« 1)) .5 «+ « !*!%0/ - upmc health plan · 2015. 8. 31. · tagalog: mayroon kaming libreng...

Multi-Language Interpreter Services

EEnglish: 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 1-877-539-3080. 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 1-877-539-3080. Alguien que hable español le podrá ayudar. Este es un servicio gratuito.

Chinese Mandarin: 1-877-539-3080

Chinese Cantonese: 1-877-539-3080

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 1-877-539-3080. 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 1-877-539-3080. 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 1-877-539-3080 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 1-877-539-3080. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos.

Korean: . 1-877-539-3080

. . .

1

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 UPMC for Life Dual (HMO SNP)).

Tips for comparing your Medicare choices

This Summary of Benefits booklet gives you a summary of what UPMC for Life Dual (HMO SNP) 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 UPMC for Life Dual (HMO SNP)

Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services

Covered Medical and Hospital Benefits

Prescription Drug Benefits

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 1-800-606-8648. TTY users call 1-866-407-8762.

2

Things to Know About UPMC for Life Dual (HMO SNP)

Hours of Operation

From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time.

From February 15 to September 30, you can call us Monday from 8:00 a.m. to 8:00 p.m. Eastern time, Tuesday from 8:00 a.m. to 8:00 p.m. Eastern time, Wednesday from 8:00 a.m. to 8:00 p.m. Eastern time, Thursday from 8:00 a.m. to 8:00 p.m. Eastern time, Friday from 8:00 a.m. to 8:00 p.m. Eastern time, Saturday from 8:00 a.m. to 3:00 p.m. Eastern time.

UPMC for Life Dual (HMO SNP) Phone Numbers and Website

If you are a member of this plan, call toll-free 1-800-606-8648. TTY users call 1-866-407-8762. If you are not a member of this plan, call toll-free 1-866-405-8762. TTY users call 1-866-407-8762. Our website: http://www.upmchealthplan.com/snp

Who can join?

To join UPMC for Life Dual (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and the Pennsylvania Medical Assistance (Medicaid) program and live in our service area. Our service area includes the following counties in Pennsylvania: Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington, and Westmoreland.

Which doctors, hospitals, and pharmacies can I use?

UPMC for Life Dual (HMO SNP) 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 services.

You must generally use network pharmacies to fill your prescriptions for covered Part D drugs.

You can see our plan's provider directory at our website (http://www.upmchealthplan.com/snp).

You can see our plan's pharmacy directory at our website (http://www.upmchealthplan.com/snp/learn/plan-benefits/prescription-drug-coverage/).

Or, call us and we will send you a copy of the provider and pharmacy directories.

3

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, www.upmchealthplan.com/snp/learn/plan-benefits/prescription-drug-coverage/.

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 five "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.

4

SUMMARY OF BENEFITS

January 1, 2016 – December 31, 2016

Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services

UPMC for Life Dual (HMO SNP)

How much is the monthly premium?

$0 per month.

How much is the deductible?

This plan does not have a deductible.

Is there any limit on how much I will pay for my covered services?

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 Pennsylvania Medical Assistance (Medicaid) eligibility. Your yearly limit(s) in this plan:

$3,400 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 services. For Pennsylvania Medical Assistance (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.

UPMC for Life Dual is an HMO SNP plan with a Medicare contract and a contract with the Pennsylvania Medical Assistance (Medicaid) program. Enrollment in UPMC for Life Dual depends on contract renewal.

5

Covered Medical and Hospital Benefits Note:

Services with a ¹ may require prior authorization.

OUTPATIENT CARE AND SERVICES

Acupuncture Not covered

Ambulance You pay nothing

Chiropractic Care¹ Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position). You pay nothing May require prior authorization.

Dental Services Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth). You pay nothing Preventive dental services:

Cleaning (for up to 1 every six months): $0 copay Dental x-ray(s) (for up to 1 every six months): $0 copay Oral exam (for up to 1 every six months): $0 copay An allowance of $1,500 to use toward comprehensive dental

services, such as: o Bridges o Crowns o Full/partial dentures o Onlays o Root canals o Fillings and simple tooth extractions

Diabetes Supplies and Services

Diabetes monitoring supplies: You pay nothing Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: You pay nothing

Diabetic supplies and services are limited to specific manufacturers, products, and/or brands. Contact the plan for a list of covered supplies.

Diagnostic Tests, Lab and Radiology Services, and X-Rays(Costs for these services may vary based on place of service)¹

Diagnostic radiology services (such as MRIs, CT scans): You pay nothing Diagnostic tests and procedures: You pay nothing Lab services: You pay nothing Outpatient x-rays: You pay nothing Therapeutic radiology services (such as, radiation treatment for cancer): You pay nothing May require prior authorization.

6




Doctor’s Office Visits Primary care physician visit: You pay nothing Specialist visit: You pay nothing

Durable Medical Equipment (wheelchairs,oxygen, etc.)¹

You pay nothing May require prior authorization.

Emergency Care You pay nothing

Foot Care (podiatryservices)

Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing

Hearing Services Exam to diagnose and treat hearing and balance issues. You pay nothing

Home Health Care¹ You pay nothing May require prior authorization.

Mental Health Care¹ 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 does not apply 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. You pay nothing A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. Benefit periods are unlimited. Outpatient group therapy visits: You pay nothing Outpatient individual therapy visit: You pay nothing May require prior authorization.

7




Outpatient Rehabilitation Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): You pay nothing Occupational therapy visit: You pay nothing Physical therapy and speech and language therapy visit: You pay nothing

Outpatient Substance Abuse

Group therapy visit: You pay nothing Individual therapy visit: You pay nothing

Outpatient Surgery¹ Ambulatory surgical center: You pay nothing Outpatient hospital: You pay nothing

May require prior authorization.

Over-the-counter Items Not covered

Prosthetic Devices (braces, artificial limbs, etc.)¹

Prosthetic devices: You pay nothing Related medical supplies: You pay nothing

May require prior authorization.

Renal Dialysis You pay nothing

Transportation¹ You pay nothing We cover 11 one-way trips to a plan-approved location.

Authorization rules apply.

Urgently Needed Services You pay nothing

Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing Routine eye exam (for up to 1 every two years): $0 copay Contact lenses (for up to 1 every two years)*: $0 copay Eyeglasses (frames and lenses) (for up to 1 every two years)*: $0 copay Eyeglasses or contact lenses after cataract surgery: You pay nothing

*Our plan pays up to $135 every two years for contact lenses or eyeglasses (frames and lenses).

8

Covered Medical and Hospital BenefitsNote:


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 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 screening (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 Care You pay nothing for hospice care from a Medicare-certified hospice.

You may have to pay part of the cost for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details.

9



Inpatient Hospital Care¹ 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. You pay nothing A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. Benefit periods are unlimited. Authorization rules apply.

Inpatient Mental Health Care

For inpatient mental health care, see the “Mental Health Care” section of this booklet.

Skilled Nursing Facility (SNF)¹

Our plan covers up to 100 days in a SNF. You pay nothing A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. Benefit periods are unlimited. Authorization rules apply.

10


How much do I pay? For Part B drugs such as chemotherapy drugs¹: You pay nothing Other Part B drugs¹: You pay nothing Authorization rules may apply.

Initial Coverage You pay the following: You may get your drugs at network retail pharmacies and mail-order pharmacies.

Standard Retail Cost Sharing

Tier One-month supply Three-month supply

Tier 1 (Generic)

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 2 (Preferred Brand)







11


Tier 3 (Non-Preferred Brand)







Tier 4 (Specialty Tier)




Not offered.

Tier 5 (Select Care Drugs)

$0 $0

Standard Mail-Order Cost Sharing

Tier One-month supply Three-month supply including standard mail –

order cost sharing

Tier 1 (Generic)

Not Offered For generic drugs (including brand drugs treated as generic), either:



12

Tier 2 (Preferred Brand)




Tier 3 (Non-Preferred Brand)




Tier 4 (Specialty Tier)




Not offered.

Tier 5 (Select Care Drugs)

Not Offered $0

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, but may pay more than you pay at an in-network pharmacy.

Catastrophic Coverage

Catastrophic Coverage You pay nothing

13

Additional Information AboutUPMC for Life Dual (HMO SNP)

This section provides information on some of the health and wellness benefits covered by UPMC forLife Dual.

Additional Information: Health and Wellness Benefits

Benefit UPMC for Life Dual (HMO SNP)

Additional Sessions of Medical Nutritional Therapy (MNT)

You pay nothing. This benefit will cover three hours of nutritional education/counseling during a member’s first plan year and two hours of education/counseling during subsequent years for conditions, such as; Alzheimer’s disease, Parkinson’s disease, cancer, multiple sclerosis, stroke, and other chronic conditions as deemed necessary.

Additional Smoking and Tobacco Use Cessation

You pay nothing. The smoking cessation benefit covers four additional face-to-face visits with a qualified network provider annually.

Membership in Health Club/Fitness Classes

You pay nothing. Active&Fit® is a fitness program that is provided to our members. The program includes membership at participating fitness facilities and an in-home fitness program.

Remote Access Technologies (Including Web/Phone Based-Technologies and Nursing Hotline)

You pay nothing. Web/Phone Based Technologies: With UPMC AnywhereCare, members can get quick 24/7 online medical care for many common conditions anywhere in Pennsylvania or Maryland. Members answer a few simple questions and they will get a personalized care plan through their e-mail in about 30 minutes. Nursing Hotline: The nurse advice line is a toll-free number that members can call to get advice from a registered nurse, 24 hours a day, 7 days a week.

14

for Life This section demonstrates the Medicaid benefit package for full benefit dual-eligible recipients in the Commonwealth of Pennsylvania. The services offered in your Medicaid benefit package are based on your Medicaid eligibility level (Categorically Needy or Medically Needy). In addition to the Medicare benefits described in this booklet, you may have Medicaid benefits that will cover some or all of your cost-sharing, plus some services and other items not covered by UPMC forLife Dual (HMO SNP). Medicare coverage must be used first, and the Medicaid Program may then cover payment of Medicare Part A and B deductibles (when applicable) and cost-sharing for all Medicare covered services. 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 the Pennsylvania Department of Human Services Medical Assistance covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. Note: If you remain full dual eligible, you will not have to pay out-of-pocket costs for premiums, deductibles, copayments, and coinsurances for medical services. These costs should be considered under your Medical Assistance (Medicaid) benefits. You will be responsible for your prescription drug copayments and your Medical Assistance (Medicaid) copayments, if applicable. The following is a listing of services that may be available in your benefit package through your Medicaid provider:

Benefit Medicaid State Plan UPMC for Life Dual(HMO SNP)

Doctors or Medical Personnel

Certified Registered Nurse Practitioner*

$0.65 - $7.60 copay, refer to Pennsylvania Department of Public Welfare (DPW) guidelines below under #6.

Primary care physician visit: You pay nothing Specialist visit: You pay nothing

Chiropractor* $0.65 - $7.60 copay, refer to DPW guidelines below under #6.

Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position). You pay nothing May require prior authorization.

Summary of Medicaid-Covered Benefits Section

15


Nurse Midwife* $0.65 - $7.60 copay, refer to DPW guidelines below under #6.

Not a Medicare-covered benefit.

Optometrist (Eye Doctor)* $0.65 - $7.60 copay, refer to DPW guidelines below under #6.

Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing Routine eye exam (for up to 1 every two years): You pay nothing Contact lenses (for up to 1 every two years)*: You pay nothing Eyeglasses (frames and lenses) (for up to 1 every two years)*: You pay nothing Eyeglasses or contact lenses after cataract surgery: You pay nothing

*Our plan pays up to $135 every two years for contact lenses and eyeglasses (frames and lenses).

Physician (Medical Doctor)* $0.65 - $7.60 copay, refer to DPW guidelines below under #6.


Podiatrist* $0.65 - $7.60 copay, refer to DPW guidelines below under #6.

Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing

16


Dentist $0.65 - $7.60 copay, refer to DPW guidelines below under #6.

Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth). You pay nothing Preventive dental services:

Cleaning (for up to 1 every six months): You pay nothing

Dental x-ray(s) (for up to 1 every six months): You pay nothing

Oral exam (for up to 1 every six months): You pay nothing

An allowance of $1,500 to use toward comprehensive dental services, such as:

Bridges Crowns Full/partial dentures Onlays Root canals Fillings and simple tooth extractions

17


Inpatient Services

Acute Care Hospital $3 - $6 per day up to $21-$42 per admission, depending on level of assistance, refer to DPW guidelines below under #1.

The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods. Our plan covers 90 days for an inpatient hospital stay. This plan 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. You pay nothing Authorization rules apply.

18


Drug and Alcohol Facility $3 - $6 copay, refer to DPW guidelines below under #1.

Refer to Acute Care Hospital section above.

Private Intermediate Care Facility for the Mentally Retarded

$3 - $6 copay, refer to DPW guidelines below under #1.


Private Intermediate Care Facility for Other Related Conditions

$3 - $6 copay, refer to DPW guidelines below under #1.


19


Psychiatric Facility (Does not include Psychiatric Partial Hospitalization, see Psychiatric Partial Hospitalization Facility for further details).

$3 - $6 copay, refer to DPW guidelines below under #1. Limited up to 30 days per fiscal year (i.e. 7/1 through 6/30). If you need additional services beyond the limit, you or your provider may apply for an exception through the DPW.

Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. 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. You pay nothing

20


Rehabilitation Hospital Facility

$3 - $6 copay, refer to DPW guidelines below under #1. One admission per fiscal year. If you need additional services beyond the limit, you or your provider may apply for an exception through the DPW.

Refer to Acute Care Hospital section.

Other Settings

Birthing Centers $0.65 - $7.60 copay, refer to DPW guidelines below under #6. (Pregnant women have a $0 copay until post-partum period has ended).


Nursing Facilities $0.65 - $7.60 copay, refer to DPW guidelines below under #6.

Our plan covers up to 100 days in a skilled nursing facility. You pay nothing Authorization rules apply.

Outpatient Services

Ambulatory Surgery Center (ASC) and Same Day Surgery (SPU)

$0.65 - $7.60 copay, refer to DPW guidelines below under #6.

Ambulatory surgical center: You pay nothing Outpatient hospital: You pay nothing May require prior authorization.

Federally Qualified Health Center*



Hospital Clinic* and Emergency Room Services


Hospital Clinic: You pay nothing Emergency Room Services: You pay nothing for these services. World-wide coverage

Drug and Alcohol Clinic Services

$0 .65- $7.60 copay, refer to DPW guidelines below under #6.

Group therapy visit: You pay nothing Individual therapy visit: You pay nothing

21


Independent Medical/Surgical Clinic*


Ambulatory surgical center: You pay nothing Outpatient hospital: You pay nothing May require prior authorization.

Renal Dialysis Center $0 copay You pay nothing

Rural Health Clinic* $0.65 - $7.60 copay, refer to DPW guidelines below under #6.


Psychiatric Clinic $0.65 - $7.60 copay, refer to DPW guidelines below under #3 or #6. Limited up to 5 hours or 10 one-half-hour sessions of psychotherapy per recipient in a 30-consecutive-day period. If you need additional services beyond the limit, you or your provider may apply for an exception through the DPW.

Outpatient group therapy visits: You pay nothing Outpatient individual therapy visit: You pay nothing May require prior authorization

Psychiatric Partial Hospitalization Facility

$0 copay Limited up to 180 three-hour sessions, 540 total hours per fiscal year. If you need additional services beyond the limit, you or your provider may apply for an exception through the DPW.

Outpatient group therapy visits: You pay nothing Outpatient individual therapy visit: You pay nothing May require prior authorization

Other Services

Ambulance $0.65 - $7.60 copay, refer to DPW guidelines below under #6.

You pay nothing

Family Planning Services $0 copay Not a Medicare-covered benefit.

Home Health (Visiting Nurse) $0 copay You pay nothing May require prior authorization

22


Hospice $0.65 - $7.60 copay, refer to DPW guidelines below under #6.

You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.

Medical Supplies and Equipment

$0.65 - $7.60 copay, refer to DPW guidelines below under #6. For Medically Needy recipients, medical supplies and equipment are only covered when prescribed for the purpose of family planning or in conjunction with Home Health Agency Services. $0 copay for rental of durable medical equipment and ostomy supplies. (Copay applies for durable medical equipment that is bought instead of rented.)

You pay nothing May require prior authorization.

Laboratory $0 copay, refer to DPW guidelines below under #6.

Lab services: You pay nothing

Portable X-Ray $1 - $2 copay, refer to DPW guidelines below under #4.

Diagnostic radiology services (such as, MRIs, CT scans): You pay nothing Diagnostic tests and procedures: You pay nothing Outpatient x-rays: You pay nothing Therapeutic radiology services (such as, radiation treatment for cancer): You pay nothing May require prior authorization.

23


Transportation Services $0 copay You pay nothing. We cover 11 one-way trips to a plan-approved location. Authorization rules apply.

Pharmacy $1 - $3 copay, refer to DPW guidelines below under #2 and #3.




Psychiatric Rehabilitation $0.65 - $7.60 copay, refer to DPW guidelines below under #6.


Peer Specialist Services $0.65 - $7.60 copay, refer to DPW guidelines below under #6.


Long Term Care Services

Nursing Home** $0 copay. Not a Medicare-covered benefit.

24


Home Community Based Waiver Services **Services Include:

Adult Day Living Care Coordination Counseling Community Transition Environmental Modifications Home Delivered Meals Home Health Care Personal Care Personal Emergency Response Respite Specialized Medical Equipment and Supplies TeleCare Transportation Financial Management Services Participant-Directed Goods and Service

$0 Copay Not a Medicare-covered benefit.

Pennsylvania Department of Public Welfare Guidelines

1) $3 - $6 for each day you are in a hospital, up to $42 for one hospital stay. This includes general hospitals, rehabilitation hospitals and private psychiatric hospitals.

2) $1 for each prescription and prescription refill of a generic drug 3) $3 for each prescription and prescription refill of a brand name drug 4) $1 - $2 for each x-ray or other medical diagnostic test or for treatment by nuclear medicine or

radiation therapy. 5) For outpatient psychotherapy services, the copayment is $.50 - $1 per unit of service 6) For all other services where copayments are required, the amount of the copayment is based on

the Medical Assistance fee for the service, as shown in the following table: o If the Medical Assistance fee is $2 through $10, the copayment is $0.65 - $1.30 o If the Medical Assistance fee is $10.01 through $25, the copayment is $1.30 - $2.60 o If the Medical Assistance fee is $25.01 through $50, the copayment is $2.55 - $5.10 o If the Medical Assistance fee is $50.01 or more, the copayment is $3.80 - $7.60

*Certain evaluation, management, and consultation procedures are limited to a combined maximum of 18 clinic, office, and home visits per fiscal year (July 1 through June 30) by physicians, podiatrists, optometrists, certified registered nurse practitioners (CRNP), chiropractors, outpatient hospital clinics,

25

independent medical clinics, rural health clinics, and federally qualified health centers (FQHC). Talk with your provider if you have any questions about these procedures. If you need more than 18 visits, you or your provider may ask for an exception through the Department of Public Welfare. ** In order to receive Nursing Home or Home and Community-Based Waiver Services, individuals must meet clinical criteria to be considered Nursing Facility Clinically Eligible (NFCE) by the local Area Agency on Aging. Note: Benefits and co-payments for Medical Assistance recipients in the state of Pennsylvania are established by the Department of Public Welfare. These benefits and copayments may change. If you have questions about your Medicaid benefits, please contact your local County Assistance Office. If you need additional help, you can call the HELPLINE at 1-800-692-7462 between 8:30 a.m. and 4:45 p.m., Monday through Friday. If you have a hearing impairment, call TTY/TDD at 1-800-451-5886.

« 1)) .5 «+ « !*!%0/ - upmc health plan · 2015. 8. 31. · tagalog: mayroon kaming libreng...

Documents