Section IV - Information for People with Medicare and Medicaid
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1 TM Section IV - Information for People with Medicare and People who qualify for Medicare and are known as dual eligibles. As a dual eligible, you are eligible for benefits under both the federal Medicare program and the state-operated program. The Original Medicare and benefits you receive as a member of this plan are listed in Section II. The kind of benefits you receive are determined by your state and may vary based upon your income and resources. With the assistance of, some dual eligibles do not have to pay for certain Medicare costs. The benefit categories and type of assistance are listed below: 0 Full Benefit Dual Eligible (FBDE):Payment of your Medicare Part B premiums, in some cases Medicare Part A premiums and full benefits. 0 Qualified Medicare Beneficiary (QMB Only):Payment of your Medicare Part A and/or Part B premiums, deductibles and cost-sharing (excluding Part D copayments). 0 QMB-Plus: Payment of your Medicare Part A and Part B premiums, deductibles, cost-sharing (excluding Part D copayments) and full benefits. If you are a QMB or QMB-Plus, you pay $0 for Medicare-covered services as shown in Section II, except any copayments for Part D prescription drugs. If you are not a QMB or QMB-Plus but qualify for full benefits, you may have to pay some copayments, coinsurance, and deductibles, depending on your coverage. The following chart describes benefits that may be available to you under your state program, depending on your coverage. The chart also explains if a similar benefit is available under our plan. It is important to understand that benefits can vary based on your income level and other standards. Also, your benefits can change throughout the year. Depending on your current status, you may not be qualified for all benefits. However, while a member of our plan, you can access plan benefits regardless of your status. Residents of the City Boroughs should contact City Human Resources Administration at for the most current and accurate information regarding your eligibility and benefits. Nassau County residents should contact the Nassau County Department of Social Services at for this information. The services listed below are available under using your benefit identification card for people who qualify for full benefits. Medicare-covered services Inpatient Hospital Care Includes Substance Abuse and Rehabilitation Services
2 TM Inpatient Mental Health Care Skilled Nursing Facility (SNF) Home Health Care Hospice Doctor Office Visits Chiropractic Services Podiatry Services Outpatient Mental Health Care Up to 365 days per year (366 days for leap year) All inpatient mental health services, including voluntary or involuntary admissions for mental health services over the Medicare 190-Day Lifetime Limit covers additional days beyond Medicare 100 day limit Medically necessary intermittent skilled nursing care, home health aide services and rehabilitation services. Also includes non-medicare covered home health services (e.g., home health aide services with nursing supervision to medically unstable individuals). (QMB and QMB Plus Only) (QMB and QMB Plus Only) Plan covers up to 100 days each benefit period You must get care from Medicare-certified hospice. Non-Medicare-covered services include: Includes 4 routine visits per year. Please see Section 2 for additional benefit details.
3 TM Outpatient Substance Abuse Care Outpatient Services/ Surgery Ambulance Services Emergency Care Urgently Needed Care Outpatient Rehabilitation Services Durable Medical Equipment Prosthetic Devices Diabetes Self-Monitoring covered durable medical equipment, including devices and equipment other than medical/surgical supplies, Enteral formula, and prosthetic or orthotic appliances having the following characteristics: can withstand repeated use for a protracted period time; are primarily and customarily used for medical purposes; are generally not useful to a person in the absence of illness or injury and are usually fitted, designed or fashioned for a particular individual s use. Must be ordered by a practitioner. No homebound prerequisite and including non-medicare DME covered by (e.g. tub stool; grab bars). covered prosthetics, orthotics, and orthopedic footwear. No diabetic prerequisite for orthotics.
4 TM Training, Nutrition Therapy, and Supplies Diagnostic Tests, X-Rays, Lab Services, and Radiology Services Bone Mass Measurement Colorectal Screening Exams Immunizations Mammograms Pap Smears and Pelvic Exams Prostate Cancer Screening Exams End-Stage Renal Disease Prescription Drugs Dental Services does not cover Part D covered drugs Pharmacy Benefits allowed by State Law (select drug categories excluded from the Medicare Part D Depending on your income and institutional status, you pay the following: For Part D generic drugs (including brand drugs treated as generic), either: 0 A or benefit and certain medications included 0 A $1.10 copay or in the Part D benefit when the Enrollee 0 A $2.50 copay is unable to receive them from his/her For all other Part D drugs, either: Medicare Advantage Plan), also certain Medical Supplies and Enteral Formula 0 A or when not covered by Medicare 0 A $3.30 copay or 0 A $6.30 copay
5 TM Hearing Services Vision Services covered dental services including necessary preventive, prophylactic and other routine dental care, services and supplies and dental prosthetics to alleviate a serious health condition. Ambulatory or inpatient surgical dental services subject to prior authorization. Hearing services and products when medically necessary to alleviate disability caused by the loss or impairment of hearing. Services include hearing and selecting, fitting, and dispensing; hearing aid checks following dispensing, conformity evaluations and hearing aid repairs; audiology services including examinations and testing, hearing aid evaluations and hearing aid prescriptions; and hearing aid products including hearing aids, ear molds, special fittings and replacement parts. Services of Optometrists, Opthalmologists and Opthalmic dispensers including eyeglasses, medically necessary contact lenses and polycarbonate lenses, artificial eyes (stock or custom-made), low vision aids and low vision services. Coverage also includes the repair or replacement of parts. Coverage also includes examinations for diagnosis and treatment for visual defects and/or eye disease. Examinations for refraction are limited to every two (2) years unless otherwise justified as medically necessary. Eyeglasses do not require changing more frequently than every two (2) years unless medically necessary or unless the glasses are lost, damaged or destroyed. Non-Medicare-covered services include: Includes routine eye exam and credit for eyeglasses or contacts. Please see Section 2 for additional benefit details.
6 TM Welcome to Medicare; and Annual Wellness Visit Health/Wellness Education No coverage Non-Medicare-covered services included: Includes written education materials, including newsletters. The plan also has a 24-hour nurseline benefit. Please see Section 2 for additional benefit details. Non-Medicare-covered additional services Transportation (non-emergency) Non-emergency transportation services covered beyond the 24 trips provided by the plan Includes 24 one-way trips to plan approved locations. Please see Section 2 for additional benefit information. only services Private Duty Nursing Out-of-Network Family Planning services provided under the direct access provisions of the waiver Personal Care Services Certain Mental Health Services Methadone Maintenance Treatment Programs (MMTP) coverage includes: 0 Intensive Psychiatric Rehabilitation Treatment Programs 0 Day Treatment 0 Continuing Day Treatment 0 Case Management for Seriously and Persistently Mentally Ill (sponsored by state or local mental health units) 0 Partial Hospitalizations 0 Assertive Community Treatment (ACT) 0 Personalized Recovery Oriented Services (PROS)
7 TM Rehabilitation Services Provided to Residents of OMH Licensed Community Residences (CRs) and Family Based Treatment Programs Office of Mental Retardation and Developmental Disabilities (OMRDD) Services Comprehensive Case Management Directly Observed Therapy for Tuberculosis (TB) Disease AIDS Adult Day Health Care HIV COBRA Case Management Adult Day Health Care Personal Emergency Response Services (PERS)
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