2016 icare Medicare Advantage Special Needs Plan SUMMARY OF BENEFITS H2237_IC1174 Accepted Friends for Health. Friends for Life.
Multi-language Interpreter Services English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-800-777-4376. Someone who speaks English/Language can help you. This is a free service. Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-800-777-4376. Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Chinese Mandarin: 我 们 提 供 免 费 的 翻 译 服 务, 帮 助 您 解 答 关 于 健 康 或 药 物 保 险 的 任 何 疑 问 如 果 您 需 要 此 翻 译 服 务, 请 致 电 1-800-777-4376 我 们 的 中 文 工 作 人 员 很 乐 意 帮 助 您 这 是 一 项 免 费 服 务 Chinese Cantonese: 您 對 我 們 的 健 康 或 藥 物 保 險 可 能 存 有 疑 問, 為 此 我 們 提 供 免 費 的 翻 譯 服 務 如 需 翻 譯 服 務, 請 致 電 1-800-777-4376 我 們 講 中 文 的 人 員 將 樂 意 為 您 提 供 幫 助 這 是 一 項 免 費 服 務 Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-800-777-4376. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au 1-800-777-4376. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-800-777-4376 sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí. German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-800-777-4376. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화 1-800-777-4376번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. H2237_IC828 CMS Accepted
Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону 1-800-777-4376. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная. Arabic: إننا نقدم خدمات المترجم الفوري المجانية لإلجابة عن أي أسئلة تتعلق بالصحة أو جدول األدوية لدينا. للحصول على مترجم فوري ليس عليك سوى االتصال بنا على 4376-777-800-1. سيقوم شخص ما.بمساعدتك. هذه خدمة مجانية يتحدث العربية Hindi: हम र स व स य य दव क य जन क ब र म आपक ककस भ प रश न क जव ब द न क ल ए हम र प स म फ त द भ ष य स व ए उप ब ध ह. एक द भ ष य प र प त करन क ल ए, बस हम 1-800-777-4376 पर फ न कर. क ई व यक तत ज हहन द ब त ह आपक मदद कर सकत ह. यह एक म फ त स व ह. Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-800-777-4376. Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito. Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número 1-800-777-4376. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito. French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-800- 777-4376. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-800-777-4376. Ta usługa jest bezpłatna. Japanese: 当 社 の 健 康 健 康 保 険 と 薬 品 処 方 薬 プランに 関 するご 質 問 にお 答 えするため に 無 料 の 通 訳 サービスがありますございます 通 訳 をご 用 命 になるには 1-800-777 4376にお 電 話 ください 日 本 語 を 話 す 人 者 が 支 援 いたします これは 無 料 のサー ビス です Hmong: Peb muaj tib neeg los pab ntxhais lus dawb rau koj yog koj muaj kev nug txog ntawm peb cov ntaub ntawv ua yog kev los pab kho mob los yog kev muab tshuaj noj. Yog xav tau kev pab txhais lus, hu tau rau peb tus xov tooj 1-800-777-4376. Muaj ib tus neeg ua paub hais lus Hmoob yuav los pab koj. Qhov no yog kev pab dawb xwb. H2237_IC828 CMS Accepted
icare MEDICARE PLAN (a Medicare Advantage Health Maintenance Organization (HMO) offered by INDEPENDENT CARE HEALTH PLAN, INC. with a Medicare contract) Summary of Benefits January 1, 2016 - 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 icare Medicare Plan. Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what icare Medicare Plan 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 http://www.medicare.gov. 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 http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. Sections in this booklet Things to Know About icare Medicare Plan Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services Covered Medical and Hospital Benefits Prescription Drug Benefits Additional Information About icare Medicare Plan Medicaid Benefit Comparison
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 1-800-777-4376. THINGS TO KNOW ABOUT icare MEDICARE PLAN Hours of Operation You can call us 24 hours-a-day, 7 days-a-week (office hours: Monday-Friday, 8:30 a.m. to 5:00 p.m), or visit www.icare-wi.org icare Medicare Plan Phone Numbers and Website If you are a member of this plan, call toll-free 1-800-777-4376. If you are not a member of this plan, call toll-free 1-855-689-7690. Our website: http://www.icare-wi.org Who can join? To join icare Medicare Plan, you must be entitled to Medicare Part A, be enrolled in Medicare Part B and Wisconsin Medicaid, and live in our service area. Our service area includes the following counties in Wisconsin: Brown, Calumet, Dane, Kenosha, Kewaunee, Manitowoc, Marinette, Menominee, Milwaukee, Oconto, Outagamie, Ozaukee, Racine, Rock, Sauk, Shawano, Sheboygan, Walworth, Washington, Waukesha, Waupaca, and Winnebago. Which doctors, hospitals, and pharmacies can I use? icare Medicare Plan has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan's provider and pharmacy directory at our website (http://www.icare-wi.org). 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, http://www.icare-wi.org. Or, call us and we will send you a copy of the formulary. How will I determine my drug costs? Our plan groups each medication into one of three "tiers." You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug's tier 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. MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW MUCH YOU PAY FOR COVERED SERVICES How much is the monthly premium? $0 per month. In addition, you must keep paying your Medicare Part B premium. How much is the deductible? This plan has deductibles for some hospital and medical $0 or $147 per year for in-network services, depending on your level of Medicaid eligibility. This amount may change for 2016. Is there any limit on how much I will pay for my covered services? This plan does not have a deductible for Part D prescription drugs. 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 Wisconsin Medicaid eligibility. Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers.
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 For Wisconsin Medicaid -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 in-network benefits. Contact us for the services that apply. The icare Medicare Plan HMO SNP is a Coordinated Care plan with a Medicare contract and a contract with the Wisconsin Medicaid program. Enrollment in the icare Medicare Plan depends on contract renewal. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.
COVERED MEDICAL AND HOSPITAL BENEFITS NOTE: Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor. OUTPATIENT CARE AND SERVICES Acupuncture Not covered Ambulance Chiropractic Care Dental Services Diabetes Supplies and Services 1 0% or 20% of the cost Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): 0% or 20% of the cost Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): 0% or 20% of the cost Diabetes monitoring supplies: You pay nothing Diabetes self-management training: 0% or 20% of the cost Therapeutic shoes or inserts: 0% or 20% of the cost Diagnostic Tests, Lab and Radiology Services, and X-Rays (Costs for these services may be different if received in an outpatient surgery setting) 1 Diagnostic radiology services (such as MRIs, CT scans): 0% or 20% of the cost Diagnostic tests and procedures: 0% or 20% of the cost Lab services: 0% or 20% of the cost Outpatient x-rays: 0% or 20% of the cost Therapeutic radiology services (such as radiation treatment for cancer): 0% or 20% of the cost Doctor's Office Visits Primary care physician visit: 0% or 20% of the cost Specialist visit: 0% or 20% of the cost
Durable Medical Equipment (wheelchairs, oxygen, etc.) 1 0% or 20% of the cost Emergency Care $0 or $75 copay If you are admitted to the hospital within 3 days, 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 (podiatry services) Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: 0% or 20% of the cost Hearing Services Home Health Care 1,2 Mental Health Care 1,2 Exam to diagnose and treat hearing and balance issues: 0% or 20% of the cost You pay nothing Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit applies to inpatient mental services provided in a general hospital. 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 2015 the amounts for each benefit period were $0 or: $1,260 deductible for days 1 through 60 $315 copay per day for days 61 through 90
$630 copay per day for 60 lifetime reserve days These amounts may change for 2016. Outpatient group therapy visit: 0% or 20% of the cost Outpatient individual therapy visit: 0% or 20% of the cost Outpatient Rehabilitation 1,2 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): 0% or 20% of the cost Occupational therapy visit: 0% or 20% of the cost Physical therapy and speech and language therapy visit: 0% or 20% of the cost Outpatient Substance Abuse Group therapy visit: 0% or 20% of the cost Individual therapy visit: 0% or 20% of the cost Outpatient Surgery Ambulatory surgical center: 0% or 20% of the cost Outpatient hospital: 0% or 20% of the cost Over-the-Counter Items Prosthetic Devices (braces, artificial limbs, etc.) 1 Renal Dialysis Transportation Please visit our website to see our list of covered over-the-counter items. Prosthetic devices: 0% or 20% of the cost Related medical supplies: 0% or 20% of the cost 0% or 20% of the cost Not covered Urgently Needed Services 0% or 20% of the cost (up to $65) Vision Services Exam to diagnose and treat diseases and conditions of the eye
(including yearly glaucoma screening): 0% or 20% of the cost Eyeglasses or contact lenses after cataract surgery: 0% or 20% of the cost PREVENTIVE CARE You pay nothing 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 Colonoscopy 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: You pay nothing HOSPICE You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and
INPATIENT CARE Inpatient Hospital Care 1 respite care. Hospice is covered outside of our plan. Please contact us for more details. 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 2015 the amounts for each benefit period were $0 or: $1,260 deductible for days 1 through 60 $315 copay per day for days 61 through 90 $630 copay per day for 60 lifetime reserve days These amounts may change for 2016. Inpatient Mental Health Care For inpatient mental health care, see the "Mental Health Care" section of this booklet. Skilled Nursing Facility (SNF) 1,2 Our plan covers up to 100 days in a SNF. PRESCRIPTION DRUG BENEFITS How much do I pay? In 2015 the amounts for each benefit period were $0 or: You pay nothing for days 1 through 20 $157.50 copay per day for days 21 through 100 These amounts may change for 2016. For Part B drugs such as chemotherapy drugs 1 : 0% or 20% of the cost Other Part B drugs 1 : 0% or 20% of the cost Initial Coverage Our plan does not have a deductible for Part D prescription drugs.
You pay the following: You may get your drugs at network retail pharmacies and mail order pharmacies. Standard Retail and Mail Order Cost-Sharing Tier Tier 1 (generic), Tier 2 (brand) One-Month Supply 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 Two-month supply 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 Three-month supply 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 Tier 3 (specialty) 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; Not Offered Not Offered
or $7.40 copay 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.
ADDITIONAL INFORMATION ABOUT icare MEDICARE PLAN Fitness Center Membership Up to $35.00 per month reimbursement for a single fitness center membership fee. Reimbursement is limited to one membership per month. Contact icare for more details. Over-the-Counter Drug Program Up to $17 per month for Over-the-Counter drugs and supplies. The icare OTC program allows members to purchase over-the-counter Drug Store type items using an account that is replenished with funds on a monthly basis. The following product categories are offered: Medicines, ointments and sprays with active medical ingredients First aid supplies Incontinence supplies Vitamins and minerals Diagnostic equipment Weight loss items
Medicaid Benefit Comparison 2016 Summary of Benefits for icare Medicare Plan 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 Wisconsin Medicaid covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. Benefit Category Medicaid Fee-for-Service icare Medicaid SSI Plan Alcohol and Other Drug Abuse (AODA) Day Treatment Full coverage - $.50-$3 copay per service Prior Authorization is required. Alcohol and Other Drug Abuse (AODA) Services Full coverage - $.50-$3 copay per service Ambulatory Prenatal Services Full coverage. No copay. Ambulatory Surgical Centers Coverage of certain surgical procedures and related lab $3.00 copayment per service. Anesthesiology Services Full coverage - $.50-$3 copay per service Audiology Services Full coverage - $.50-$3 copay per service
Medicaid Benefit Comparison 2016 Summary of Benefits for icare Medicare Plan Benefit Category Medicaid Fee-for-Service icare Medicaid SSI Plan Case Management Services (Targeted) Full coverage. No copay. Chiropractic services Full coverage $.50 to $3.00 copayment per service Chiropractic services are provided by Medicaid Fee-for-Service, not icare. $.50 to $3.00 copayment per service Dental services Full coverage $0.50 - $3.00 copay per service. services (Covered by icare in Kenosha, Milwaukee, Racine and Waukesha counties. For members in other counties, these services are provided by Medicaid Fee-for-Service). Durable Medical Equipment and Supplies Full coverage $0.50 - $3.00 per item. Rental items are not subject to copayment.
Medicaid Benefit Comparison 2016 Summary of Benefits for icare Medicare Plan Benefit Category Medicaid Fee-for-Service icare Medicaid SSI Plan Drugs (Prescription) Coverage of generic and brand name prescription drugs, and some over-the-counter (OTC) drugs. Members are limited to 5 prescriptions per month for opioid drugs. Copayments: $0.50 for OTC drugs $1.00 for generic drugs $3.00 for brand Copayments are limited to $12 per member, per provider, per month. OTCs are excluded from this $12 maximum. Drugs excluded by Medicare Part D may be covered by Medicaid Fee-for-Service, not icare. Copayments: $0.50 for OTC drugs $1.00 for generic drugs $3.00 for brand Copayments are limited to $12 per member, per provider, per month. OTCs are excluded from this $12 maximum. Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services Full coverage - No copayment Home Care Services (Home Health, Private Duty Nursing and Personal Care) Full coverage of private duty nursing, home health services, and personal care. No copayment Hospice Care Services Full coverage No copayment
Medicaid Benefit Comparison 2016 Summary of Benefits for icare Medicare Plan Benefit Category Medicaid Fee-for-Service icare Medicaid SSI Plan Hospital Services - Inpatient Full coverage $3 copay per day with a $75.00 cap per stay. Hospital Services - Outpatient Hospital and Emergency Room Full coverage $3 copay per visit. Mental Health and Mental Health Day Treatment Full coverage (not including room and board). $0.50 to $3.00 copayment per service, limited to the first 15 hours or $825 of services, whichever comes first, provided per calendar year. Copayment is not required when services are provided in a hospital setting. Nursing Home Services Full coverage No copayment. Nursing and Private Duty Nursing Full Coverage. $0 copay
Medicaid Benefit Comparison 2016 Summary of Benefits for icare Medicare Plan Benefit Category Medicaid Fee-for-Service icare Medicaid SSI Plan Physician Services (May include: Physician Assistants, Nurse Practitioners, Rural Health Clinics) Full coverage, including laboratory and radiology. $.50 to $3.00 copayment per service limited to $30 per provider per calendar year. (No copay for emergency services, preventive services, anesthesia or clozapine management) Podiatry Services Full coverage $.50 to $3.00 copayment per service; limited to $30 per provider per calendar year. Prenatal/Maternity Care (May include: Nurse Midwife) Reproductive Health Services - Family Planning Services Full coverage, including prenatal care coordination, and preventive mental health and substance abuse screening and counseling for women at risk of mental health or substance abuse problems. Full coverage - No copayment. Full coverage with the exceptions listed below. No copay for services provided by a family planning clinic or contraceptive management. Does not cover: reversal of voluntary sterilization, infertility treatments, surrogate parenting and related
Medicaid Benefit Comparison 2016 Summary of Benefits for icare Medicare Plan Benefit Category Medicaid Fee-for-Service icare Medicaid SSI Plan services, including: o artificial insemination o obstetrical care o labor or delivery o prescription and over-the-counter drugs. Respiratory Care for Ventilator Assisted Recipients Full Coverage. $0 copay School-Based Services (under age 21) Covered if listed in child s Individualized Education Program (IEP) No copayment If listed in member s Individualized Education Program (IEP), covered by Medicaid Fee-for-Service during regular school hours and by icare Medicaid SSI Plan when applicable after school hours, school breaks or during the summer. No copayment Skilled Nursing Services Full coverage No copayment Transportation - Ambulance, Specialized Medical Vehicle (SMV), Full coverage of emergency and non-emergency medical transportation to and from a covered service. emergency transportation
Medicaid Benefit Comparison 2016 Summary of Benefits for icare Medicare Plan Benefit Category Medicaid Fee-for-Service icare Medicaid SSI Plan Common Carrier $2 copayment for non-emergency ambulance trips. $1 copayment per trip for transportation by SMV (Specialized Medical Vehicle). No copayment for transportation by common carrier or emergency ambulance. Call MTM at 1-866-907-1493 to arrange transportation. Non-emergency transportation to and from a covered service is covered by Medicaid Fee-for-Service, who has contracted with MTM to arrange transportation. $2 copayment for non-emergency ambulance trips. $1 copayment per trip for transportation by SMV (Specialized Medical Vehicle). No copayment for transportation by common carrier or emergency ambulance. Therapy - Physical Therapy (PT), Occupational Therapy (OT), and Speech and Language Pathology (SLP) Full coverage $.50 to $3.00 copayment per service. Copayment obligation limited to the first 30 hours or $1,500, whichever occurs first, during one calendar year (copayment limits calculated separately for each discipline). Call MTM at 1-866-907-1493 to arrange transportation. Vision Care Services Full coverage including eyeglasses. $.50 to $3.00 copayment per service.
Independent Care Health Plan 1555 N. RiverCenter Dr. Suite 206 Milwaukee, WI 53212 1-800-777-4376 www.icare-wi.org 2015 Independent Care Health Plan