Health Partners Plans Provider Manual Health Partners Medicare Benefits Summary

Transcription

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

2 Health Partners Plans Provider Manual HP Medicare Benefits Section 5 Page 5-2

3 Table of Contents Overview 5-4 Summary of Benefits 5-4 Table 1: Health Partners Medicare Basic (HMO) Benefits 5-5 Table 2: Health Partners Medicare Prime (HMO) Benefits 5-7 Table 3: Health Partners Medicare PrimePlus (HMO) Benefits 5-10 Table 4: Health Partners Medicare Special (HMO SNP) Benefits 5-13 Health Partners Medicare n-covered Services 5-15 Health Partners Plans Provider Manual HP Medicare Benefits Section 5 Page 5-3

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

5 Table 1: Health Partners Medicare Basic (HMO) Health Partners Medicare Basic (HMO) Benefits Benefit/Service Cost-sharing/Limits Prior Authorization Acupuncture t covered N/A Ambulance Services Audiology Services Cardiac and Pulmonary Rehabilitation Services Chiropractic Services Dental Services Diabetes Programs and Supplies Diagnostic Radiology Doctor Office Visits $225 copay for non-emergent ambulance services $0 copay for routine hearing exam every year; $50 copay for Medicare-covered hearing exams; hearing aid coverage Health Partners Plans Provider Manual HP Medicare Benefits Section 5 Page 5-5 $50 copay for each service $20 copay for each Medicarecovered visit $50 copay for Medicare-covered dental benefits; Preventive dental services not covered $0 copay for test strips and monitors; 20% for other diabetes supplies; $0 copay for diabetes self-management training $40 copay for each X-Ray; $200 copay for other diagnostic radiology services $0 copay for each primary care visit; $50 copay for each specialist visit, for CT/PET/MRI services contact Landmark Durable Medical Equipment 20% Emergency Care $65 copay per visit; $0 copay if admitted to the hospital within 24 hours for the same condition (if member reasonably believes emergency care is needed) Home Health Care $0 copay per visit Hospice $0 copay Hospital Care (Inpatient) limit to the number of days of hospital stay; Days 1-7: $260 copay per day; Days 8-90: $0 copay per day; Days 91 and beyond: $0 copay per day Kidney Disease 20%

6 and Conditions Health Partners Medicare Basic (HMO) Benefits Laboratory Services $0 copay per lab service/test Mental Health Care (Inpatient) up to 190 days in a lifetime; Days 1-7: $215 copay per day; Days 8-90: $0 copay per day - contact Magellan Behavioral Health Mental Health Care (Outpatient) $40 copay per visit Outpatient Services Physical/Occupational/Speech Therapy Services (Outpatient) Podiatry Services $180 copay for each ambulatory surgical center visit; $250 copay for each outpatient hospital facility visit $40 copay per visit $50 copay per visit; $50 copay for Medicare-covered foot care, Supplemental routine care not covered. Prescription Drugs (Outpatient) Part D drugs not covered N/A Preventive Services $0 copay per visit Prosthetic Devices 20% Radiation Therapy 20% Skilled Nursing Facility (SNF) Substance Abuse Treatment (Outpatient) Up to 100 days each benefit period; Days 1-20: $0 copay per day; Days : $ copay per day ( prior hospital stay required) $50 copay per visit Transportation (Routine) t covered N/A Urgently Needed Care Vision Services $45 copay per visit; $0 copay for routine eye exam every year; $0 copay for one pair of eyeglasses or contact lenses after cataract surgery Weight Watchers $2 copay per weekly visit Health Partners Plans Provider Manual HP Medicare Benefits Section 5 Page 5-6

7 Table 2: Health Partners Medicare Prime (HMO) Health Partners Medicare Prime (HMO) Benefits Benefit/Service Cost-sharing/Limits Prior Authorization Acupuncture t covered N/A Ambulance Services Audiology Services Cardiac and Pulmonary Rehabilitations Services Chiropractic Services Dental Services Diabetes Programs and Supplies Diagnostic Radiology Doctor Office Visits $225 copay for non-emergent ambulance services $0 copay for routine hearing exam every year; hearing aid coverage $50 copay for each service $20 copay for each Medicarecovered visit $50 copay for Medicare-covered dental benefits; Preventive dental services not covered $0 copay for test strips and monitors; 20% for other diabetes supplies; $0 copay for diabetes selfmanagement training $30 copay for each X-Ray; $200 copay for other diagnostic radiology services $0 copay for each primary care visit; $50 copay for each specialist visit, for CT/PET/MRI services contact Landmark Durable Medical Equipment 20% Emergency Care $65 copay per visit; $0 copay if admitted to the hospital within 24 hours for the same condition (if member reasonably believes emergency care is needed) Home Health Care $0 copay per visit Hospice $0 copay Hospital Care (Inpatient) limit to the number of days of hospital stay; Days 1-7: $250 copay per day; Days 8-90: $0 copay per day; Days 91 and beyond: $0 copay per day Hospice $0 copay Health Partners Plans Provider Manual HP Medicare Benefits Section 5 Page 5-7

8 Health Partners Medicare Prime (HMO) Benefits Kidney Disease and Conditions 20% Laboratory Services $0 copay per lab service/test Mental Health Care (Inpatient) Up to 190 days in a lifetime; Days 1-7: $215 copay per day; Days 8-90: $0 copay per day - contact Magellan Behavioral Health Mental Health Care (Outpatient) $40 copay per visit Outpatient Services Physical/Occupational/Speech Therapy Services (Outpatient) Podiatry Services Prescription Drugs (Outpatient) $180 copay for each ambulatory surgical center visit; $250 copay for each outpatient hospital facility visit Health Partners Plans Provider Manual HP Medicare Benefits Section 5 Page 5-8 $40 copay per visit $50 copay per visit; $50 copay for Medicare-covered foot care. Supplemental routine care not covered. $3 copay for Tier 1 generic for up to a 30-day supply, and a $6 copay for up to a 90-day supply; $45 copay for Tier 2 preferred brand for up to a 30-day supply and $90 copay for up to a90-day supply $90 copay for Tier 3 nonpreferred brand up to a 30 day supply and $180 copay for up to a 90-day supply; 33% coinsurance for Tier 4, specialty medications, Once the total yearly drug costs reach $2,960, the member enters the coverage gap phase where the coinsurance is no more than 45% for brand drugs and 65% for generic drugs. Once the member reaches the catastrophic phase with a total out of pocket expense of $4,700, the member pays the greater of 5% coinsurance or $2.65 copay for generic and $6.60 copay for all other drugs. Required for certain drugs see Formulary Preventive Services $0 copay per visit Prosthetic Devices 20% Radiation Therapy 20% Skilled Nursing Facility (SNF) Up to 100 days each benefit period; Days 1-20: $0 copay per ( prior hospital

9 Substance Abuse Treatment (Outpatient) Health Partners Medicare Prime (HMO) Benefits day; Days : $ copay per day stay required) $50 copay per visit Transportation (Routine) t covered N/A Urgently Needed Care $45 copay per visit Vision Services $0 copay for routine eye exam every year; $0 copay for one pair of eyeglasses or contact lenses after cataract surgery; $50 copay for Medicare covered vision services Weight Watchers $2 copay per weekly visit Health Partners Plans Provider Manual HP Medicare Benefits Section 5 Page 5-9

10 Table 3: Health Partners Medicare PrimePlus (HMO) Health Partners Medicare PrimePlus (HMO) Benefits Benefit/Service Cost-sharing/Limits Prior Authorization Acupuncture $5 copay per visit up to 20 visits Ambulance Services Audiology Services Cardiac and Pulmonary Rehabilitations Services Chiropractic Services Dental Services Diabetes Programs and Supplies Diagnostic Radiology Doctor Office Visits $175 copay for non-emergent ambulance services $0 copay for routine hearing exam every year; $0 copay for hearing aid every three years, up to $1,000 limit Health Partners Plans Provider Manual HP Medicare Benefits Section 5 Page 5-10 $35 copay for each service $20 copay for each Medicarecovered visit; $20 copay per visit for up to 20 routine visits $35 copay for Medicare-covered dental benefits; $0 copay for up to 2 dental exams/cleanings and one fluoride treatment and dental X-ray yearly; Additional supplemental coverage limited to $800, with $50 deductible $0 copay for test strips and monitors; 20% for other diabetes supplies; $0 copay for diabetes selfmanagement training $20 copay for each X-Ray; $195 copay for other diagnostic radiology services $0 copay for each primary care visit; $35 copay for each specialist visit, for CT/PET/MRI services contact Landmark Durable Medical Equipment 20% Emergency Care $65 copay per visit; $0 copay if admitted to the hospital within 24 hours for the same condition (if member reasonably believes emergency care is needed) Home Health Care $0 copay per visit Hospice $0 Hospital Care (Inpatient) limit to the number of days of hospital stay; Days 1-5: $195

11 Health Partners Medicare PrimePlus (HMO) Benefits copay per day; Days 6-90: $0 copay per day Kidney Disease and Conditions 20% Laboratory Services $0 copay per lab service/test Mental Health Care (Inpatient) Up to 190 days in a lifetime; Days 1-5: $200 copay per day; Days 6-90: $0 copay per day - contact Magellan Behavioral Health Mental Health Care (Outpatient) $35 copay per visit Outpatient Services $165 copay for each ambulatory surgical center visit;$200 copay for each outpatient hospital facility visit Physical/Occupational/Speech Therapy Services (Outpatient) $35 copay per visit Podiatry Services $35 copay per visit Prescription Drugs (Outpatient) $0 copay for Tier 1 generic for up to a 30-day supply, and a $0 copay for up to a 90-day supply $45 copay for Tier 2 preferred brand for up to a 30-day supply and $90 copay for up to a90-day supply $90 copay for Tier 3 nonpreferred brand up to a 30 day supply and $180 copay for up to a 90-day supply; 33% coinsurance for Tier 4, specialty medications, Once the total yearly drug costs reach $2,960, the member enters the coverage gap phase where the coinsurance is no more than 45% for brand drugs and 65% for generic drugs. Once the member reaches the catastrophic phase with a total out of pocket expense of $4,700, the member pays the greater of 5% coinsurance or $2.65 copay for generic and $6.60 copay for all other drugs. Required for certain drugs see Formulary Preventive Services $0 copay per visit Prosthetic Devices 20% Radiation Therapy 20% Health Partners Plans Provider Manual HP Medicare Benefits Section 5 Page 5-11

12 Health Partners Medicare PrimePlus (HMO) Benefits Skilled Nursing Facility (SNF) Substance Abuse Treatment (Outpatient) Up to 100 days each benefit period; Days 1-20: $0 copay per day; Days : $ copay per day ( prior hospital stay required) $35 copay per visit Transportation (Routine) t covered N/A Urgently Needed Care $35 copay per visit Vision Services $35 copay for Medicare-covered exams; $0 copay for one routine eye exam yearly; $0 copay for one pair of eyeglasses or contact lenses after cataract surgery; $0 copay for one pair of eyeglasses or contact lenses every two years, up to $200 limit Weight Watchers $2 copay per weekly visit Health Partners Plans Provider Manual HP Medicare Benefits Section 5 Page 5-12

13 Table 4: Health Partners Medicare Special (HMO SNP) Health Partners Medicare Special (HMO SNP) Benefits Cost sharing in this plan depends on the member s Medicaid eligibility level. Benefit/Service Cost-sharing/Limits Prior Authorization Acupuncture Ambulance Services Audiology Services Cardiac and Pulmonary Rehabilitation Services Chiropractic Services Dental Services Diabetes Programs and Supplies Diagnostic Radiology $0 or 20% Doctor Office Visits $5 copay per visit up to 20 visits $0 or 20% for non-emergent ambulance benefits $0 or 20% for Medicare-covered services; $0 copay for one routine hearing exam yearly; $0 copay for hearing aid every three years, up to $1,000 limit $0 or 20% $0 or 20% for each Medicarecovered chiropractic visit; $0 copay for up to 20 routine visits every year $0 or 20% for Medicare-covered dental services; $0 copay for up to 2 dental exams/cleanings and one fluoride treatment and dental X-ray yearly; Additional supplemental coverage limited to $475 every two years $0 or 20% $0 or 20% for each primary care visit and specialist visit, for CT/PET/MRI services - contact Landmark Durable Medical Equipment $0 or 20% Emergency Care $0 or 20% of the cost (up to $65) for each visit; $0 copay if admitted to the hospital within 24 hours for the same condition (if a member reasonably believe emergency care is needed) Home Health Care $0 copay per visit Hospice $0 Health Partners Plans Provider Manual HP Medicare Benefits Section 5 Page 5-13

14 Health Partners Medicare Special (HMO SNP) Benefits Hospital Care (Inpatient) Kidney Disease and Conditions limit to the number of days of hospital stay. Days 1-60: $1,260 deductible; Days 61-90: $315 copay per day; Days : $630 copay per lifetime reserve day. Health Partners Plans Provider Manual HP Medicare Benefits Section 5 Page 5-14 $0 or 20% Laboratory Services $0 or 20% Mental Health Care (Inpatient) Up to 190 days in a lifetime; Days 1-60: $1,260 deductible; Days 61-90: $315 copay per day; Days : $630 copay per lifetime reserve day. - contact Magellan Behavioral Health Mental Health Care (Outpatient) $0 or 20% Outpatient Services Physical/ Occupational/ Speech Therapy Services Podiatry Services Prescription Drugs (Outpatient) $0 or 20% for each ambulatory surgical center visit and outpatient hospital facility visit $0 or 20% $0 or 20% for each Medicarecovered podiatry visit; $15 copay for one routine visit every three months $0 annual deductible for dual eligible members; Depending on income subsidy level, members pay either $0 copay or $1.20 copay or $2.65 copay or 15% coinsurance for generic drugs; for all other drugs, pay either $0 copay or $3.60 copay or $6.60 copay or 15% coinsurance. Once the member reaches the catastrophic phase with a total out of pocket expense of $4,700, depending on income subsidy level, members pay $0 copay or $2.65 for generic drugs or $6.60 for all other drugs. Required for certain drugs see Formulary Preventive Services $0 copay per visit Prosthetic Devices $0 or 20% Radiation Therapy $0 or 20% Skilled Nursing Facility (SNF) Up to 100 days each benefit period; $0 or Days 1-20: $0 copay ( prior hospital

15 Health Partners Medicare Special (HMO SNP) Benefits per day; Days : $ copay per day. stay required) Substance Abuse Treatment (Outpatient) $0 or 20% Transportation (Routine) Urgently Needed Care Vision Services 10 one-way trips to plan-approved locations per quarter $0 or 20% for each Medicarecovered visit; $0 or 20% for Medicare-covered exams; $0 copay for one routine eye exam yearly; $0 copay for one pair of eyeglasses or contact lenses after cataract surgery; $0 copay for one pair of eyeglasses or contact lenses every two years, up to $150 limit Weight Watchers $2 copay per weekly visit n-covered Services The following services and benefits are excluded or limited under Health Partners Medicare plans. Services considered not reasonable and necessary, according to the standards of Original Medicare, unless these services are listed by our plan as covered services. Experimental medical and surgical procedures, equipment and medications, unless covered by Original Medicare or under a Medicare-approved clinical research study or by our plan. Experimental procedures and items are those items and procedures determined by our plan and Original Medicare to not be generally accepted by the medical community. Surgical treatment for morbid obesity, except when it is considered medically necessary and covered under Original Medicare. Private room in a hospital, except when it is considered medically necessary. Private duty nurses. Personal items in your room at a hospital or a skilled nursing facility, such as a telephone or a television. Full-time nursing care in your home. Custodial care, including care provided in a nursing home, hospice, or other facility setting when you do not require skilled medical care or skilled nursing care. Custodial care is personal care that does not require the continuing attention of trained medical or paramedical personnel, such as care that helps you with activities of daily living, such as bathing or dressing. Health Partners Plans Provider Manual HP Medicare Benefits Section 5 Page 5-15

16 Homemaker services including basic household assistance, such as light housekeeping or light meal preparation. Fees charged by your immediate relatives or members of your household. Meals delivered to your home. Elective or voluntary enhancement procedures or services (including weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance), except when medically necessary. Cosmetic surgery or procedures, unless because of an accidental injury or to improve a malformed part of the body. However, all stages of reconstruction are covered for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance. Routine dental care, such as cleanings, fillings or dentures, except for services specifically covered in the Health Partners Medicare PrimePlus and Special plans, as shown in the charts in this chapter. However, non-routine dental care required to treat illness or injury may be covered as inpatient or outpatient care. Chiropractic care, other than manual manipulation of the spine consistent with Medicare coverage guidelines, except for services specifically covered in the Health Partners Medicare PrimePlus and Special plans, as shown in the charts in this chapter. Routine foot care, except for the limited coverage provided according to Medicare guidelines, except for services specifically covered in the Health Partners Medicare PrimePlus and Special plans, as shown in the charts in this chapter. Orthopedic shoes, unless the shoes are part of a leg brace and are included in the cost of the brace or the shoes are for a person with diabetic foot disease. Supportive devices for the feet, except for orthopedic or therapeutic shoes for people with diabetic foot disease. Hearing aids or exams to fit hearing aids, except for services specifically covered in the Health Partners Medicare PrimePlus and Special plans, as shown in the charts in this chapter. Eyeglasses, except as specifically covered in the Health Partners Medicare PrimePlus and Special plans, as shown in the charts in this chapter. (However, eyeglasses are covered for people after cataract surgery.) Radial keratotomy, LASIK surgery, vision therapy and other low vision aids. Reversal of sterilization procedures, sex change operations, and non-prescription contraceptive supplies. Acupuncture, except for services specifically covered in the Health Partners Medicare PrimePlus and Special plans, as shown in the charts in this chapter. Naturopath services (uses natural or alternative treatments). Services provided to veterans in Veterans Affairs (VA) facilities. However, when emergency services are received at a VA hospital and the VA cost sharing is more than Health Partners Plans Provider Manual HP Medicare Benefits Section 5 Page 5-16

17 the cost sharing under our plan, we will reimburse veterans for the difference. Members are still responsible for our cost-sharing amounts. Drugs used to treat anorexia, weight loss, or weight gain, even if used for a non-cosmetic purpose (i.e., morbid obesity). Drugs used to promote fertility. Drugs used for cosmetic purposes or hair growth. Drugs used to treat symptomatic relief of cough and colds, including over-the-counter medications. Prescription vitamin and mineral products, except prenatal vitamins and fluoride preparations. Covered outpatient drugs which the manufacturer seeks to require, as a condition of sale, that associated tests or monitoring services be purchased exclusively from the manufacturer or its designee. Agents used to treat sexual or erectile dysfunction except when prescribed to treat medically accepted indications other than sexual dysfunction or erectile dysfunction. n-prescription drugs, such as over-the-counter (OTC) products except the items used in the administration of insulin. Please note that members in the Health Partners Medicare Special plan have a benefit providing an over-the-counter allowance of $30 per month for plan-specified OTC medications when obtained with a prescription. The plan will not cover the excluded services listed above. Even if received at an emergency facility, the excluded services are still not covered. Health Partners Plans Provider Manual HP Medicare Benefits Section 5 Page 5-17