D-SNP Benefits. A Quick Guide to Understanding the AmeriHealth VIP Care D-SNP Benefits
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1 D-SNP Benefits A Quick Guide to Understanding the AmeriHealth VIP Care D-SNP Benefits
2 Benefits Why AmeriHealth VIP Care Was Created The dual-eligible special needs Medicare Advantage plan, AmeriHealth VIP Care, was created to coordinate Medicare and Medicaid services, simplify the delivery system and to streamline payment to the provider. The goals of creating this plan are: Improve health outcomes. Keep beneficiaries in the community. Provide enhanced benefits in addition to Medicare and Medicaid benefits. 2
3 Benefits AmeriHealth VIP Care Plan Overview AmeriHealth VIP Care provides Medicare Parts A, B and D and additional services. AmeriHealth VIP Care also coordinates the care of members who are receiving Medicaid benefits from the state. The plan s service area includes the following counties: Lancaster, Lehigh and Northampton. 3
4 Benefits Medicare vs. Medicaid: Which Program Pays for Which Service? Plan name Medicare Parts A and B Medicare Part D Medicaid Medicaid Pennsylvania Department of Public Welfare (PA DPW) N/A N/A X Medicare Advantage MAPD X X Not applicable for nondual-eligible Medicare beneficiaries Fee-for-service (FFS) for dual-eligible beneficiaries Dual-eligible special needs plans (D-SNP) AmeriHealth VIP Care X X State 4
5 Benefits PA 2014 Eligibility Guidelines for the Medicare Savings Program Qualified Medicare Beneficiary (QMB, QMB+) Specified Low- Income Medicare Beneficiary (SLMB, SLMB+) 2014 Eligibility Guidelines for the Medicare Savings Programs Monthly Income* Assets** Benefits*** (All States and DC, except Alaska and Hawaii) State pays for (All States and DC, except Alaska and Hawaii) 100% FPL individual's $7,160 - individual $993 - individual copays and $10,570 - couple $1,331 - couple premiums (All States and DC, except Alaska and Hawaii) 100%-120% FPL $993-$1,187 - individual $1,331-$1,594 - couple (All States and DC, except Alaska and Hawaii) $7,160 - individual $10,750 - couple State pays for individual's copays and premiums * Federal poverty levels are updated each year, usually in January or February. ** Asset limits can change each year and are usually updated in December for the following year. ***Benefits differ from state to state; this graph refers to PA benefits only. 5
6 Benefits Medicare Part A and B Benefits * Ambulance services. Cardiac and pulmonary rehabilitation services. Catastrophic coverage. Chiropractic care. Dental services. Diabetes program and supplies. Diagnostic tests, X-rays, lab services and radiology services. Doctor office visits Durable medical equipment. Emergency care. Hearing services. Home health care. Hospice initial consultation. Inpatient hospital care. Inpatient mental health care. LTC pharmacy. Mail order prescriptions. Out-of-network catastrophic coverage. Out-of-network catastrophic prescriptions. Out-of-network initial coverage. Outpatient mental health care. Outpatient prescription drugs. Outpatient rehabilitation. Outpatient services and surgery. Outpatient substance abuse care. Pharmacy. Podiatry. Preventive services and wellness education. Prosthetic devices. Skilled nursing facility services. Urgent care. *Exceptions may apply, see provider manual for full list of benefits. Referral or prior authorization may be required. 6
7 Benefits Supplemental Benefits: Dental, Vision and Hearing Dental services Preventive dental Oral exams: one every six months. Cleaning: one every six months. Fluoride treatment: one every six months. Dental X-rays: one every year. Non-routine services, including minor restorations such as fillings, simple extractions and denture repair. Comprehensive dental Non-routine services. $500 every two years. Coverage for minor restorations. Fillings, simple extractions and denture repair. Vision services Up to one supplemental routine eye exam every year. Up to one pair of eyeglasses or contact lenses every two years. Hearing services Up to one supplemental routine hearing exam every year. Up to one fitting evaluation for a hearing aid every three years. Up to $1,000 coverage for hearing aids every three years. 7
8 Benefits Supplemental Benefits (Continued): OTC and Transportation Over the counter (OTC) Typically includes medicines or products that alleviate or treat injuries or illness. May use the benefit without a statement or documentation of a diagnosis from a medical provider. Up to $60 every three months. No rollover quarter to quarter. Member may fill out OTC Catalog or call Member Services at to order OTC products. Convey Health Solutions keeps track of OTC utilization and will inform members, providers and pharmacy when limit is reached. Transportation services Must be plan-approved location. Twenty-four (24) one-way trips per year to a plan-approved location. Car, shuttle and van services include nonemergent transportation to doctor visits, preventive services, pharmacies and fitness centers. Authorization and scheduling rules apply. Members may call Member Services at or their care managers to arrange transportation. 8
9 Benefits Supplemental Benefits (Continued): 24/7/365 Nurse Line If members are unable to reach their PCPs offices, registered nurses are available 24 hours/7 days to assist members through the toll-free AmeriHealth VIP Care Nurse Call Line at
10 Benefits Supplemental Benefits (Continued): Care Management Team The Care Management Team (CMT) consists of care managers (nurses and social workers) trained to help members investigate and overcome barriers to achieve their health care goals. Outreach services include: Contacting members. Educating members. Calling providers. Calling pharmacies. Completing surveys and assessments to support special projects. Providers may request CMT support directly by calling toll-free: , 8 a.m. 5 p.m., Monday through Friday. 10
11 Benefits Additional Information For additional information on benefits, please refer to the Provider Manual or call Provider Services at
12
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