Enrollment Guide. You could get more benefits than Original Medicare. UnitedHealthcare Dual Complete (PPO SNP) H

Transcription

1 2016 Enrollment Guide You could get more benefits than Original Medicare. Hospital Stays Doctor Visits Additional Benefits Prescription Drug Coverage UnitedHealthcare Dual Complete (PPO SNP) H Service area: Texas- El Paso County

2 Table of Contents Introduction... 3 Plan INFORMATION Benefit Highlights... 8 How Your Plan Works...10 Benefits and Services Beyond Original Medicare Summary of Benefits...13 Plan Ratings Required Information Drug LIST Drug List...46 Ready to ENROLL Enrollment Instructions...76 Scope of Sales Appointment Confirmation Form...77 Enrollment Request Form...79 Enrollment Checklist Enrollment Receipt What's Next...115

3 It s more than a health plan. IT S A HEALTHY RELATIONSHIP. From preventive care to treating a chronic condition, there are many ways you may use your Medicare plan. We will work with you to help you live a healthier life and we strive to give you the best health care experience possible. Here are some reasons why this plan may be right for your needs. Doctor coverage Access your personal plan information online, anytime Worldwide ER coverage Care coordination Out-of-pocket maximums HouseCalls SM We are committed to providing the personal service that can help you get the most from your benefits. Your local licensed sales representative is ready to answer all your questions. Have any questions? We can help. Call: Toll-Free , TTY a.m. to 8 p.m. local time, 7 days a week. Se habla español. Learn more online at 3 CSTX16PP _000

4 Medicare EDUCATION What is Medicare? Medicare is a federal health insurance program for people age 65 and older and others with disabilities. Original Medicare is provided by the government and covers some of the costs of hospital stays (Part A) and doctor visits (Part B), but it does not cover everything you don t get coverage for prescription drugs or for routine vision, dental or hearing care. Original Medicare Provided by the government Part A covers hospital stays Part B covers doctor and outpatient visits What if you need more coverage beyond Original Medicare? Add one or both of the following to Original Medicare: Medicare Supplement Insurance* OR Add additional coverage by choosing a Medicare Advantage plan: Medicare Advantage (Part C)* Covers some of the costs not covered by Parts A and B Part C combines Parts A and B Medicare Part D* Often provides additional benefits Part D covers prescription drugs Most plans cover prescription drugs When can you enroll? *Offered by private companies It s important to know your enrollment period so you always have health care coverage. You can enroll or change Medicare Advantage or Part D plans at least once a year, typically during your Initial Enrollment Period or the Open Enrollment Period. Medicare supplement plans have different rules about enrolling, please contact the Medicare Helpline for more information on enrolling. Initial Enrollment Period: For Medicare Advantage or Part D plans, this is the three months before and three months after the month you turn 65 or become Medicare eligible. For Medicare supplement plans, you must submit your application no later than six months after the date your Medicare Part B coverage takes effect. Special Election Period: Depending on certain circumstances, you may be able to enroll in a Medicare plan outside of the Initial Enrollment Period or Open Enrollment time frames. Open Enrollment Period: October 15 December 7 Medicare Advantage Disenrollment Period: January 1 February 14. If you disenroll from a Medicare Advantage plan during this time, you will return to Original Medicare and have a Special Election Period to enroll in a Medicare Part D plan. 4

5 Medicare EDUCATION What are the drug payment stages? If your plan includes prescription drug coverage, the amount you pay each time to fill a prescription depends on which payment stage you re in. How do you know which stage you re in? It depends on how much money you and your plan have paid for prescription drugs so far in the plan year. If your plan has a deductible, you pay the total cost of your drugs until you reach the deductible amount. You then move to the initial coverage stage. The chart below shows the different payment stages you may go through in the plan year. Initial Coverage In this drug payment stage: You pay a co-pay or co-insurance (percentage of a drug s total cost). The plan pays the rest You stay in this stage until your total drug costs reach $3,310 Coverage Gap (Donut Hole) After your total drug costs reach $3,310: You pay: 45% of the cost of brand name drugs 58% of the cost of generic drugs You stay in this stage until your total out of pocket costs reach $4,850 Catastrophic Coverage After your total out-of-pocket costs reach $4,850: You pay a small co-pay or co-insurance amount You stay in this stage for the rest of the plan year Total Drug Costs: The amount you pay (or others pay on your behalf) and the plan pays for prescription drugs starting on January 1, Out-of-Pocket Costs: The amount you pay (or others pay on your behalf) for prescription drugs starting on January 1, This does not include premiums. Do you qualify for Extra Help? If you have a limited income, you may be able to get Extra Help with your Medicare prescription drug plan premiums, deductibles and co-pays. Many people qualify and don t even know it. To find out if you qualify, call the Social Security Administration at , TTY , 7 a.m. 7 p.m., Monday Friday 5

6 Medicare EDUCATION Are you eligible for this plan? You are eligible for a Dual Special Needs Plan (DSNP) if you re enrolled in Original Medicare Parts A and B and receive state Medicaid benefits. Your state Medicaid benefits vary based on your level of Medicaid eligibility. DSNP enrollment is not limited to a specific time; you can enroll year-round What are the levels of eligibility in most states? Qualified Medicare Beneficiary Only (QMB Only) Qualified Medicare Beneficiary Plus (QMB Plus) Specified Low-Income Medicare Beneficiary Only (SLMB Only) Specified Low-Income Medicare Beneficiary Plus (SLMB Plus) What are the income requirements for each eligibility level? Federal Poverty Income Level Social Security Income Level QMB Only At or lower than Resources not more than two times QMB Plus At or lower than Resources not more than two times SLMB Only Between 100% and 120% Resources not more than two times SLMB Plus Between 100% and 120% Resources not more than two times QI Between 120% and 135% Resources not more than two times QDWI Below 200% Resources not more than two times FBDE Based on Medical Need status, institutionalized income levels, home/community based waivers What benefits does each eligibility level cover? Eligibility Level Part A Premium Part B Premium Based on your needs you may also qualify for Low Income Subsidy (LIS) assistance Qualified Individual (QI) Qualified Disabled and Working Individual (QDWI) Full Benefit Dual Eligible (FBDE) Part D Premium 1 Medicare Deductibles, Co-pays, Co-insurance QMB Only Yes Yes No 2 Yes No QMB Plus Yes Yes No 2 Yes Yes SLMB Only No Yes No 2 No No SLMB Plus No Yes No 2 Varies by state Yes QI No Yes No 2 No No QDWI Yes No No No No FBDE No Varies by state No Varies by state Yes Full Medicaid Benefits 1 Low Income Subsidy may be available to help with Part D premium cost. 2 QMBs, SLMBs and QIs are automatically enrolled in the low income subsidy program to cover Part D premium costs and will not have Part D premium expenses. Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in the plan depends on the plan s contract renewal with Medicare. Y0066_150728_ Accepted UHEX16MP _000 6

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8 Benefit highlights UnitedHealthcare Dual Complete (PPO SNP) This is a short description of 2016 plan benefits. Values shown are for those with Medicare Parts A and B cost sharing covered by the state. For complete information and for costs for those without Medicare Parts A and B cost sharing covered by the state, please refer to your Summary of Benefits or Evidence of Coverage. Limitations, exclusions, and restrictions may apply. Plan Costs Monthly plan premium $0 Medical Benefits In-Network Out-of-Network Doctor s office visit Primary Care Provider: $0 copay Primary Care Provider: $0 copay Specialist: $0 copay Specialist: $0 copay Preventive Services $0 copay $0 copay Inpatient hospital care $0 copay per day, up to 90 days $0 copay per day, up to 90 days Skilled nursing facility (SNF) $0 copay per day: days $0 copay per day: days Outpatient surgery $0 copay $0 copay Diabetes monitoring supplies $0 copay for covered brands $0 copay Home health care $0 copay $0 copay Diagnostic radiology services $0 copay $0 copay (such as MRIs, CT scans) Diagnostic tests and procedures $0 copay $0 copay (non-radiological) Lab services $0 copay $0 copay Outpatient x-rays $0 copay $0 copay Ambulance $0 copay $0 copay Emergency care $0 copay Urgently needed services $0 copay Benefits and Services beyond Original Medicare In-Network Out-of-Network Vision - routine eye exams $0 copay; 1 every 2 years* 30% of the cost; 1 every 2 years* Vision - eyewear $0 copay every 2 years; up to $150 for lenses/frames and contacts* $0 copay every 2 years; up to $150 for lenses/frames and contacts* Dental - preventive $0 copay for covered services $0 copay for covered services (exam, cleaning, x-rays)* (exam, cleaning, x-rays)* Dental - comprehensive $0 copay for covered services* $0 copay for covered services* Dental - benefit limit $2,000 limit on all covered dental services Foot care - routine $0 copay; 4 visits per year* 30% of the cost; 4 visits per year* Hearing - routine exam $0 copay; 1 per year* 30% of the cost; 1 per year* Hearing aids $2,000 allowance every 2 years* $2,000 allowance every 2 years* $0 copay; 24 one-way trips per 75% of the cost* Transportation year to or from approved locations* Over-the-counter items $100 credit per quarter to use on approved health products NurseLine SM Speak with a registered nurse (RN) 24 hours a day, 7 days a week *Benefits combined in and out-of-network 8

9 Prescription Drugs If you don t qualify for Low-Income Subsidy (LIS), you pay the Medicare Part D cost share outlined in the Summary of Benefits and Evidence of Coverage. If you do qualify for Low-Income Subsidy (LIS) you pay: Annual prescription deductible $0 30-day supply from retail network pharmacy Generic (including brand drugs $0, $1.20, $2.95 copay treated as generic) All other drugs $0, $3.60, $7.40 copay Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in the plan depends on the plan s contract renewal with Medicare. This plan is available to anyone who has both Medical Assistance from the State and Medicare. Benefits, premium and/or co-payments/co-insurance may change on January 1 of each year. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details. This information is not a complete description of benefits. Contact the plan for more information. You must continue to pay your Medicare Part B premium, if not otherwise paid for under Medicaid or by another third party. Limitations, copayments, and restrictions may apply. Plan INFORMATION Y0066_MABH_16_FINAL_H ACCEPTED CSTX16PP _001 9

10 How your PPO PLAN WORKS Your plan is a Preferred Provider Organization (PPO) plan. With this plan, you have access to a local network of doctors and hospitals. Plus, you can see out-of-network providers, generally at a higher cost, as long as they participate in Medicare and accept the plan. In-Network Out-of-Network Will the doctor or hospital accept my plan? Do I need to choose a primary care provider (PCP)? Do I need a referral to see a specialist? Are emergency or urgently needed services covered? Do I have to pay the full cost for all covered doctor or hospital services? Is there a limit on my total out-of-pocket spending for the year? Yes Yes No Yes Plan co-pay or co insurance applies. Yes Has the choice to accept plan (except for emergencies). No No Yes You may pay a higher co-pay or co-insurance. Yes Save money by using in-network care providers. If you want help choosing a primary care provider (PCP), call Customer Service or your licensed sales representative. The website and Customer Service phone number are listed on the first page of this booklet. Plan co-pays and co-insurance apply. As a member, you will receive a Provider Directory listing all network providers and facilities within your plan. You can also find a complete listing on our website or you can request a Provider Directory from Customer Service. Please refer to the Summary of Benefits and Benefit Highlights for more complete plan information. Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in the plan depends on the plan s contract renewal with Medicare. Y0066_150612_ Accepted 10 UHEX16PP _000

11 Benefits and services beyond ORIGINAL MEDICARE Get all the benefits of Original Medicare and more. With this plan, you get additional benefits and services designed to help you live a healthier life most at little or no additional cost. More benefits mean more value. It also means more peace of mind for you, knowing you have access to a full range of services dedicated to your health and wellness. This is a short description of some of the 2016 plan benefits. For more information, please refer to your Summary of Benefits. Limitations, exclusions and restrictions may apply. Plan INFORMATION A health and wellness program that comes to you With the HouseCalls SM program, you get an in-home clinical visit from one of our licensed health care practitioners for no additional cost. A HouseCalls visit is designed to support but not take the place of your regular doctor s care. What to expect from a HouseCalls visit: A knowledgeable health care practitioner will review your health history and medications, perform a health screening, identify health risks and provide health education You can talk about health concerns and ask questions You ll get an Ask Your Doctor worksheet which you can bring to your next doctor visit We may call to talk to you about eligibility for the HouseCalls program or you can call TTY 711, Monday Saturday 8:00AM 8:00PM CST, to schedule your in-home visit. Vision coverage Protect your eyesight and health with routine eye exams. Your vision coverage may include: One routine eye exam every 2 years Credit toward contact lenses or eyeglass frames with standard lenses Network restrictions may apply. 11

12 Benefits and services beyond ORIGINAL MEDICARE (CONTINUED) Dental coverage Preventive and comprehensive. Recommended routine dental checkups are covered. Plus, a set amount is covered each year for other procedures you may need. Your dental coverage may include: Regular checkups and cleanings Dental X-rays Other comprehensive services Co-pays and network restrictions may apply. Hearing coverage Don t let hearing loss affect your life. Your plan includes the following hearing coverage: A routine hearing exam every year Credit toward a hearing aid provided by Epic Co-pays and network restrictions may apply. Learn more about these extra benefits and services For more information, call the number on the first page of this booklet. Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicareapproved Part D sponsor. Enrollment in the plan depends on the plan s contract renewal with Medicare. Y0066_150612_074537_ Accepted CSTX16PP _000 12

13 2016 Summary of BENEFITS UnitedHealthcare Dual Complete (PPO SNP) Texas El Paso County Plan INFORMATION Y0066_SB_H2228_041_2016 CMS Accepted 13

14 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 Medicare health plan (such as UnitedHealthcare Dual Complete (PPO SNP)). Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what UnitedHealthcare Dual Complete (PPO SNP) covers 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 UnitedHealthcare Dual Complete (PPO SNP) Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits This document is available in other formats such as Braille and large print. This document may be available in a non-english language. For additional information, call us at Es posible que este documento esté disponible en otro idioma. Para información adicional llame al Things to Know About UnitedHealthcare Dual Complete (PPO SNP) Hours of Operation You can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Local time. UnitedHealthcare Dual Complete (PPO SNP) Phone Numbers and Website If you are a member of this plan, call toll-free If you are not a member of this plan, call toll-free Our website: Who can join? 14

15 To join UnitedHealthcare Dual Complete (PPO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and Texas Medicaid Health and Human Services Commission, and live in our service area. Our service area includes the following county in Texas: El Paso. Which doctors, hospitals, and pharmacies can I use? UnitedHealthcare Dual Complete (PPO SNP) has a network of doctors, hospitals, pharmacies, 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 must generally use network pharmacies to fill your prescriptions for covered Part D drugs. Plan INFORMATION You can see our plan s provider and pharmacy directory at our website ( Or, call us and we will send you a copy of the provider and pharmacy directories. What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers - and more. Our plan members get all of the benefits covered by Original Medicare. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? The amount you pay for drugs depends on the drug you are taking and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage. 15

16 Summary of Benefits January 1, December 31, 2016 Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services How much is $17.80 per month. In addition, you must keep paying your Medicare Part the monthly B premium. premium? How much is the deductible? This plan has deductibles for some hospital and medical services. $0 or $147 per year for per year for some in-network and out-of-network services, depending on your level of Medicaid eligibility. This amount may change for $0 to $74 per year for Part D prescription drugs. Is there any limit on how much I will pay for my covered services? Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. In this plan, you may pay nothing for Medicare-covered services, depending on your level of Texas Medicaid Health and Human Services Commission eligibility. Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers. $10,000 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit. 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. Refer to the "Medicare & You" handbook for Medicare-covered services. For Texas Medicaid Health and Human Services Commission-covered services, refer to the Medicaid Coverage section in this document. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs. Is there a limit on how much the plan will pay? Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply. Covered Medical and Hospital Benefits Outpatient Care and Services Acupuncture Not covered 16

17 Ambulance In-network: 0% or 20% of the cost Out-of-network: 20% of the cost Chiropractic Care Dental Services Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): In-network: 0% or 20% of the cost Out-of-network: 30% of the cost Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): In-network: 0% or 20% of the cost Out-of-network: 30% of the cost Preventive dental services: Plan INFORMATION Cleaning (for up to 1 every six months): In-network: $0 copay Out-of-network: $0 copay Dental x-ray(s) (for up to 1): In-network: $0 copay Out-of-network: $0 copay Oral exam (for up to 1 every six months): In-network: $0 copay Out-of-network: $0 copay Our plan pays up to $2,000 every year for most dental services from any provider. Diabetes Diabetes monitoring supplies: Supplies and In-network: You pay nothing Services Out-of-network: 30% of the cost Diabetes self-management training: In-network: You pay nothing Out-of-network: 30% of the cost Therapeutic shoes or inserts: In-network: 0% or 20% of the cost Out-of-network: 30% of the cost The plan covers the following brands of blood glucose monitors and test strips: OneTouch UltraMini, OneTouch Ultra 2 System, OneTouch Verio IQ, OneTouch Verio Sync, ACCU-CHEK Nano SmartView, ACCU-CHEK Aviva Plus 17

18 Diagnostic Diagnostic radiology services (such as MRIs, CT scans): Tests, Lab and In-network: 0% or 20% of the cost Radiology Out-of-network: 30% of the cost Services, and Diagnostic tests and procedures: X-Rays In-network: 0% or 20% of the cost (Costs for these Out-of-network: 30% of the cost services may Lab services: vary based on In-network: You pay nothing place of service) Out-of-network: You pay nothing Outpatient x-rays: In-network: 0% or 20% of the cost Out-of-network: 30% of the cost Therapeutic radiology services (such as radiation treatment for cancer): In-network: 0% or 20% of the cost Out-of-network: 30% of the cost Doctor s Office Primary care physician visit: Visits In-network: You pay nothing Out-of-network: 30% of the cost Specialist visit: In-network: 0% or 20% of the cost Out-of-network: 30% of the cost Durable In-network: 0% or 20% of the cost Medical Equipment (wheelchairs, oxygen, etc.) Out-of-network: 30% of the cost Emergency $0 or $75 copay Care 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. Foot Care Foot exams and treatment if you have diabetes-related nerve damage (podiatry and/or meet certain conditions: services) In-network: 0% or 20% of the cost Out-of-network: 30% of the cost Routine foot care (for up to 4 visit(s) every year): In-network: You pay nothing Out-of-network: 30% of the cost 18

19 Hearing Exam to diagnose and treat hearing and balance issues: Services In-network: 0% or 20% of the cost Out-of-network: 30% of the cost Routine hearing exam (for up to 1 every year): In-network: You pay nothing Out-of-network: 30% of the cost Hearing aid: In-network: $0 copay Out-of-network: $0 copay Our plan pays up to $2,000 every two years for hearing aids from any provider. Home Health In-network: You pay nothing Care Out-of-network: 30% of the cost Mental Health Inpatient visit: Care 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. Plan INFORMATION 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. You must pay the inpatient hospital deductible for each benefit period. 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. In-network: $0 or $1,200 copay per stay Out-of-network: 30% of the cost per stay Outpatient group therapy visit: In-network: 0% or 20% of the cost Out-of-network: 30% of the cost Outpatient individual therapy visit: In-network: 0% or 20% of the cost Out-of-network: 30% of the cost 19

20 Outpatient Rehabilitation Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): In-network: 0% or 20% of the cost Out-of-network: 30% of the cost Occupational therapy visit: In-network: 0% or 20% of the cost Out-of-network: 30% of the cost Physical therapy and speech and language therapy visit: In-network: 0% or 20% of the cost Out-of-network: 30% of the cost Outpatient Group therapy visit: Substance In-network: 0% or 20% of the cost Abuse Out-of-network: 30% of the cost Individual therapy visit: In-network: 0% or 20% of the cost Out-of-network: 30% of the cost Outpatient Ambulatory surgical center: Surgery In-network: 0% or 20% of the cost Out-of-network: 30% of the cost Outpatient hospital: In-network: 0% or 20% of the cost Out-of-network: 30% of the cost Over-the- Please visit our website to see our list of covered over-the-counter items. Counter Items Prosthetic Prosthetic devices: Devices In-network: 0% or 20% of the cost (braces, artificial Out-of-network: 30% of the cost limbs, etc.) Related medical supplies: In-network: 0% or 20% of the cost Out-of-network: 30% of the cost Renal Dialysis In-network: 0% or 20% of the cost Out-of-network: 20% of the cost Transportation In-network: You pay nothing Out-of-network: 75% of the cost Urgently 0% or 20% of the cost (up to $65) Needed Services 20

21 Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): In-network: 0% or 20% of the cost Out-of-network: 30% of the cost Routine eye exam (for up to 1 every two years): In-network: You pay nothing Out-of-network: 30% of the cost Contact lenses In-network: $0 copay Out-of-network: $0 copay Eyeglass frames (for up to 1 every two years): In-network: $0 copay Out-of-network: $0 copay Eyeglass lenses (for up to 1 every two years): In-network: $0 copay Out-of-network: $0 copay Eyeglasses or contact lenses after cataract surgery: In-network: You pay nothing Out-of-network: You pay nothing Our plan pays up to $150 every two years for contact lenses, eyeglass lenses, and eyeglass frames from any provider. Plan INFORMATION 21

22 Preventive In-network: You pay nothing Care Out-of-network: 0-30% of the cost, depending on the service 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. Annual physical exam: In-network: You pay nothing 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. 22

23 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. You must pay the inpatient hospital deductible for each benefit period. 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. In-network: $0 or $1,200 copay per stay Out-of-network: 30% of the cost per stay Plan INFORMATION Inpatient For inpatient mental health care, see the "Mental Health Care" section of Mental Health this booklet. Care Skilled Nursing Our plan covers up to 100 days in a SNF. Facility (SNF) In-network: In 2015 the amounts for each benefit period were $0 or: You pay nothing for days 1 through 20 $ copay per day for days 21 through 100 These amounts may change for Out-of-network: 30% of the cost per stay Prescription Drug Benefits How much do I For Part B drugs such as chemotherapy drugs: pay? In-network: 0% or 20% of the cost Out-of-network: 20% of the cost Other Part B drugs: In-network: 0% or 20% of the cost Out-of-network: 20% of the cost 23

24 Initial Coverage Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs, either: $0 copay; or $3.60 copay; or $7.40 copay. You may get your drugs at network retail pharmacies and mail order pharmacies. If you reside in a long-term care facility, you pay the same as at a retail pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay nothing for all drugs. 24

25 Medicaid Benefits Information for People with Medicare and Medicaid UnitedHealthcare Dual Complete (PPO SNP) is for people who have both Medicare and Medicaid. It is called an All-Dual Eligible Special Needs Plan (D-SNP). If you have both Medicare and Medicaid, your services are paid first by Medicare and then by Medicaid. Your Medicaid coverage depends on your income, resources and other factors. Some persons get full Medicaid benefits. Some only get help to pay for Medicare cost sharing. (Cost sharing may include premiums, deductibles, coinsurance, or copays.) Below are the categories of people who can enroll in UnitedHealthcare Dual Complete (PPO SNP): Plan INFORMATION Qualified Medicare Beneficiary (QMB). You get Medicaid coverage of Medicare cost-share but are not eligible for full Medicaid benefits. Medicaid pays your Part A and Part B premiums, deductibles, coinsurance and copayments amounts only. Qualified Medicare Beneficiary Plus (QMB+). You get Medicaid coverage of Medicare cost-share and are also eligible for full Medicaid benefits. Medicaid pays your Part A and Part B premiums, deductibles, coinsurance and copayment amounts. Specified Low-Income Medicare Beneficiary (SLMB). Medicaid pays your Part B premium only. Specified Low-Income Medicare Beneficiary (SLMB+). Medicaid pays your Part B premium and provides full Medicaid benefits. Qualifying Individual (QI). Medicaid pays your part B premium only. Full Benefits Dual Eligible (FBDE). Medicaid may provide limited assistance with Medicare cost-sharing. Medicaid also provides full Medicaid benefits. Qualified Disabled and Working Individual (QDWI). Medicaid pays your Part A premium only. If you are a QMB or QMB+ Beneficiary: You have 0% cost-share, except for Part D prescription drug copays. If you are a SLMB+ or FBDE: You are eligible for full Medicaid benefits. At times you may also be eligible for limited assistance from the Texas Medicaid Health and Human Services Commission in paying your Medicare cost share amounts. Generally your cost share is 0% when the service is covered by both Medicare and Medicaid. There may be cases where you have to pay cost sharing when a service or benefit is not covered by Medicaid. If you are a SLMB, QI or QDWI: Texas Medicaid Health and Human Services Commission does not pay your cost-share. You do not have full Medicaid benefits. You pay the cost share amounts listed in Section II (often 20%). There may be some services that do not have a member cost share amount. If your category of Medicaid eligibility changes, your cost share may also increase or decrease. You must recertify your Medicaid enrollment to continue to receive your Medicare coverage. 25

26 How to Read the Medicaid Benefit Chart: The benefits described below are covered by Medicaid. The benefits described in the Covered Medical and Hospital Benefits section of the Summary of Benefits are covered by Medicare. For each benefit listed below, you can see what Texas Medicaid Health and Human Services Commission covers and what our plan covers. If a benefit is used up or not covered by Medicare, then Medicaid may provide coverage. This depends on your type of Medicaid coverage. UnitedHealthcare Dual Benefit Medicaid Complete (PPO SNP) Medicaid only services - The services listed below are available under Medicaid for people who qualify for full Medicaid coverage. Community For information on waiver No coverage Based services and eligibility for this Alternatives waiver, contact the (CBA) Waiver Department of Aging and Disability Services (DADS). Community For information on waiver No coverage Living services and eligibility for this Assistance and waiver, contact the Support Department of Aging and Services (CLASS) Waiver Consolidated Disability Services (DADS). For information on waiver No coverage Waiver Program services and eligibility for this (CWP) - Bexar waiver, contact the County/San Department of Aging and Antonio Only Disability Services (DADS). Deaf Blind with For information on waiver No coverage Multiple Disabilwaiver, services and eligibility for this ities Waiver (DB- contact the MD) Department of Aging and Disability Services (DADS). Home and For information on waiver No coverage Community services and eligibility for this Based Waiver waiver, contact the Services Department of Aging and Disability Services (DADS). Medically For information on waiver No coverage Dependent services and eligibility for this Children waiver, contact the Program Department of Aging and (MDCP) Disability Services (DADS). 26

27 Benefit Medicaid STAR + PLUS For information on waiver No coverage Waiver services and eligibility for this waiver, contact the Department of Aging and Disability Services (DADS). Texas Home For information on waiver No coverage Living Waiver services and eligibility for this (TxHmL) waiver, contact the Department of Aging and Disability Services (DADS). Telemedicine For Dual-eligible Members, No coverage Services Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. UnitedHealthcare Dual Complete (PPO SNP) Plan INFORMATION Medicare-covered services $0 copay for Medicaid-covered services. Ambulance Emergency and Covered. See Section 2 for nonemergency ambulance applicable cost sharing transport services are a benefit amount. of Texas Medicaid. Emergency transports (including emergency interfacility ambulance transports) do not require prior authorization. Prior authorization is required for all non-emergency ambulance transports. For Dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. 27

28 Benefit Medicaid UnitedHealthcare Dual Complete (PPO SNP) Chiropractic Chiropractic manipulative Covered. See Section 2 for Care treatment CMT) performed by applicable cost sharing a chiropractor licensed by the amount. Texas State Board of Chiropractic Examiners is a benefit of Texas Medicaid. CMT is reimbursed only for a diagnosis of subluxation of the spine. Diagnostic, therapeutic services, or adjunctive therapies furnished by a chiropractor or by others under his or her orders or direction are not a benefit of Texas Medicaid For Dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services Dental Services Dental Services are benefits of Covered. See Section 2 for Texas Medicaid for applicable cost sharing Medicaid-eligible clients who amount. are 20 years of age or younger through the THSteps program and for clients who are 21 years of age or older in an ICF-MR. For Dual-eligible Members who meet the above criteria, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. 28

29 Benefit Medicaid UnitedHealthcare Dual Complete (PPO SNP) Diabetes Medicaid pays for this service Covered. See Section 2 for Supplies and if it is not covered by Medicare applicable cost sharing Services or when the Medicare benefit amount. is exhausted. Glucose monitors are not covered $0 copay for Medicaid-covered services. Plan INFORMATION Diagnostic Medically necessary Covered. See Section 2 for Tests, Lab and diagnostic tests, lab and applicable cost sharing Radiology radiological services are a amount. Services, and benefit. CT/MRI requires prior X-Rays authorization. (Costs for these Each procedure is subject to services may be limitations. different if received in an For Dual-eligible Members, Medicaid pays for this service outpatient if it is not covered by Medicare surgery setting) or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Doctor Office Texas Medicaid reimburses Covered. See Section 2 for Visits physician evaluation and applicable cost sharing management office visits. amount. Group visits are limited to a maximum of 4 per year. For Dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. 29

30 Benefit Medicaid UnitedHealthcare Dual Complete (PPO SNP) Durable Medical For Dual-eligible Members, Covered. See Section 2 for Equipment Medicaid pays for this service applicable cost sharing (wheelchairs, if it is not covered by Medicare amount. oxygen, etc.) or when the Medicare benefit is exhausted. 0 copay for Medicaid-covered services. Emergency For Dual-eligible Members, Covered. See Section 2 for Care Medicaid pays for this service applicable cost sharing if it is not covered by Medicare amount. or when the Medicare benefit is exhausted. 0 copay for Medicaid-covered services. Foot Care Podiatry and related services Covered. See Section 2 for (podiatry are a benefit of Texas applicable cost sharing services) Medicaid. amount. For Dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Note: Prior authorization requirements applied to services provided by physicians (M.D. or D.O.) also apply to services provided by a podiatrist 30

31 Benefit Medicaid UnitedHealthcare Dual Complete (PPO SNP) Hearing Hearing screening and both Covered. See Section 2 for Services monaural and binaural applicable cost sharing hearing aids are a benefit. amount. Hearing aids do not require prior authorization for the initial hearing aid(s), except beyond stated limitations. For Dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. Plan INFORMATION $0 copay for Medicaid-covered services. 31

32 Benefit Medicaid UnitedHealthcare Dual Complete (PPO SNP) Home Health Home health skilled nursing Covered. See Section 2 for Care (SN) and home health aide applicable cost sharing (HHA) visits are a benefit of amount. Texas Medicaid Title XIX Home Health Services Private Duty Nursing services are a benefit of the Texas Health Steps-Comprehensive Care Program (THSteps-CCP) for Medicaid clients 20 years of age or younger. Personal Care Services (PCS) is a benefit of the Texas Health Steps-Comprehensive Care Program THSteps-CCP) for Texas Medicaid clients birth through 20 years of age, who are not an inpatient or a resident of a hospital, in a nursing facility or ICF/MR, or in an institution for mental disease. For Dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. 32

33 Benefit Medicaid UnitedHealthcare Dual Complete (PPO SNP) Mental Health Outpatient Mental Health Care Covered. See Section 2 for Care is a benefit of Texas Medicaid. applicable cost sharing For Dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. amount. Plan INFORMATION $0 copay for Medicaid-covered services. Note: Age limit of 13 years of age and older. Prior authorization is optional; however, outpatient behavioral health services without prior authorization are limited to 30 encounters/visits per client, for each calendar year. Outpatient For Members birth through Covered. See Section 2 for Rehabilitation age 20, Medicaid pays for this applicable cost sharing service if it is not covered by amount. Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Outpatient For Dual-eligible Members, Covered. See Section 2 for Substance Medicaid pays for this service applicable cost sharing Abuse if it is not covered by Medicare amount. or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Note: Tobacco, caffeine and occupational therapy as part of detoxification or treatment program are not covered. Therapy hour limitations do apply. 33

34 Benefit Medicaid UnitedHealthcare Dual Complete (PPO SNP) Outpatient For Dual-eligible Members, Covered. See Section 2 for Surgery Medicaid pays for this service applicable cost sharing if it is not covered by Medicare amount. or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Prosthetic For Dual-eligible Members Covered. See Section 2 for Devices birth through age 20 (CCP), applicable cost sharing (braces, artificial Medicaid pays for this service amount. limbs, etc.) if it is not covered by Medicare or when the Medicare benefit is exhausted. Prior authorization required For all Dual-eligible Members, Medicaid pays for breast prostheses if not covered by Medicare or when the Medicare benefit is exhausted. Quantity limitations apply, and vary with each device. Prior authorization will NOT be required within limitations, except for miscellaneous codes. $0 copay for Medicaid-covered services. 34

35 Benefit Medicaid UnitedHealthcare Dual Complete (PPO SNP) Renal Dialysis Texas Medicaid covers both Covered. See Section 2 for the Composite Rate and the applicable cost sharing Dealing Direct methods of amount. reimbursement. Physician services for the management of dialysis are also covered. Prior authorization is not required. Plan INFORMATION For Dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Urgently For Dual-eligible Members, Covered. See Section 2 for Needed Medicaid pays for this service applicable cost sharing Services if it is not covered by Medicare amount. or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Vision Services For Dual-eligible Members, Covered. See Section 2 for Medicaid pays for this service applicable cost sharing if it is not covered by Medicare amount. or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Note: Services by an optician are limited to fitting and dispensing of medically necessary eyeglasses and contact lenses. 35

36 Benefit Medicaid UnitedHealthcare Dual Complete (PPO SNP) Preventive Care For Dual-eligible Members, Covered. See Section 2 for Medicaid managed care pays applicable cost sharing for this service if it is not amount. covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Hospice For Dual-eligible Members, Covered. See Section 2 for Medicaid pays for this service applicable cost sharing if it is not covered by Medicare amount. or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Note: When clients elect hospice services, they waive their rights to all other Medicaid services related to their terminal illness. They do not waive their rights to Medicaid services unrelated to their terminal illness. Medicare and Medicaid clients must elect both the Medicare and Medicaid Hospice programs 36

37 Benefit Medicaid UnitedHealthcare Dual Complete (PPO SNP) Inpatient For Dual-eligible Members, Covered. See Section 2 for Hospital Care Medicaid pays for this service applicable cost sharing if it is not covered by Medicare amount. or when the Medicare benefit is exhausted. Prior authorization is required for inpatient substance abuse treatment. Plan INFORMATION $0 copay for Medicaid-covered services. Note: Age restrictions are 13 years of age and above. Admissions for the single diagnosis of chemical dependency or abuse without an accompanying medical complication are not a benefit of Texas Medicaid. Inpatient Mental Inpatient admissions to acute Covered. See Section 2 for Health Care care hospitals for adults and applicable cost sharing children for psychiatric amount. conditions are a benefit of Texas Medicaid. For Dual-eligible Members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. Skilled Nursing For Dual-eligible Members, Covered. See Section 2 for Facility (SNF) Medicaid pays for this service applicable cost sharing if it is not covered by Medicare amount. or when the Medicare benefit is exhausted. $0 copay for Medicaid-covered services. 37

38 Benefit Medicaid UnitedHealthcare Dual Complete (PPO SNP) Prescription Medicaid does not cover Part Covered. See Section 2 for Drug Benefits D covered drugs applicable cost sharing Outpatients prescribed medications are a benefit to eligible clients when obtained through a pharmacy contracted with the Medicaid Vendor amount. $0 copay for Medicaid covered prescription drugs not covered by Medicare Part D. Additional services available through UnitedHealthcare Dual Complete (PPO SNP) Additional No coverage Covered. See Section 2 for Dental Services applicable cost sharing amount. Additional Foot No coverage Covered. See Section 2 for Care applicable cost sharing amount. Additional No coverage Covered. See Section 2 for Hearing applicable cost sharing Services amount. Over-the- No coverage Covered. See Section 2 for Counter Items additional information. Transportation For Dual-eligible Members, Covered. See Section 2 for (routine) the Medicaid Medical applicable cost sharing Transportation Program (MTP) amount. provides non-emergency transportation, if it is not covered by Medicare. $0 copay for Medicaid-covered services. Additional No coverage Covered. See Section 2 for Vision Services applicable cost sharing amount. 38