Molina Dual Options: Summary of Benefits

Transcription

1 Mlina Dual Optins: Summary f Benefits H2533_15_16900_0001_MMPSCSB Apprved This is a summary f health services cvered by Mlina Dual Optins Medicare-Medicaid Plan fr This is nly a summary. Please read the Member Handbk fr the full list f benefits. Mlina Dual Optins is a health plan that cntracts with bth Medicare and Suth Carlina Healthy Cnnectins Medicaid t prvide benefits f bth prgrams t enrllees. This cmbined prgram is called Healthy Cnnectins Prime. It is fr peple with bth Medicare and Healthy Cnnectins Medicaid wh are 65 r lder, have Medicare Parts A, B, and D, and are eligible fr full Healthy Cnnectins Medicaid benefits. Mre infrmatin abut wh is eligible can be fund in Chapter 1 f the Member Handbk. Under Mlina Dual Optins yu can get yur Medicare and Healthy Cnnectins Medicaid services in ne health plan. A Mlina Dual Optins care crdinatr will help manage yur health care needs. This is nt a cmplete list. The benefit infrmatin is a brief summary, nt a cmplete descriptin f benefits. Fr mre infrmatin cntact the plan r read the Member Handbk. Limitatins, c-payments, and restrictins may apply. Fr mre infrmatin, call Mlina Dual Optins Member Services r read the Mlina Dual Optins Member Handbk. Benefits, List f Cvered Drugs, pharmacy and prvider netwrks, and/r cpayments may change frm time t time thrughut the year and n January 1 f each year. Cpays fr prescriptin drugs may vary based n the level f Extra Help yu receive. Please cntact the plan fr mre details. Yu can ask fr this infrmatin in ther frmats, such as Braille r large print. Call (855) , TTY/TDD: 711. The call is free. This infrmatin is available fr free in ther languages. Please call ur custmer service number at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Usted puede btener esta infrmación gratuitamente en trs idimas. Cmuníquese cn servici al cliente al (855) , TTY/TDD al 711, ls 7 días de la semana, de 8:00 a. m. a 8:00 p. m., hra lcal. La llamada es gratuita. If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 1

2 Mlina Dual Optins: Summary f Benefits The fllwing chart lists frequently asked questins. Frequently Asked Questins (FAQ) What is a Medicare-Medicaid Plan What is a Mlina Dual Optins care crdinatr What are lng-term services and supprts Answers A Medicare-Medicaid Plan is an rganizatin made up f dctrs, hspitals, pharmacies, prviders f lng-term services, and ther prviders. It als has care crdinatrs t help yu manage all yur prviders and services. They all wrk tgether t prvide the care yu need. A Mlina Dual Optins care crdinatr is ne main persn fr yu t cntact. This persn helps manage all yur prviders and services and makes sure yu get what yu need. Lng-term services and supprts (LTSS) are a variety f services and supprts that help peple meet their daily needs fr assistance and imprve the quality f their lives. LTSS are help fr peple wh need assistance t d everyday tasks like taking a bath, getting dressed, making fd, and taking medicine. Mst f these services are prvided at yur hme r in yur cmmunity but culd be prvided in a nursing hme r hspital. If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 2

3 Mlina Dual Optins: Summary f Benefits Frequently Asked Questins (FAQ) Will yu get the same Medicare and Medicaid benefits in Mlina Dual Optins that yu get nw Answers Yu will get yur cvered Medicare and Healthy Cnnectins Medicaid benefits directly frm Mlina Dual Optins. Yu will wrk with a team f prviders wh will help determine what services will best meet yur needs. This means that sme f the services yu get nw may change. Yu will get almst all f yur cvered Medicare and Healthy Cnnectins Medicaid benefits directly frm Mlina Dual Optins, but yu may get sme benefits the same way yu d nw, utside f the plan. This plan als ffers services that are nt usually cvered by Medicare r Healthy Cnnectins Medicaid. When yu enrll in Mlina Dual Optins, yu and yur care team will wrk tgether t develp an Individualized Care Plan (ICP) t address yur health and supprt needs. During this time, yu can keep seeing the prviders yu see nw fr 180 days. Yu can als cntinue t receive the same services and any that were authrized prir t yur enrllment in Mlina Dual Optins. When yu jin ur plan, if yu are taking any Medicare Part D prescriptin drugs that Mlina Dual Optins des nt nrmally cver, yu can get a temprary supply. We will help yu get anther drug r get an exceptin fr Mlina Dual Optins t cver yur drug, if medically necessary. If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 3

4 Mlina Dual Optins: Summary f Benefits Frequently Asked Questins (FAQ) Can yu g t the same dctrs yu see nw What happens if yu need a service but n ne in Mlina Dual Optins netwrk can prvide it Where is Mlina Dual Optins available D yu pay a mnthly amunt (als called a premium) under Mlina Dual Optins What is prir authrizatin Answers Often that is the case. If yur prviders (including dctrs, therapists, and pharmacies) wrk with Mlina Dual Optins and have a cntract with us, yu can keep ging t them. Prviders with an agreement with us are in-netwrk. Yu must use the prviders in Mlina Dual Optins netwrk. If yu need urgent r emergency care r ut-f-area dialysis services, yu can use prviders utside f Mlina Dual Optins plan. T find ut if yur dctrs are in the plan s netwrk, call Member Services r read Mlina Dual Optins Prvider and Pharmacy Directry. If Mlina Dual Optins is new fr yu, yu can cntinue seeing the dctrs yu g t nw fr 180 days after yu first enrll, even if they are ut-f-netwrk. If yu need t cntinue seeing yur ut-f-netwrk prviders after yur first 180 days in ur plan, we will nly cver that care if the prvider enters a single case agreement with us. If yu are getting nging treatment frm an ut-f-netwrk prvider and think they may need a single case agreement in rder t keep treating yu, cntact Member Services at (855) , TTY/TDD 711. Mst services will be prvided by ur netwrk prviders. If yu need a service that cannt be prvided within ur netwrk, Mlina Dual Optins will pay fr the cst f an ut-f-netwrk prvider. The service area fr this plan includes Bamberg, Barnwell, Calhun, Chester, Chesterfield, Dilln, Fairfield, Flrence, Kershaw, Lee, Marin, Marlbr, Newberry, Richland, Saluda, Unin, and Williamsburg cunties, Suth Carlina. Yu must live in ne f these areas t jin the plan. Yu will nt pay any mnthly premiums t Mlina Dual Optins fr yur health cverage. Prir authrizatin means that yu must get apprval frm Mlina Dual Optins befre yu can get a specific service r drug r see an ut-f-netwrk prvider. Mlina Dual Optins may nt cver the service r drug if yu dn t get apprval. If yu need urgent r emergency care r utf-area dialysis services, yu dn't need t get apprval first. If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 4

5 Mlina Dual Optins: Summary f Benefits Frequently Asked Questins (FAQ) What is a referral What is Extra Help Wh shuld yu cntact if yu have questins r need help Answers A referral means that yur primary care prvider must give yu apprval t see smene wh isn t yur primary care prvider. If yu dn t get apprval, Mlina Dual Optins may nt cver the services, and yu may be billed fr these services. Yu dn t need a referral fr sme specialists, such as wmen s health specialists. Fr mre infrmatin n when a referral is necessary, see the Member Handbk. Extra Help is a Medicare prgram that helps reduce yur prescriptin drug prgram csts such as cpays. Yur prescriptin drug cpays under Mlina Dual Optins already include the amunt f Extra Help yu qualify fr. Fr mre infrmatin abut Extra Help, cntact yur lcal Scial Security Office, r call Scial Security at TTY users may call If yu have general questins r questins abut ur plan, services, billing, r member cards, please call Mlina Dual Optins Member Services: CALL (855) Calls t this number are free. 7 days a week, 8 a.m. t 8 p.m., lcal time. Assistive technlgies, including self-service and vic ptins, are available. Member Services als has free language interpreter services available fr peple wh d nt speak English. TTY 711 Calls t this number are free. 7 days a week, 8 a.m. t 8 p.m., lcal time. If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 5

6 Mlina Dual Optins: Summary f Benefits Frequently Asked Questins (FAQ) Wh shuld yu cntact if yu have questins r need help (cntinued) Answers If yu have questins abut yur health, please call the Nurse Advice Call line: CALL (888) Calls t this number are free. 24 hurs a day, 7 days a week. TTY 711 Calls t this number are free. 24 hurs a day, 7 days a week. If yu need immediate behaviral health services, please call the Nurse Advice Call Line: CALL (888) Calls t this number are free. 24 hurs a day, 7 days a week. TTY 711 Calls t this number are free. 24 hurs a day, 7 days a week. If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 6

7 Mlina Dual Optins: Summary f Benefits The fllwing chart is a quick verview f what services yu may need, yur csts and rules abut the benefits. Health need r prblem Services yu may need Yu want t see a dctr Visits t treat an injury r illness $0 Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Wellness visits, such as a physical $0 Yearly wellness visit Specialist care $0 Yu shuld talk t yur prvider and get a referral. Authrizatin rules may apply. Care t keep yu frm getting sick, such as flu shts Welcme t Medicare preventive visit (ne time nly) Yu need medical tests Lab tests, such as bld wrk $0 Yu shuld talk t yur prvider and get a referral. Authrizatin rules may apply fr special tests. X-rays r ther pictures, such as CAT scans Screening tests, such as tests t check fr cancer r genetic testing $0 $0 $0 Yu shuld talk t yur prvider and get a referral. Authrizatin rules may apply. $0 Yu shuld talk t yur prvider and get a referral. Authrizatin rules may apply. If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 7

8 Mlina Dual Optins: Summary f Benefits Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need drugs t treat yur illness r cnditin Generic drugs (n brand name) $0 fr a 31-day supply. There may be limitatins n the types f drugs cvered. Please see Mlina Dual Optins List f Cvered Drugs (Drug List) fr mre infrmatin. 90 day supply at retail and mail rder is available fr the same Lw Incme Cst Sharing (LICS) cpay as a ne-mnth supply. Different ut-f-pcket csts may apply fr peple wh: - have limited incmes, r - live in lng-term care facilities The plan may require yu t first try ne drug t treat yur cnditin befre it will cver anther drug fr that cnditin. Sme drugs have quantity limits. Yur prvider must get prir authrizatin frm Mlina Dual Optins fr certain drugs. If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 8

9 Mlina Dual Optins: Summary f Benefits Health need r prblem Yu need drugs t treat yur illness r cnditin (cntinued) Services yu may need Yur csts fr in-netwrk prviders Brand name drugs $0 - $6.60 fr a 31- day supply. Cpays fr prescriptin drugs may vary based n the level f Extra Help yu receive. Please cntact the plan fr mre details. Limitatins, exceptins, & benefit infrmatin (rules abut benefits) There may be limitatins n the types f drugs cvered. Please see Mlina Dual Optins List f Cvered Drugs (Drug List) fr mre infrmatin. 90 day supply at retail and mail rder is available fr the same Lw Incme Cst Sharing (LICS) cpay. Different ut-f-pcket csts may apply fr peple wh: - have limited incmes, r - live in lng-term care facilities The plan may require yu t first try ne drug t treat yur cnditin befre it will cver anther drug fr that cnditin. Sme drugs have quantity limits. Yur prvider must get prir authrizatin frm Mlina Dual Optins fr certain drugs. Yu need drugs t treat yur illness r cnditin (cntinued) Over-the-cunter drugs $0 There may be limitatins n the types f drugs cvered. Please see Mlina Dual Optins List f Cvered Drugs (Drug List) fr mre infrmatin. If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 9

10 Mlina Dual Optins: Summary f Benefits Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Medicare Part B prescriptin drugs $0 Authrizatin rules may apply. Part B drugs include drugs given by yur dctr in his r her ffice, sme ral cancer drugs, and sme drugs used with certain medical equipment. Read the Member Handbk fr mre infrmatin n these drugs. Yu need therapy after a strke r accident Occupatinal, physical, r speech therapy $0 Yu shuld talk t yur prvider and get a referral. Authrizatin rules may apply. Chirpractic services (nly fr manual manipulatin fr certain apprved cnditins) $0 Authrizatin rules may apply. Yu need emergency care Emergency rm services $0 Yu may get cvered emergency medical care whenever yu need it, anywhere in the United States r its territries, withut prir authrizatin. Nt cvered utside the U.S. and its territries except under limited circumstances. Cntact plan fr details. Ambulance services $0 Authrizatin rules may apply. Authrizatin is nt required fr emergency transprtatin. If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 10

11 Mlina Dual Optins: Summary f Benefits Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Urgent care $0 Yu may get urgent care services whenever yu need it, anywhere in the United States r its territries, withut prir authrizatin. Nt cvered utside the U.S. and its territries except under limited circumstances. Cntact plan fr details. Yu need hspital care Hspital stay $0 Authrizatin rules may apply. Dctr r surgen care $0 Yu shuld talk t yur prvider and get a referral. Authrizatin rules may apply. Yu need help getting better r have special health needs Rehabilitatin services $0 Yu shuld talk t yur prvider and get a referral. Authrizatin rules may apply. Medical equipment fr hme care $0 Authrizatin rules may apply. Skilled nursing care $0 Yu shuld talk t yur prvider and get a referral. Our plan cvers Medicare and nn-medicare stays in a SNF with n prir hspitalizatin required. Yu need eye care Treatment fr eye injuries r diseases $0 Initial replacement f lens due t cataract surgery $0 If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 11

12 Mlina Dual Optins: Summary f Benefits Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need dental care Emergency medical prcedures by ral surgens $0 Dental prcedures related t rgan transplants, cancer, jint replacement, heart valve replacement, and trauma $0 Yu need ft care Pdiatry services $0 Authrizatin rules may apply. Yu need hearing/auditry services Hearing screenings $0 One rutine hearing exam per year Exam t diagnse and treat hearing and balance issues Hearing aids $0 Authrizatin rules may apply. Hearing aid fitting/evaluatin (1 every tw years) Our plan cvers up t $1000 every tw years fr hearing aids. Yu have a chrnic cnditin, such as diabetes r heart disease Yu have a mental health cnditin Services t help manage yur disease $0 Diabetes self-management training. Disease management prgram nutritinal training fr diabetics. Diabetes supplies and services $0 Authrizatin rules may apply. Benefit includes diabetic mnitring supplies and therapeutic shes r inserts. Cardiac and pulmnary rehabilitatin services $0 Authrizatin rules may apply. Mental r behaviral health services $0 Authrizatin rules may apply. Outpatient grup therapy visit. Outpatient individual therapy visit. If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 12

13 Mlina Dual Optins: Summary f Benefits Health need r prblem Yu have a substance abuse prblem Yu need lng-term mental health services Yu need durable medical equipment (DME) Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Partial hspitalizatin $0 Authrizatin rules may apply. Substance abuse services $0 Authrizatin rules may apply. Outpatient grup therapy visit. Outpatient individual therapy visit. Inpatient care fr peple wh need mental health care $0 Authrizatin rules may apply. Wheelchairs $0 r $3.40 Authrizatin rules may apply. The cpay is $0 fr wheelchairs cvered by Medicare. The cpay is $0 r $3.40 fr wheelchairs cvered nly by Healthy Cnnectins Medicaid. Canes $0 r $3.40 The cpay is $0 fr canes cvered by Medicare. The cpay is $0 r $3.40 fr canes cvered nly by Healthy Cnnectins Medicaid. Crutches $0 r $3.40 The cpay is $0 fr crutches cvered by Medicare. The cpay is $0 r $3.40 fr crutches cvered nly by Healthy Cnnectins Medicaid. Walkers $0 r $3.40 The cpay is $0 fr walkers cvered by Medicare. The cpay is $0 r $3.40 fr walkers cvered nly by Healthy Cnnectins Medicaid. If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 13

14 Mlina Dual Optins: Summary f Benefits Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Oxygen $0 r $3.40 Authrizatin rules may apply fr xygen equipment. The cpay is $0 fr xygen cvered by Medicare. The cpay is $0 r $3.40 fr xygen cvered nly by Healthy Cnnectins Medicaid. Yu need prsthetics Prsthetic devices $0 r $3.40 Authrizatin rules may apply. The cpay is $0 fr prsthetic devices cvered by Medicare. The cpay is $0 r $3.40 fr prsthetic devices cvered nly by Healthy Cnnectins Medicaid. If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 14

15 Mlina Dual Optins: Summary f Benefits Health need r prblem Yu need help living at hme Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Meals brught t yur hme $0 This service is prvided nly t members enrlled in the Cmmunity Chices r HIV/AIDS waiver. Hmemaker services, such as cleaning r husekeeping Changes t yur hme, such as ramps and wheelchair access Persnal care assistant (Yu may be able t emply yur wn assistant. Call Member Services fr mre infrmatin.) $0 These services are prvided nly t members enrlled in the Cmmunity Chices, HIV/AIDS, r Mechanical Ventilatr Dependent waiver. $0 These services are prvided nly t members enrlled in the Cmmunity Chices, HIV/AIDS, r Mechanical Ventilatr Dependent waiver. $0 This service is prvided nly t members enrlled in the Cmmunity Chices, HIV/AIDS, r Mechanical Ventilatr Dependent waiver. Hme health care services $0 r $3.30 Yu shuld talk t yur prvider and get a referral. Authrizatin rules may apply. Hme health care services cvered by Medicare have a $0 cpay. Hme health services cvered by Healthy Cnnectins Medicaid have a $3.30 cpay. Services t help yu live n yur wn $0 r $3.30 Authrizatin rules may apply. Hme health care services cvered by Medicare have a $0 cpay. Hme health services cvered by Healthy Cnnectins Medicaid have a $3.30 cpay. If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 15

16 Mlina Dual Optins: Summary f Benefits Health need r prblem Services yu may need Adult day services r ther supprt services Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) $0 Yu shuld talk t yur prvider and get a referral. Authrizatin rules may apply. These services are prvided nly t members enrlled in the Cmmunity Chices waiver. Yu need a place t live with peple available t help yu Nursing hme care $0 Authrizatin rules may apply. Yu must cntribute tward the cst f this service when yur incme is mre than an allwable amunt. This cntributin, knwn as the patient pay amunt, is required nly fr thse living in a nursing hme. Yu will nt need t pay if yu are in the nursing hme fr shrt-term rehabilitatin. These services are available nly if yur need fr lng-term care has been determined by Healthy Cnnectins Medicaid. Yu may be respnsible fr paying a patient liability fr nursing facility services that are cvered thrugh yur Healthy Cnnectins Medicaid benefit. Healthy Cnnectin Medicaid will determine if yur incme and certain expenses require yu t have a patient liability and if s, hw much that patient liability will be. If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 16

17 Mlina Dual Optins: Summary f Benefits Health need r prblem Yur caregiver needs sme time ff Yu need care fr advanced illness r lifethreatening injury Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Respite care $0 These services are prvided nly t members enrlled in the Cmmunity Chices r Mechanical Ventilatr Dependent waiver. Respite services can be prvided in a cmmunity residential care facility (CRCF) r a nursing hme. Members are limited t 28 ttal days f respite services per year. Up t 14 days f respite services can be received in a nursing hme. Yu shuld talk t yur prvider and get a referral. Authrizatin rules may apply. Palliative care $0 Yu shuld talk t yur prvider and get a referral. Authrizatin rules may apply. If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 17

18 Mlina Dual Optins: Summary f Benefits Health need r prblem Services yu may need Yur csts fr in-netwrk prviders Limitatins, exceptins, & benefit infrmatin (rules abut benefits) Yu need family planning services Birth cntrl (cndms) $0 Family planning supplies are cvered nly with a prescriptin. Family planning lab and diagnstic tests $0 Treatment fr sexually transmitted infectins (STIs) $0. If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 18

19 Mlina Dual Optins: Summary f Benefits Other services that Mlina Dual Optins cvers This is nt a cmplete list. Call Member Services r read the Member Handbk t find ut abut ther cvered services. Other services cvered by Mlina Dual Optins Yur csts fr in-netwrk prviders Educatin and Wellness Prgrams $0 End Stage Renal Disease Services $0 Infusin Services $0 Nursing Hme Transitin Services $0 Preventive Services $0 Services Prvided at Federally Qualified Health Centers $0 Targeted Case Management $0 Telemedicine $0 Visin Services $0 One rutine eye exam per year Up t $150 every tw years fr eyeglasses (frames and lenses) Exam t diagnse and treat diseases and cnditins f the eye (including yearly glaucma screening) If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 19

20 Mlina Dual Optins: Summary f Benefits Services that Mlina Dual Optins des nt cver This is nt a cmplete list. Call Member Services t find ut abut ther excluded services. Services nt cvered by Mlina Dual Optins but still available under Healthy Cnnectins Medicaid Please cntact yur care crdinatr fr mre infrmatin. Dental services Diagnstics (ral evaluatin and x-rays): $3.40 cpay Preventive care (annual cleaning): $3.40 cpay Restrative care (fillings): $3.40 cpay Surgical care (extractins / remvals): $3.40 cpay Nn-emergency medical transprtatin: $0 cpay Services nt cvered by Mlina Dual Optins Acupuncture Chirpractic care (except manual manipulatin fr certain apprved cnditins) Csmetic surgery r csmetic wrk Dentures Elective r vluntary enhancement prcedures r services Experimental medical and surgical treatments, items and drugs Certain visual prcedures such as LASIK Full-time nursing care in yur hme Naturpath services Nn-prescriptin cntraceptive supplies If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 20

21 Mlina Dual Optins: Summary f Benefits Services nt cvered by Mlina Dual Optins Orthpedic shes (unless included with brace r fr diabetic ft disease). Supprtive devices fr feet (except fr diabetic ft disease) Persnal items in yur hspital r nursing hme rm Private rm in hspital Rutine ft care (except fr certain apprved cnditins) Services nt cnsidered reasnable and necessary Services prvided t veterans in a VA facility If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 21

22 Mlina Dual Optins: Summary f Benefits Yur rights as a member f the plan As a member f Mlina Dual Optins, yu have certain rights. Yu can exercise these rights withut being punished. Yu can als use these rights withut lsing yur health care services. We will tell yu abut yur rights at least nce a year. Fr mre infrmatin n yur rights, please read the Member Handbk. Yur rights include, but are nt limited t, the fllwing: Yu have a right t respect, fairness and dignity. This includes the right t: Get cvered services withut cncern abut race, ethnicity, natinal rigin, religin, gender, age, mental r physical disability, sexual rientatin, genetic infrmatin, ability t pay, r ability t speak English Request infrmatin in ther frmats (e.g., audi CD ROM, large print, cassette, Braille) Be free frm any frm f restraint r seclusin Nt be billed by netwrk prviders Chse a Primary Care Prvider (PCP) and change yur PCP at any time See a wmen s health care prvider withut a referral Get yur cvered services and drugs quickly Knw abut all treatment ptins, n matter what they cst r whether they are cvered Refuse treatment, even if yur dctr advises against it Stp taking medicine Ask fr a secnd pinin. Mlina Dual Optins will pay fr the cst f yur secnd pinin visit. Yu have the right t get infrmatin abut yur health care. This includes infrmatin n treatment and yur treatment ptins. This infrmatin shuld be in a frmat yu can understand. These rights include getting infrmatin n: Descriptin f the services we cver Hw t get services Hw much services will cst yu Names f health care prviders and care managers Yu have the right t timely access t care that des nt have any cmmunicatin r physical access barriers. This includes the right t: Get timely medical care Get in and ut f a health care prvider s ffice. This means barrier free access fr peple with disabilities, in accrdance with the Americans with Disabilities Act. Have interpreters t help with cmmunicatin with yur dctrs and yur health plan. Yu have the right t make decisins abut yur care, including refusing treatment. This includes the right t: Yu have the right t seek emergency and urgent care when yu need it. This means yu have the right t: If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 22

23 Mlina Dual Optins: Summary f Benefits Get emergency services withut prir apprval in an emergency File a cmplaint r grievance against us r ur prviders See an ut f netwrk urgent r emergency care prvider, when necessary Ask fr a state fair hearing Get a detailed reasn fr why services were denied Yu have a right t cnfidentiality and privacy. This includes the right t: Ask fr and get a cpy f yur medical recrds in a way that yu can understand and t ask fr yur recrds t be changed r crrected. Have yur persnal health infrmatin kept private. Yu have the right t make cmplaints abut yur cvered services r care. This includes the right t: Fr mre infrmatin abut yur rights, yu can read the Mlina Dual Optins Member Handbk. If yu have questins, yu can als call Mlina Dual Optins Member Services. If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 23

24 Mlina Dual Optins: Summary f Benefits If yu have a cmplaint r think we shuld cver smething we denied If yu have a cmplaint r think Mlina Dual Optins shuld cver smething we denied, call Mlina Dual Optins at (855) , TTY/TDD 711. Yu may be able t appeal ur decisin. Fr questins abut cmplaints and appeals, yu can read Chapter 9 f the Mlina Dual Optins Member Handbk. Yu can als call Mlina Dual Optins Member Services. Or yu can write t Mlina Dual Optins Attn: Grievance and Appeals P.O. Bx Lng Beach, CA FAX: There is a special mbudsman fr Prime called the Healthy Cnnectins Prime Advcate. The Healthy Cnnectins Prime Advcate des nt wrk fr Mlina Dual Optins r the State. They can help yu understand yur rights and the appeal prcess, and they can help yu with yur appeal. Yu can reach the Healthy Cnnectins Prime Advcate at If yu suspect fraud Mst health care prfessinals and rganizatins that prvide services are hnest. Unfrtunately, there may be sme wh are dishnest. If yu think a dctr, hspital r ther pharmacy is ding smething wrng, please cntact us. Call us at Mlina Dual Optins Member Services. Phne numbers are n the cver f this summary, r Call Medicare at MEDICARE ( ). TTY users shuld call Yu can call these numbers fr free, 24 hurs a day, 7 days a week. Call the Suth Carlina Department f Health and Human Services (SCDHHS) Cmpliance Htline fr Fraud and Abuse at If yu have questins, please call Mlina Dual Optins at (855) , TTY/TDD 711, 7 days a week, 8 a.m. t 8 p.m., lcal time. The call is free. Fr mre infrmatin, visit 24