5 Health Partners Plans Provider Manual Health Partners Plans Medicare Benefits Summary Purpose: This chapter provides a benefit summary for Health Partners Plans Medicare members, by plan. Topics: Health Partners Plans Medicare Benefit Summary Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-1
Module Contents Overview 5-3 Summary of Benefits 5-4 Health Partners Plans Medicare Basic Benefits 5-5 Health Partners Plans Medicare Prime Benefits 5-8 Health Partners Plans Medicare Prime Plus Benefits 5-11 Health Partners Plans Medicare Special Benefits 5-14 Health Partners Plans Medicare n-covered Services 5-18 Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-2
Overview This chapter provides an overview of the benefits that Health Partners Plans Medicare members are entitled to and guidelines for appropriately utilizing authorizations. Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-3
Summary of Benefits Health Partners Plans Medicare The following charts summarize Health Partners Plans 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 Plans Medicare Plan. Separate charts are provided for each of our Medicare plans: Health Partners Plans Basic (HMO) Health Partners Plans Prime (HMO) Health Partners Plans Prime Plus (HMO) Health Partners Plans 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 - February 2014 Page 5-4
Health Partners Plans Medicare Basic (HMO) Benefit/Service Cost-sharing/Limits Prior Authorization Acupuncture t covered N/A Ambulance Services $200 copay for non-emergent ambulance services Audiology Services $45 copay for routine hearing exam every year; hearing aid coverage Cardiac and Pulmonary Rehabilitation Services $45 copay for each service Chiropractic Services $20 copay for each Medicarecovered visit Dental Services $45 copay for Medicare-covered dental benefits; Preventive dental services not covered Diabetes Programs and Supplies $0 copay for test strips and monitors; 20% for other diabetes supplies; $0 copay for diabetes selfmanagement training Diagnostic Radiology $30 copay for each X-Ray; $195 copay for other diagnostic radiology services, for CT/PET/MRI services contact Landmark Doctor Office Visits $0 copay for each primary care visit; $45 copay for each specialist visit; referral required for plan specialists Durable Medical Equipment 20% Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-5
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: $235 copay per day; Days 8-90: $0 copay per day Kidney Disease and Conditions 20% Laboratory Services $20 copay per lab service/test Mental Health Care (Inpatient) up to 190 days in a lifetime; Days 1-7: $200 copay per day; Days 8-90: $0 copay per day - contact Magellan Behavioral Health Mental Health Care (Outpatient) $40 copay per visit Outpatient Services $215 copay for each ambulatory surgical center visit and outpatient hospital facility visit Physical/Occupational/Speech Therapy Services (Outpatient) $45 copay per visit Podiatry Services $45 copay per visit Prescription Drugs (Outpatient) Part D drugs not covered N/A Preventive Services $0 copay per visit Prosthetic Devices 20% Radiation Therapy 20% Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-6
Skilled Nursing Facility (SNF) Up to 100 days each benefit period; Days 1-5: $0 copay per day; Days 6-20: $25 copay per day; Days 21-100: $140 copay per day ( prior hospital stay required) Substance Abuse Treatment (Outpatient) $45 copay per visit Transportation (Routine) t covered N/A Urgently Needed Care $45 copay per visit; $0 copay if admitted to the hospital within 24 hours for the same condition Vision Services $45 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 - February 2014 Page 5-7
Health Partners Plans Medicare Prime (HMO) 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 $200 copay for non-emergent ambulance services $45 copay for routine hearing exam every year; hearing aid coverage $45 copay for each service $20 copay for each Medicarecovered visit $45 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; $195 copay for other diagnostic radiology services $0 copay for each primary care visit; $45 copay for each specialist visit; referral required for plan specialists, 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 Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-8
Hospice $0 copay Hospital Care (Inpatient) limit to the number of days of hospital stay; Days 1-7: $235 copay per day; Days 8-90: $0 copay per day Kidney Disease and Conditions 20% Laboratory Services $25 copay per lab service/test Mental Health Care (Inpatient) Up to 190 days in a lifetime; Days 1-7: $200 copay per day; Days 8-90: $0 copay per day - contact Magellan Behavioral Health Mental Health Care (Outpatient) $40 copay per visit Outpatient Services $240 copay for each ambulatory surgical center visit and outpatient hospital facility visit Physical/Occupational/Speech Therapy Services (Outpatient) $50 copay per visit Podiatry Services $45 copay per visit Prescription Drugs (Outpatient) $0 copay for generic, $45 copay for brand for 30-day supply and $90 copay for 60-day or 90-day supply; and 33% coinsurance for specialty tier, until total yearly drug costs reach $2,850. Then no more than 47.5% for brand drugs and 72% for generic drugs until reaching $4,550. After that, the member pays the greater of 5% coinsurance or $2.55 copay for generic and brand and $6.35 copay for all other drugs. Quantity limits may apply. Required for certain drugs see Formulary Preventive Services $0 copay per visit Prosthetic Devices 20% Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-9
Radiation Therapy 20% Skilled Nursing Facility (SNF) Up to 100 days each benefit period; Days 1-5: $0 copay per day; Days 6-20: $25 copay per day; Days 21-100: $140 copay per day ( prior hospital stay required) Substance Abuse Treatment (Outpatient) $45 copay per visit Transportation (Routine) t covered N/A Urgently Needed Care Vision Services $45 copay per visit; $0 copay if admitted to the hospital within 24 hours for the same condition $45 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 - February 2014 Page 5-10
Acupuncture Health Partners Plans Medicare Prime Plus (HMO) Benefit/Service Cost-sharing/Limits Prior Authorization Ambulance Services Audiology Services Cardiac and Pulmonary Rehabilitations Services Chiropractic Services Dental Services Diabetes Programs and Supplies Diagnostic Radiology Doctor Office Visits $5 copay per visit up to 20 visits $175 copay for non-emergent ambulance services $35 copay for routine hearing exam every year; $0 copay for 1 hearing aid every three years, up to $1,000 limit $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 $500, with $50 deductible $0 copay for test strips and monitors; 20% for other diabetes supplies; $0 copay for diabetes selfmanagement training $30 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; referral required for plan specialists, for CT/PET/MRI services contact Landmark Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-11
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) Kidney Disease and Conditions limit to the number of days of hospital stay; Days 1-5: $175 copay per day; Days 6-90: $0 copay per day 20% Laboratory Services $0 copay per lab service/test Mental Health Care (Inpatient) Up to 190 days in a lifetime; Days 1-5: $175 copay per day; Days 6-90: $0 copay per day - contact Magellan Behavioral Health Mental Health Care (Outpatient) $35 copay per visit Outpatient Services Physical/Occupational/Speech Therapy Services (Outpatient) $165 copay for each ambulatory surgical center visit and outpatient hospital facility visit $35 copay per visit Podiatry Services $35 copay per visit Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-12
Prescription Drugs (Outpatient) $0 copay for generic, $45 copay for brand for 30-day supply and $90 copay for 60-day and 90-day supply; and 33% coinsurance for specialty tier, until total yearly drug costs reach $2,850. Then no more than 47.5% for brand drugs and 72% for generic drugs until reaching $4,550. After that, the member pays the greater of 5% coinsurance or $2.55 copay for generic and brand and $6.35 copay for all other drugs. Quantity limits may apply. 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 1-5: $0 copay per day; Days 6-20: $25 copay per day; Days 21-100: $140 copay per day ( prior hospital stay required) Substance Abuse Treatment (Outpatient) $35 copay per visit Transportation (Routine) t covered N/A Urgently Needed Care Vision Services $35 copay per visit; $0 copay if admitted to the hospital within 24 hours for the same condition $35 copay for Medicare-covered exams; $35 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 Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-13
Health Partners Plans Medicare Special (HMO SNP) Cost sharing in this plan depends on the member s Medicaid eligibility level. Benefit/Service Cost-sharing/Limits Prior Authorization Acupuncture $5 copay per visit up to 20 visits Ambulance Services $0 or 20% for non-emergent ambulance benefits Audiology Services $0 or 20% for Medicare-covered services; $0 copay for one routine hearing exam yearly; $0 copay for one hearing aid every three years, up to $1,000 limit Cardiac and Pulmonary Rehabilitation Services $0 or 20% Chiropractic Services $0 or 20% for each Medicarecovered chiropractic visit; $0 copay for up to 20 routine visits every year Dental Services $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 $500 every two years Diabetes Programs and Supplies $0 or 20% Diagnostic Radiology $0 or 20%, for CT/PET/MRI services - contact Landmark Doctor Office Visits $0 or 20% for each primary care visit and specialist visit; referral required for Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-14
plan specialists 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 Hospital Care (Inpatient) limit to the number of days of hospital stay; Days 1-60: $1,184 deductible; Days 61-90: $296 copay per day; Days 91-150: $592 copay per lifetime reserve day Kidney Disease and Conditions $0 or 20% Laboratory Services $0 or 20% Mental Health Care (Inpatient) Up to 190 days in a lifetime; Days 1-60: $1,184 deductible; Days 61-90: $296 copay per day; Days 91-150: $592 copay per lifetime reserve day - contact Magellan Behavioral Health Mental Health Care (Outpatient) $0 or 20% Outpatient Services $0 or 20% for each ambulatory surgical center visit and outpatient hospital facility visit Physical/ Occupational/ Speech Therapy Services $0 or 20% Podiatry Services $0 or 20% for each Medicarecovered podiatry visit; $15 copay for one routine visit Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-15
every three months Prescription Drugs (Outpatient) $0 annual deductible; Depending on income, pay either $0 copay or $1.15 copay or $2.55 copay for generic and brand drugs; for all other drugs, pay either $0 copay or $3.50 copay or $6.35 copay. After yearly out-of-pocket drug costs reach $4,550, members pay $0 copay. Some drugs have quantity limits. 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; Days 1-20: $0 copay per day; Days 21-100: $148 copay per day ( prior hospital stay required) Substance Abuse Treatment (Outpatient) $0 or 20% Transportation (Routine) 10 one-way trips to plan-approved locations per quarter Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-16
Urgently Needed Care $0 or 20% for each Medicarecovered visit; $0 copay if admitted to the hospital within 24 hours for the same condition Vision Services $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 Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-17
n-covered Services The following services and benefits are excluded or limited under Health Partners Plans 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. 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 Plans Medicare Prime Plus 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 Plans Medicare Prime Plus and Special plans, as shown in the charts in this chapter. Health Partners Plans Provider Manual HP Medicare Benefits - February 2014 Page 5-18
Routine foot care, except for the limited coverage provided according to Medicare guidelines, except for services specifically covered in the Health Partners Plans Medicare Prime Plus 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 Plans Medicare Prime Plus and Special plans, as shown in the charts in this chapter. Eyeglasses, except as specifically covered in the Health Partners Plans Medicare Prime Plus 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 Plans Medicare Prime Plus 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 VA hospital and the VA cost sharing is more than the cost sharing under our plan, we will reimburse veterans for the difference. Members are still responsible for our cost-sharing amounts. 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 - February 2014 Page 5-19