See deductible information on page 4. Emergency Care $75 copay. $65 copay. $65 copay. $50 copay. 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. Emergency care coverage is provided worldwide. The copay for emergency care is waived only if admitted to hospital for the same condition. Foot Care (podiatry services) Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $55 copay. $50 copay. $45 copay. $40 copay. Hearing Services Exam to diagnose and treat hearing and balance issues: $25-$55 copay, $20-$50 copay, $20-$45 copay, $15-$40 copay, Routine hearing exam (for up to 1 every year): $25 copay. $20 copay. $20 copay. $15 copay. Routine hearing exams must be provided by RMHPs specified audiology network. Routine hearing exams are not covered by Original Medicare. Copays for routine hearing exams do not count toward the maximum out-of-pocket. Home Health Care You pay nothing. 7

8 Mental Health Care 1 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 does not apply to inpatient mental services provided in a general hospital. The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. There's no limit to the number of benefit periods. 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. $350 copay per day for days 1 through 7. $250 copay per day for days 1 through 5. $700 copay per stay. $500 copay per stay. You pay nothing per day for days 8 through 90. You pay nothing per day for days 6 through 90. Outpatient group therapy visit: $55 copay. $50 copay. $45 copay. $40 copay. Outpatient individual therapy visit: $55 copay. $50 copay. $45 copay. $40 copay. Medical deductible applies to inpatient mental health care. There is no deductible for Rocky Mountain. See deductible information on page 4. See Inpatient Hospital Care for the cost-sharing for lifetime reserve days. The per-day cost-sharing for partial hospitalization services is the same as outpatient therapy above. 8

9 Outpatient Rehabilitation Cardiac (heart) rehabilitation services (for a maximum of 2 one-hour sessions per day for up to 36 sessions, up to 36 weeks): You pay nothing. Occupational therapy visit: $25 copay. $20 copay. $20 copay. $15 copay. Physical therapy and speech and language therapy visit: $25 copay. $20 copay. $20 copay. $15 copay. Medical deductible applies to all outpatient rehabilitation services/visits. After the deductible, you pay nothing for Medicare-covered pulmonary rehabilitation services. There is no deductible for. See deductible information on page 4. Outpatient Substance Abuse 1 Group therapy visit: $55 copay. $50 copay. $45 copay. $40 copay. Individual therapy visit: $55 copay. $50 copay. $45 copay. $40 copay. Outpatient Surgery 1 Ambulatory surgical center: $400 copay. $400 copay. $350 copay. $300 copay. Outpatient hospital: $400 copay. $400 copay. $350 copay. $300 copay. Note: Deductible applies to outpatient surgery services at an Ambulatory surgical center or outpatient hospital. There is no deductible for. See deductible information on page 4. 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. Note: Deductible applies to prosthetic devices and medical supplies. There is no deductible for Rocky Mountain. See deductible information on page 4. 9

10 Renal Dialysis 20% of the cost. Note: Deductible applies to outpatient renal dialysis. There is no deductible for. See deductible information on page 4. Transportation Not covered. Urgently Needed Services $55 copay. $50 copay. $45 copay. $40 copay. Note: Urgent care coverage is provided worldwide. Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-$55 copay, depending on the service. $0-$50 copay, depending on the service. $0-$45 copay, depending on the service. $0-$40 copay, depending on the service. Routine eye exam (for up to 1 every year): $25 copay. $20 copay. $20 copay. $15 copay. Eyeglasses or contact lenses after cataract surgery: You pay nothing. Medical deductible applies to Medicare-covered eyeglasses or contacts. There is no deductible for. See deductible information on page 4. You pay nothing for an annual glaucoma screening. Copays for routine eye exams do not count toward the maximum out-of-pocket. Also see Optional Benefit Package 2: Vision Services. 10

11 Preventive 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. Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy). Depression screening. Diabetes screenings. 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. RMHP offers a fitness benefit on some plans. See page 15 for more information. RMHP covers a routine physical every year. If your doctor provides non-preventive services during the preventive visit, cost-sharing may apply. Visit for more on preventive services. Hospice You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details. 11

12 Inpatient Care Inpatient Hospital Care The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. There's no limit to the number of benefit periods. 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. $350 copay per day for days 1 through 7. You pay nothing per day for days 8 through 90. $250 copay per day for days 1 through 5. You pay nothing per day for days 6 through 90. $700 copay per stay. $500 copay per stay. Medical deductible applies for inpatient hospital care. There is no deductible for. See deductible information on page 4. Cost per lifetime reserve day: $350 copay per day for days 1 through 7 (per benefit period). Inpatient Mental Health Care $250 copay per day for days 1 through 5 (per benefit period). You pay nothing. You pay nothing. 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. You pay nothing per day for days 1 through 20. $100 copay per day for days 21 through 100. $100 copay per day for days 21 through 100. $95 copay per day for days 21 through 100. $95 copay per day for days 21 through 100. Note: Medical deductible applies for SNF care. There is no deductible for. See deductible information on page 4. 12

13 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 plans do not cover Part D prescription drugs. Optional Benefits (you must pay an extra premium each month for these benefits) Package 1: Dental Services Benefits include: Preventive Dental Comprehensive Dental How much is the monthly premium? Additional $20 per month. You must keep paying your Medicare Part B premium and your $20 monthly plan premium. You must keep paying your Medicare Part B premium and your $40 monthly plan premium. You must keep paying your Medicare Part B premium and your $55 monthly plan premium. You must keep paying your Medicare Part B premium and your $175 monthly plan premium. How much is the deductible? $50 per year. This package has additional deductibles for some services. Is there any limit on how much the plan will pay? Our plan pays up to $1,500 every year. Our plan has additional coverage limits for certain benefits. You pay 30% of the cost for preventive services (deductible does not apply). After the deductible: 50% of the cost for x-rays, simple extractions, pain treatment, & fillings. 70% of the cost for endodontic/periodontic services. Must use Delta Dental providers. Cost-sharing does not count toward the medical maximum out-of-pocket. 13

14 Package 2: Vision Services Benefits include: Eyewear How much is the monthly premium? Additional $12 per month. You must keep paying your Medicare Part B premium and your $20 monthly plan premium. You must keep paying your Medicare Part B premium and your $40 monthly plan premium. How much is the deductible? This package does not have a deductible. Is there any limit on how much the plan will pay? You must keep paying your Medicare Part B premium and your $55 monthly plan premium. You must keep paying your Medicare Part B premium and your $175 monthly plan premium. Our plan pays up to $130 every year. Our plan has additional coverage limits for certain benefits. You pay nothing for: An annual vision exam. One set of single-vision, lined bifocal, or lined trifocal lenses per year. $130 allowance covers one set of frames OR contact lenses (not both). Additional discounts available. Must use VSP providers. Cost-sharing does not count toward the medical maximum out-of-pocket. 14

15 Additional information about Health Plans Silver&Fit Exercise & Healthy Aging Program The Silver&Fit Exercise & Healthy Aging Program is a fitness program designed to help seniors stay active and improve their health. You pay nothing for: Access to a website with online tools, fitness facility locator, challenges, trackers, and fitness apps. Quarterly newsletters with nutrition, exercise, weight management, and other articles geared toward older adults. Access to 48 healthy aging education at-home classes. You also have access to: A basic fitness center membership at participating fitness centers for a $75 yearly copay (paid directly to the fitness center). Two at-home fitness kits for a yearly $10 copay. Available on the following plans:... Not offered on the. Covered Services RMHP covers all benefits covered by Original Medicare. RMHP also covers additional supplemental benefits that Original Medicare does not cover. Additional benefits include a routine physical exam, a hearing exam, and a vision exam. RMHP also offers optional dental and vision packages (you must pay an extra premium each month for these benefits.) Enrollment in these benefit packages is voluntary. Out-of-Network Providers You can use Medicare providers that are not in the RMHP network. Except for emergent or urgently needed care, or care that is prior authorized, you will have to pay Original Medicare cost-sharing. 15

16 Multi language Interpreter Services English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at Someone who speaks English/Language can help you. This is a free service. Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Chinese Mandarin: 我 们 提 供 免 费 的 翻 译 服 务, 帮 助 您 解 答 关 于 健 康 或 药 物 保 险 的 任 何 疑 问 如 果 您 需 要 此 翻 译 服 务, 请 致 电 我 们 的 中 文 工 作 人 员 很 乐 意 帮 助 您 这 是 一 项 免 费 服 务 Chinese Cantonese: 您 對 我 們 的 健 康 或 藥 物 保 險 可 能 存 有 疑 問, 為 此 我 們 提 供 免 費 的 翻 譯 服 務 如 需 翻 譯 服 務, 請 致 電 我 們 講 中 文 的 人 員 將 樂 意 為 您 提 供 幫 助 這 是 一 項 免 費 服 務 Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling wika, tawagan lamang kami sa Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí. German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화 번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. H0602_MA_MLIS_ Accepted 07/27/2012

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18 RMHP Customer Service HOURS... 8:00 a.m. to 8:00 p.m., Mountain Time, October 1 February 14, 7 days/week 8:00 a.m. to 8:00 p.m., Mountain Time, February 15 September 30, Monday Friday CALL / Customer Service also has free language interpreter services available for non-english speakers. TTY... Dial 711 for Relay Colorado This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking [email protected] FAX WEBSITE... WRITE... Health Plans Attn: Customer Service PO Box Grand Junction, CO