annual notice of changes for 2020 - care n' care · annual notice of changes for 2020 you are...

OMB Approval 0938-1051 (Expires: December 31, 2021) Y0107_H6328_20_004_M

Care N’ Care Choice Premium (PPO) Offered by Care N’ Care Insurance Company, Inc.

Annual Notice of Changes for 2020 You are currently enrolled as a member of Care N’ Care Choice Premium (PPO). Next year, there will be some changes to the plan’s costs and benefits. This booklet tells about the changes.

• You have from October 15 until December 7 to make changes to your Medicare coverage for next year.

What to do now

1. ASK: Which changes apply to you

Check the changes to our benefits and costs to see if they affect you.

• It’s important to review your coverage now to make sure it will meet your needs next year.

• Do the changes affect the services you use?

• Look in Sections 1.1 and 1.5 for information about benefit and cost changes for our plan.

Check the changes in the booklet to our prescription drug coverage to see if they affect you.

• Will your drugs be covered?

• Are your drugs in a different tier, with different cost sharing?

• Do any of your drugs have new restrictions, such as needing approval from us before you fill your prescription?

• Can you keep using the same pharmacies? Are there changes to the cost of using this pharmacy?

• Review the 2020 Drug List and look in Section 1.6 for information about changes to our drug coverage.

• Your drug costs may have risen since last year. Talk to your doctor about lower cost alternatives that may be available for you; this may save you in annual out-of-pocket costs throughout the year. To get additional information on drug prices visit https://go.medicare.gov/drugprices. These dashboards highlight which manufacturers have been increasing their prices and also show other year-to-year drug price information. Keep in mind that your plan benefits will determine exactly how much your own drug costs may change.

Check to see if your doctors and other providers will be in our network next year.

• Are your doctors, including specialists you see regularly, in our network?

• What about the hospitals or other providers you use?

• Look in Section 1.3 for information about our Provider Directory.

https://go.medicare.gov/drugprices

Think about your overall health care costs.

• How much will you spend out-of-pocket for the services and prescription drugs you use regularly?

• How much will you spend on your premium and deductibles?

• How do your total plan costs compare to other Medicare coverage options?

Think about whether you are happy with our plan.

2. COMPARE: Learn about other plan choices

Check coverage and costs of plans in your area.

• Use the personalized search feature on the Medicare Plan Finder at https://www.medicare.gov website. Click “Find health & drug plans.”

• Review the list in the back of your Medicare & You handbook.

• Look in Section 4.2 to learn more about your choices.

Once you narrow your choice to a preferred plan, confirm your costs and coverage on the plan’s website.

3. CHOOSE: Decide whether you want to change your plan

• If you want to keep Care N’ Care Choice Premium (PPO). you don’t need to do anything. You will stay in Care N’ Care Choice Premium (PPO).

• To change to a different plan that may better meet your needs, you can switch plans between October 15 and December 7.

4. ENROLL: To change plans, join a plan between October 15 and December 7, 2019

• If you don’t join another plan by December 7, 2019, you will stay in Care N’ Care Choice Premium (PPO). If you join another plan between October 15 and December 7, 2019, your new coverage will start on January 1, 2020.

Additional Resources • This document is available for free in Spanish.

• Please contact your Healthcare Concierge at 1-877-374-7993 for additional information. (TTY users should call 711). Hours are October 1 – March 31, 8AM – 8PM Central, 7 days a week; April 1 – September 30, 8AM – 8PM Central, Monday through Friday.

• This information is available in a different format, including large print and Spanish. Please call your Healthcare Concierge at the number listed above if you need plan information in another format or language.

• Coverage under this Plan qualifies as Qualifying Health Coverage (QHC) and satisfies the Patient Protection and Affordable Care Act’s (ACA) individual shared responsibility requirement. Please visit the Internal Revenue Service (IRS) website at https://www.irs.gov/Affordable-Care-Act/Individuals- and-Families for more information.

https://www.medicare.gov/

https://www.irs.gov/Affordable-Care-Act/Individuals-and-Families

https://www.irs.gov/Affordable-Care-Act/Individuals-and-Families

About Care N’ Care Choice Premium (PPO) • Care N’ Care Insurance is an HMO and PPO plan with a Medicare contract. Enrollment in Care N’ Care

depends on contract renewal.

• When this booklet says “we,” “us,” or “our,” it means Care N’ Care Insurance Company. When it says “plan” or “our plan,” it means Care N’ Care Choice Premium (PPO).

Care N’ Care Choice Premium (PPO) Annual Notice of Changes for 2020 1

Summary of Important Costs for 2020

The table below compares the 2019 costs and 2020 costs for Care N’ Care Choice Premium (PPO) in several important areas. Please note this is only a summary of changes. It is important to read the rest of this Annual Notice of Changes and review the Evidence of Coverage to see if other benefit or cost changes affect you. The Evidence of Coverage is located on our website at https://www.cnchealthplan.com. You may also call your Healthcare Concierge to ask us to mail you a copy of the Evidence of Coverage.

Cost 2019 (this year) 2020 (next year)

Monthly plan premium* * Your premium may be higher or lower than this amount. See Section 1.1 for details.

$119 $200

Maximum out-of-pocket amounts This is the most you will pay out-of-pocket for your covered Part A and Part B services. (See Section 1.2 for details.)

From network providers: $3,100 From network and out-of-network providers combined: $5,100

From network providers: $3,100 From network and out-of-network providers combined: $5,100

Doctor office visits In-network: Primary care visits: $5 copay per visit Specialist visits: $20 copay per visit

Out-of-network: Primary care visits: $35 Copay per visit Specialist visits: $40 Copay per visit

In-network: Primary care visits: $0 Copay per visit Specialist visits: $0 Copay per visit

Out-of-network: Primary care visits: $35 Copay per visit Specialist visits: $40 Copay per visit

Inpatient hospital stays Includes inpatient acute, inpatient rehabilitation, long-term care hospitals, and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor’s order. The day before you are discharged is your last inpatient day.

In-network: Days 1-6; $225 copay per day Days 7 and beyond; $0 copay per day

Out-of-network: 30% Coinsurance

In-network: $0 Copay for Inpatient Hospital Stay

Out-of-network: 30% Coinsurance

https://www.cnchealthplan.com



Part D prescription drug coverage (See Section 1.6 for details.)

Deductible: $0 Copayment for a 30-day supply during the Initial Coverage Stage: • Drug Tier 1: $0 copay • Drug Tier 2: $10 copay • Drug Tier 3: $40 copay • Drug Tier 4: $85 copay • Drug Tier 5: 33%

coinsurance

Deductible: $0 Copayment for a 30-day supply during the Initial Coverage Stage: • Drug Tier 1: $0 copay • Drug Tier 2: $10 copay • Drug Tier 3: $40 copay • Drug Tier 4: $85 copay • Drug Tier 5: 33%

coinsurance


Annual Notice of Changes for 2020

Table of Contents

Summary of Important Costs for 2020 ........................................................................ 1

SECTION 1 Changes to Benefits and Costs for Next Year ................................. 4

Section 1.1 – Changes to the Monthly Premium ...................................................................... 4

Section 1.2 – Changes to Your Maximum Out-of-Pocket Amounts ........................................ 4

Section 1.3 – Changes to the Provider Network ....................................................................... 5

Section 1.4 – Changes to the Pharmacy Network ..................................................................... 6

Section 1.5 – Changes to Benefits and Costs for Medical Services ......................................... 6

Section 1.6 – Changes to Part D Prescription Drug Coverage ............................................... 22

SECTION 2 Deciding Which Plan to Choose ..................................................... 25

Section 2.1 – If you want to stay in Care N’ Care Choice Premium (PPO) ........................... 25

Section 2.2 – If you want to change plans .............................................................................. 25

SECTION 3 Administrative Changes .................................................................. 27

SECTION 4 Deadline for Changing Plans .......................................................... 28

SECTION 5 Programs That Offer Free Counseling about Medicare ................ 28

SECTION 6 Programs That Help Pay for Prescription Drugs ........................... 28

SECTION 7 Questions? ...................................................................................... 29

Section 7.1 – Getting Help from Care N’ Care Choice Premium (PPO) ................................ 29

Section 6.2 – Getting Help from Medicare ............................................................................. 30


SECTION 1 Changes to Benefits and Costs for Next Year

Section 1.1 – Changes to the Monthly Premium


Monthly premium (You must also continue to pay your Medicare Part B premium.)

$119 $200

• Your monthly plan premium will be more if you are required to pay a lifetime Part D late enrollment penalty for going without other drug coverage that is at least as good as Medicare drug coverage (also referred to as “creditable coverage”) for 63 days or more.

• If you have a higher income, you may have to pay an additional amount each month directly to the government for your Medicare prescription drug coverage.

• Your monthly premium will be less if you are receiving “Extra Help” with your prescription drug costs.

Section 1.2 – Changes to Your Maximum Out-of-Pocket Amounts

To protect you, Medicare requires all health plans to limit how much you pay “out-of-pocket” during the year. These limits are called the “maximum out-of-pocket amounts.” Once you reach this amount, you generally pay nothing for covered Part A and Part B services for the rest of the year.


In-network maximum out-of-pocket amount Your costs for covered medical services (such as copays) from in-network providers count toward your in-network maximum out-of-pocket amount. Your plan premium and your costs for prescription drugs do not count toward your maximum out-of-pocket amount.

$3,100 Once you have paid $3,100 out-of-pocket for covered Part A and Part B services, you will pay nothing for your covered Part A and Part B services from network providers for the rest of the calendar year.

$3,100 Once you have paid $3,100 out-of-pocket for covered Part A and Part B services, you will pay nothing for your covered Part A and Part B services from network providers for the rest of the calendar year.



Combined maximum out-of-pocket amount Your costs for covered medical services (such as copays) from in-network and out- of-network providers count toward your combined maximum out-of-pocket amount. Your plan premium does not count toward your maximum out-of- pocket amount.

$5,100 Once you have paid $5,100 out-of-pocket for covered Part A and Part B services, you will pay nothing for your covered Part A and Part B services from network or out- of-network providers for the rest of the calendar year.

$5,100 Once you have paid $5,100 out-of-pocket for covered Part A and Part B services, you will pay nothing for your covered Part A and Part B services from network or out- of-network providers for the rest of the calendar year.

Section 1.3 – Changes to the Provider Network

There are changes to our network of providers for next year. An updated Provider Directory is located on our website at https://www.cnchealthplan.com. You may also call your Healthcare Concierge for updated provider information or to ask us to mail you a Provider Directory. Please review the 2020 Provider Directory to see if your providers (primary care provider, specialists, hospitals, etc.) are in our network.

It is important that you know that we may make changes to the hospitals, doctors and specialists (providers) that are part of your plan during the year. There are a number of reasons why your provider might leave your plan, but if your doctor or specialist does leave your plan you have certain rights and protections summarized below:

• Even though our network of providers may change during the year, we must furnish you with uninterrupted access to qualified doctors and specialists.

• We will make a good faith effort to provide you with at least 30 days’ notice that your provider is leaving our plan so that you have time to select a new provider.

• We will assist you in selecting a new qualified provider to continue managing your health care needs.

• If you are undergoing medical treatment you have the right to request, and we will work with you to ensure, that the medically necessary treatment you are receiving is not interrupted.

• If you believe we have not furnished you with a qualified provider to replace your previous provider or that your care is not being appropriately managed, you have the right to file an appeal of our decision.

• If you find out your doctor or specialist is leaving your plan, please contact us so we can assist you in finding a new provider and managing your care.



Section 1.4 – Changes to the Pharmacy Network

Amounts you pay for your prescription drugs may depend on which pharmacy you use. Medicare drug plans have a network of pharmacies. In most cases, your prescriptions are covered only if they are filled at one of our network pharmacies.

There are changes to our network of pharmacies for next year. An updated Pharmacy Directory is located on our website at https://www.cnchealthplan.com. You may also call your Healthcare Concierge for updated provider information or to ask us to mail you a Pharmacy Directory. Please review the 2020 Pharmacy Directory to see which pharmacies are in our network.

Section 1.5 – Changes to Benefits and Costs for Medical Services

We are changing our coverage for certain medical services next year. The information below describes these changes. For details about the coverage and costs for these services, see Chapter 4, Medical Benefits Chart (what is covered and what you pay), in your 2020 Evidence of Coverage.


Ambulance services Covered ambulance services include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide care if they are furnished to a member whose medical condition is such that other means of transportation could endanger the person’s health or if authorized by the plan.

Non-emergency transportation by ambulance is appropriate if it is documented that the member’s condition is such that other means of transportation could endanger the person’s health and that transportation by ambulance is medically required.

In-Network and Out-of- Network

$225 copay for Medicare- covered ambulance benefits per one-way trip.

You Pay 20% of the cost for Air Transportation

In-Network $0 copay for Medicare- covered ambulance benefits per one-way trip.

You Pay 0% of the cost for Air Transportation




Annual Routine Physical Exam

Annual Routine Physical Exam includes comprehensive physical examination and evaluation of status of chronic diseases. Doesn’t include lab tests, radiological diagnostic tests or non-radiological diagnostic tests or diagnostic tests. Additional cost share may apply to any lab or diagnostic testing preformed during your visit, as described for each separate service in this Medical Benefits Chart. Annual Routine Physical Exam visits do not need to be scheduled 12 months apart, but are limited to one each calendar year.

Not Covered In-Network: $0 copay

Out-of-Network: $30 copay

Cardiac rehabilitation services

Comprehensive programs of cardiac rehabilitation services that include exercise, education, and counseling are covered for members who meet certain conditions with a doctor’s referral. The plan also covers intensive cardiac rehabilitation programs that are typically more rigorous or more intense than cardiac rehabilitation programs.

In-Network

$10 Copay for Medicare- covered Cardiac Rehabilitation services or Medicare covered intensive Cardiac Rehabilitation services

In-Network

$0 Copay for Medicare- covered Cardiac Rehabilitation services or Medicare covered intensive Cardiac Rehabilitation services

Chiropractic services Covered services include: We cover only manual manipulation of the spine to correct subluxation (adjustments of the spine)

In-Network $10 Copay

In-Network $0 Copay



Dental services In general, preventive dental services (such as cleaning, routine dental exams, and dental x-rays) are not covered by Original Medicare.

We cover: clinical oral evaluations (Either two (2) D0120 or one (1) D0120 & D0150 per year)

We cover cleanings: Prophylaxis - 1 every 6 months (ADA Code: D1110)

We cover denture adjustments (Up to two (2) per year)

We cover dental X-Rays (Choose one (1) per year): Intraoral, complete series (includes bitewings) - 1 every 36 months (ADA Code: D0210)

In-Network

You pay a $10 Copay for Oral Exams

You pay a $10 copay for Cleanings

You pay a $10 copay for Denture Adjustments

You pay a $10 Copay for Dental X-Rays

In-Network

You pay a $0 Copay for Oral Exams

You pay a $0 copay for Cleanings

You pay a $0 copay for Denture Adjustments

You pay a $0 Copay for Dental X-Rays

Doctor Office Visits In-network: Primary care visits: $5 copay per visit Specialist visits: $20 copay per visit

In-network: Primary care visits: $0 copay per visit Specialist visits: $0 copay per visit



Durable medical equipment (DME) and related supplies (For a definition of “durable medical equipment,” see Chapter 12 of this booklet.) Covered items include, but are not limited to: wheelchairs, crutches, powered mattress systems, diabetic supplies (including insulin pumps and related supplies, insulin for use in insulin pumps and continuous glucose monitoring devices and related supplies), hospital bed ordered by a provider for use in the home, IV infusion pump, speech generating devices, oxygen equipment, nebulizers, and walkers. We cover all medically necessary DME covered by Original Medicare. If our supplier in your area does not carry a particular brand or manufacturer, you may ask them if they can special order it for you. The most recent list of suppliers is available on our website at https://www.cnchealthplan.com.

In-Network 20% Coinsurance

In-Network 0% Coinsurance

Emergency care Emergency care refers to services that are: Furnished by a provider qualified to furnish emergency services, and Needed to evaluate or stabilize an emergency medical condition.

A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.

In-Network $100 copay

In-Network $0 copay




Hearing services Diagnostic hearing and balance evaluations performed by your PCP to determine if you need medical treatment are covered as outpatient care when furnished by a physician, audiologist, or other qualified provider.

In-Network $20 Copay for Medicare- covered Diagnostic Hearing Exam

In-Network $0 Copay for Medicare- covered Diagnostic Hearing Exam

Home health agency care Prior to receiving home health services, a doctor must certify that you need home health services and will order home health services to be provided by a home health agency. You must be homebound, which means leaving home is a major effort. Covered services include, but are not limited to:

• Part-time or intermittent skilled nursing and home health aide services (To be covered under the home health care benefit, your skilled nursing and home health aide services combined must total fewer than 8 hours per day and 35 hours per week)

• Physical therapy, occupational therapy, and speech therapy

• Medical and social services

• Medical equipment and supplies

In-Network $15 Copay

In-Network $0 Copay

Inpatient hospital stays Includes inpatient acute, inpatient rehabilitation, long-term care hospitals, and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor’s order. The day before you are discharged is your last inpatient day.

In-network Days 1-6; $225 copay per day Days 7 and beyond: $0 copay per day

In-network $0 copay per day for Inpatient Hospital stay



Inpatient mental health care Covered services include mental health care services that require a hospital stay. 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.

In-Network Inpatient visit: $1,500 copay per stay

In-Network Inpatient visit: $0 copay per stay



Inpatient stay: Covered services received in a hospital of SNF during a non- covered inpatient stay If you have exhausted your inpatient benefits or if the inpatient stay is not reasonable and necessary, we will not cover your inpatient stay. However, in some cases, we will cover certain services you receive while you are in the hospital or the skilled nursing facility (SNF). Covered services include, but are not limited to:

• Physician services - Primary Care Physician - Specialist

• Diagnostic tests (like lab tests) - at laboratory facility - at outpatient hospital facility

• X-ray, radium, and isotope therapy including technician materials and services

• Surgical dressings • Splints, casts and other devices used

to reduce fractures and dislocations • Prosthetics and orthotics devices

(other than dental) that replace all or part of an internal body organ (including contiguous tissue), or all or part of the function of a permanently inoperative or malfunctioning internal body organ, including replacement or repairs of such devices

• Leg, arm, back, and neck braces; trusses, and artificial legs, arms, and eyes including adjustments, repairs, and replacements required because of breakage, wear, loss, or a change in the patient’s physical condition

• Physical therapy, speech therapy, and occupational therapy

In-Network

$5 copay $20 copay

$0 copay $5 copay $0 copay

20% of the cost 20% of the cost

20% of the cost

20% of the cost

$15 copay

In-Network

$0 copay $0 copay



0% of the cost

0% of the cost

$0 copay



Medicare Part B prescription drugs These drugs are covered under Part B of Original Medicare. Members of our plan receive coverage for these drugs through our plan. Covered drugs include: Drugs that usually aren’t self-administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services Drugs you take using durable medical equipment (such as nebulizers) that were authorized by the plan Clotting factors you give yourself by injection if you have hemophilia Immunosuppressive drugs, if you were enrolled in Medicare Part A at the time of the organ transplant Injectable osteoporosis drugs, if you are homebound, have a bone fracture that a doctor certifies was related to post- menopausal osteoporosis, and cannot self- administer the drug Antigens Certain oral anti-cancer drugs and anti- nausea drugs Certain drugs for home dialysis, including heparin, the antidote for heparin when medically necessary, topical anesthetics, and erythropoiesis-stimulating agents (such as Epogen®, Procrit®, Epoetin Alfa, Aranesp®, or Darbepoetin Alfa) Intravenous Immune Globulin for the home treatment of primary immune deficiency diseases

In-Network

For Part B drugs such as chemotherapy drugs: 20% of the cost

Other Part B drugs: 20% of the cost

In-Network

For Part B drugs such as chemotherapy drugs: 0% of the cost

Other Part B drugs: 0% of the cost



Mental Health Care Including care in a partial-hospitalization program, if a doctor certifies that inpatient treatment would be required without it. - Partial Hospitalization - Outpatient Group Therapy Visit - Individual Therapy Visit

In-Network

$55 Copay $40 Copay $40 Copay

In-Network

$0 Copay $0 Copay $0 Copay

Opioid Treatment Program Services Opioid use disorder treatment services are covered under Part B of Original Medicare. Members of our plan receive coverage for these services through our plan. Covered services include: FDA-approved opioid agonist and antagonist treatment medications and the dispensing and administration of such medications, if applicable Substance use counseling Individual and group therapy Toxicology testing

Not Covered In-Network: $0 Copay

Out-of-Network: $40 Copay


Outpatient diagnostic tests and therapeutic services and supplies Covered services include, but are not limited to:

• X-rays - included with a physician visit - at an outpatient facility

• Radiation (radium and isotope) therapy including technician materials and supplies

- Echocardiography with an approved amount from $1 to $300

- Echocardiography with an approved amount over $300

- Ultrasound - CT-Scan, MRI, MRA, PET, Nuclear

Stress Testing, Stress Echocardiography, Spec Scan and Other Services

- Therapeutic Radiology Services (such as radiation treatment for cancer)

• Surgical supplies, such as dressings • Splints, casts and other devices used to

reduce fractures and dislocations • Laboratory tests

- at laboratory facility - at outpatient hospital facility

• Blood - including storage and administration. Coverage of whole blood and packed red cells begins only with the fourth pint of blood that you need - you must either pay the costs for the first 3 pints of blood you get in a calendar year or have the blood donated by you or someone else. All other components of blood are covered beginning with the first pint used.

• Other outpatient diagnostic tests - at outpatient hospital facility - at laboratory facility

In-Network

$0 Copay $0 Copay

$50 Copay

$150 Copay

$50 Copay $150 Copay

20% of the cost


$0 copay $5 copay

$0 copay for blood after the first 3 pints

$5 copay $0 copay

In-Network

$0 Copay $0 Copay

$0 Copay

$0 Copay

$0 Copay $0 Copay

0% of the cost


$0 copay $0 copay

$0 copay for blood after the first 3 pints




- Treadmill Stress Test, Pulmonary Function Test, or Sleep Study

$100 copay

Outpatient rehabilitation services Covered services include: physical therapy, occupational therapy, and speech language therapy. Outpatient rehabilitation services are provided in various outpatient settings, such as hospital outpatient departments, independent therapist offices, and Comprehensive Outpatient Rehabilitation Facilities (CORFs).

In-Network $10 Copay for Occupational Therapy Visit $15 Copay for Physical therapy and speech and language therapy visit

In-Network $0 Copay for Occupational Therapy Visit $0 Copay for Physical therapy and speech and language therapy visit

Outpatient hospital services We cover medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury.

In-Network $125 copay for Medicare- covered outpatient hospital services $125 copay for Medicare- covered Observation Services

In-Network $0 copay for Medicare- covered outpatient hospital services $0 copay for Medicare- covered Observation Services

Outpatient substance abuse services Covered services include group and individual sessions for substance abuse treatment.

In-Network $40 Copay for Group Session $40 Copay for Individual Session

In-Network $0 Copay for Group Session $0 Copay for Individual Session

Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers Note: If you are having surgery in a hospital facility, you should check with your provider about whether you will be an inpatient or outpatient. Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered an “outpatient.”

In-Network

$100 Copay per visit Ambulatory Surgical Center

$125 Copay per visit Outpatient Hospital Facility

In-Network

$0 Copay per visit Ambulatory Surgical Center

$0 Copay per visit Outpatient Hospital Facility

$0 copay



Over-the-Counter (OTC) Items

Your coverage includes non-prescription OTC health and wellness items like vitamins, sunscreen, pain relievers, cough and cold medicine, and bandages.

You have 2 options to order:

- Online – visit https://livewell.medline.com/CNC

- By Phone – call an OTC Customer Service Representative toll-free at 833- 492-9866 (TTY users should call 711), 7 AM - 7 PM Central, Monday through Friday

At no additional cost to you, your order will be shipped to the address you provide when ordering.

Refer to your 2020 OTC Product Catalog for a complete list of plan-approved OTC items or call an OTC Customer Service Representative for more information.

Not Covered You pay $0.

You have $30 every quarter (3 months) to spend on plan-approved OTC items.

Quarterly OTC benefit periods are January-March, April-June, July-September, and October-December.

If you don’t use all of your quarterly OTC benefit amount when you order, the remaining balance will NOT roll over to the next OTC benefit period.

Any unused OTC benefit amount, will expire on December 31st of the benefit year.

Note: If you exhaust your quarterly OTC benefit, you may still order from the catalog using your own out- of-pocket payment method.

Podiatry services Covered Services Include:

Diagnosis and the medical or surgical treatment of injuries and diseases of the feet (such as hammer toe or heel spurs). Routine foot care for members with certain medical conditions affecting the lower limbs

In-Network

$10 copay

In-Network

$0 copay

https://livewell.medline.com/CNC



Prosthetic devices and related supplies Devices (other than dental) that replace all or part of a body part or function. These include, but are not limited to: colostomy bags and supplies directly related to colostomy care, pacemakers, braces, prosthetic shoes, artificial limbs, and breast prostheses (including a surgical brassiere after a mastectomy). Includes certain supplies related to prosthetic devices, and repair and/or replacement of prosthetic devices. Also includes some coverage following cataract removal or cataract surgery – see “Vision Care” later in this section for more detail.

In-Network

Prosthetic devices and related medical supplies: 20% of the cost

In-Network

Prosthetic devices and related medical supplies: 0% of the cost

Pulmonary rehabilitation services Comprehensive programs of pulmonary rehabilitation are covered for members who have moderate to very severe chronic obstructive pulmonary disease (COPD) and a referral for pulmonary rehabilitation from the doctor treating the chronic respiratory disease.

In-Network

Pulmonary rehab services: $10 copay

In-Network

Pulmonary rehab services: $0 copay



Services to treat kidney disease and conditions Covered services include:

Kidney disease education services to teach kidney care and help members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime. Outpatient dialysis treatments (including dialysis treatments when temporarily out of the service area, as explained in Chapter 3) Inpatient dialysis treatments (if you are admitted as an inpatient to a hospital for special care) Self-dialysis training (includes training for you and anyone helping you with your home dialysis treatments) Home dialysis equipment and supplies Certain home support services (such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies, and check your dialysis equipment and water supply)

Certain drugs for dialysis are covered under your Medicare Part B drug benefit. For information about coverage for Part B Drugs, please go to the section, “Medicare Part B prescription drugs.”

In-Network

There is no coinsurance, copayment, or deductible for Medicare covered kidney disease education services

$25 copay per session for Medicare-covered renal dialysis treatments

$0 Copay for Self- Dialysis Training

20% of the cost for home dialysis equipment and supplies

$15 copay for home support services

20% of the cost for Medicare Part B Drugs

In-Network

There is no coinsurance, copayment, or deductible for Medicare covered kidney disease education services.

$0 copay per session for Medicare-covered renal dialysis treatments

$0 Copay for Self- Dialysis Training

0% of the cost for home dialysis equipment and supplies

$0 copay for home support services

0% of the cost for Medicare Part B Drugs



Skilled nursing facility (SNF) care (For a definition of “skilled nursing facility care,” see Chapter 12 of this booklet. Skilled nursing facilities are sometimes called “SNFs.”) Covered services include but are not limited to: to: • Semiprivate room (or a private room if

medically necessary) • Meals, including special diets • Skilled nursing services • Physical therapy, occupational therapy,

and speech therapy • Drugs administered to you as part of

your plan of care (This includes substances that are naturally present in the body, such as blood clotting factors.)

• Blood - including storage and administration. Coverage of whole blood and packed red cells begins only with the fourth pint of blood that you need - you must either pay the costs for the first 3 pints of blood you get in a calendar year or have the blood donated by you or someone else. All other components of blood are covered beginning with the first pint used.

• Medical and surgical supplies ordinarily provided by SNFs

• Laboratory tests ordinarily provided by SNFs

• X-rays and other radiology services ordinarily provided by SNFs

• Use of appliances such as wheelchairs ordinarily provided by SNFs

• Physician/Practitioner services

In-Network

Our Plan covers up to 100 days in a SNF

Days 1 through 5; $0 Copay per day



In-Network

Our Plan covers up to 100 days in a SNF

$0 Copay per 100 day stay



Supervised Exercise Therapy (SET) SET is covered for members who have symptomatic peripheral artery disease (PAD) and a referral for PAD from the physician responsible for PAD treatment. Up to 36 sessions over a 12-week period are covered if the SET program requirements are met. The SET program must: • Consist of sessions lasting 30-60

minutes, comprising a therapeutic exercise-training program for PAD in patients with claudication

• Be conducted in a hospital outpatient setting or a physician’s office

• Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD

• Be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques

SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider.

In-Network

$10 copay for Medicare- covered Supervised Exercise Therapy (SET) services.

In-Network

$0 copay for Medicare- covered Supervised Exercise Therapy (SET) services.

Urgently needed services Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services may be furnished by network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible.

In-Network

$30 copay for Urgently needed services

In-Network

$0 copay for Urgently needed services



Vision care Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration. Original Medicare doesn’t cover routine eye exams (eye refractions) for eyeglasses/contacts.

In-Network

$20 copay for Medicare covered diagnostic eye exam

In-Network

$0 copay for Medicare covered diagnostic eye exam

Section 1.6 – Changes to Part D Prescription Drug Coverage

Changes to Our Drug List

Our list of covered drugs is called a Formulary or “Drug List.” A copy of our Drug List is provided electronically. The Drug List we provided electronically includes many – but not all – of the drugs that we will cover next year. If you don’t see your drug on this list, it might still be covered. You can get the complete Drug List by calling your Healthcare Concierge (see the back cover) or visiting our website (http://www.cnchealthplan.com/search).

We made changes to our Drug List, including changes to the drugs we cover and changes to the restrictions that apply to our coverage for certain drugs. Review the Drug List to make sure your drugs will be covered next year and to see if there will be any restrictions.

If you are affected by a change in drug coverage, you can:

• Work with your doctor (or other prescriber) and ask the plan to make an exception to cover the drug. We encourage current members to ask for an exception before next year.

o To learn what you must do to ask for an exception, see Chapter 9 of your Evidence of Coverage (What to do if you have a problem or complaint (coverage decisions, appeals, complaints)) or call your Healthcare Concierge.

• Work with your doctor (or other prescriber) to find a different drug that we cover. You can call your Healthcare Concierge to ask for a list of covered drugs that treat the same medical condition.

In some situations, we are required to cover a temporary supply of a non-formulary drug in the first 90 days of the plan year or the first 90 days of membership to avoid a gap in therapy. For 2020, members in long term care (LTC) facilities will now receive a temporary supply that is the same amount of temporary days supply provided in all other cases: 31 days supply of medication rather than the amount provided in 2019 (91 to 98 days supply of medication depending on the dispensing increment). (To learn more about when you can get a temporary supply and how to ask for one, see Chapter 5, Section 5.2 of the Evidence of Coverage.) During the time when you are getting a temporary supply of a drug, you should talk with your doctor to decide what to do when your temporary supply runs out. You can either switch to a different drug covered by the plan or ask the plan to make an exception for you and cover your current drug.

http://www.cnchealthplan.com/search


Members who have an approved formulary exception through 2019 may have that formulary exception extended through 2020 by the plan. If the formulary exception is extended, you will receive advanced notice of the terms of the extension. If the formulary exception is not extended, you will need to resubmit a formulary exception request for 2020.

Most of the changes in the Drug List are new for the beginning of each year. However, during the year, we might make other changes that are allowed by Medicare rules.

Starting in 2020, we may immediately remove a brand name drug on our Drug List if, at the same time, we replace it with a new generic drug on the same or lower cost-sharing tier and with the same or fewer restrictions. Also, when adding the new generic drug, we may decide to keep the brand name drug on our Drug List, but immediately move it to a different cost-sharing tier or add new restrictions. This means, for instance, if you are taking a brand name drug that is being replaced or moved to a higher cost-sharing tier, you will no longer always get notice of the change 30 days before we make it or get a month’s supply of your brand name drug at a network pharmacy. If you are taking the brand name drug, you will still get information on the specific change we made, but it may arrive after the change is made.

When we make these changes to the Drug List during the year, you can still work with your doctor (or other prescriber) and ask us to make an exception to cover the drug. We will also continue to update our online Drug List as scheduled and provide other required information to reflect drug changes. (To learn more about changes we may make to the Drug List, see Chapter 5, Section 6 of the Evidence of Coverage.)

Changes to Prescription Drug Costs

Note: If you are in a program that helps pay for your drugs (“Extra Help”), the information about costs for Part D prescription drugs may not apply to you. We sent you a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (also called the “Low Income Subsidy Rider” or the “LIS Rider”), which tells you about your drug costs. If you receive “Extra Help” and haven’t received this insert by September 30, 2019, please call your Healthcare Concierge and ask for the “LIS Rider.” Phone numbers for your Healthcare Concierge are in Section 6.1 of this booklet.

There are four “drug payment stages.” How much you pay for a Part D drug depends on which drug payment stage you are in. (You can look in Chapter 6, Section 2 of your Evidence of Coverage for more information about the stages.)

The information below shows the changes for next year to the first two stages – the Yearly Deductible Stage and the Initial Coverage Stage. (Most members do not reach the other two stages – the Coverage Gap Stage or the Catastrophic Coverage Stage. To get information about your costs in these stages, look at Chapter 6, Sections 6 and 7, in the Evidence of Coverage, which is located on our website at https://www.cnchealthplan.com. You may also call your Healthcare Concierge to ask us to mail you a copy of the Evidence of Coverage.)



Changes to the Deductible Stage

Stage 2019 (this year) 2020 (next year)

Stage 1: Yearly Deductible Stage Because we have no deductible, this payment stage does not apply to you.

Because we have no deductible, this payment stage does not apply to you.

Changes to Your Cost-sharing in the Initial Coverage Stage

To learn how copayments and coinsurance work, look at Chapter 6, Section 1.2, Types of out-of-pocket costs you may pay for covered drugs in your Evidence of Coverage.

Stage 2019 (this year) 2020 (next year)

Stage 2: Initial Coverage Stage

During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost.

The costs in this row are for a one- month (30-day) supply when you fill your prescription at a network pharmacy that provides standard cost-sharing. For information about the costs for a long- term supply; at a network pharmacy that offers preferred cost-sharing; or for mail-order prescriptions, look in Chapter 6, Section 5 of your Evidence of Coverage.

We changed the tier for some of the drugs on our Drug List. To see if your drugs will be in a different tier, look them up on the Drug List.

Your cost for a one-month supply filled at a network pharmacy with standard cost- sharing:

Preferred Generics: You pay $0 copay.

Generics: You pay $10 copay.

Preferred Brands: You pay $40 copay.

Non-Preferred Drugs: You pay $85 copay.

Specialty Tier: You pay 33% coinsurance

Your cost for a one-month supply filled at a network pharmacy with standard cost- sharing:

Preferred Generics: You pay $0 copay.

Generics: You pay $10 copay.

Preferred Brands: You pay $40 copay.

Non-Preferred Drugs: You pay $85 copay.

Specialty Tier: You pay 33% coinsurance

Once your total drug costs have reached $3,820 you will move to the next stage (the Coverage Gap Stage).

Once your total drug costs have reached $4,020 you will move to the next stage (the Coverage Gap Stage).


Changes to the Coverage Gap and Catastrophic Coverage Stages

The other two drug coverage stages – the Coverage Gap Stage and the Catastrophic Coverage Stage – are for people with high drug costs. Most members do not reach the Coverage Gap Stage or the Catastrophic Coverage Stage. For information about your costs in these stages, look at Chapter 6, Sections 6 and 7, in your Evidence of Coverage.

SECTION 2 Deciding Which Plan to Choose

Section 2.1 – If you want to stay in Care N’ Care Choice Premium (PPO)

To stay in our plan you don’t need to do anything. If you do not sign up for a different plan or change to Original Medicare by December 7, you will automatically stay enrolled as a member of our plan for 2020.

Section 2.2 – If you want to change plans

We hope to keep you as a member next year but if you want to change for 2020 follow these steps:

Step 1: Learn about and compare your choices • You can join a different Medicare health plan timely,

• – OR– You can change to Original Medicare. If you change to Original Medicare, you will need to decide whether to join a Medicare drug plan.

To learn more about Original Medicare and the different types of Medicare plans, read Medicare & You 2020, call your State Health Insurance Assistance Program (see Section 6.2).

You can also find information about plans in your area by using the Medicare Plan Finder on the Medicare website. Go to https://www.medicare.gov and click “Find health & drug plans.” Here, you can find information about costs, coverage, and quality ratings for Medicare plans.

As a reminder, Care N’ Care Insurance Company offers other Medicare health plans. These other plans may differ in coverage, monthly premiums, and cost-sharing amounts.

Step 2: Change your coverage

• To change to a different Medicare health plan, enroll in the new plan. You will automatically be disenrolled from Care N’ Care Choice Premium (PPO).

• To change to Original Medicare with a prescription drug plan, enroll in the new drug plan. You will automatically be disenrolled from Care N’ Care Choice Premium (PPO).

• To change to Original Medicare without a prescription drug plan, you must either: o Send us a written request to disenroll. Contact your Healthcare Concierge if you need more

information on how to do this (phone numbers are in Section 6.1 of this booklet).



o – OR – Contact Medicare, at 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week, and ask to be disenrolled. TTY users should call 1-877-486-2048.


SECTION 3 Administrative Changes


Chapter 5 Section 2.3: Using the plan’s mail-order services Automatic Refill

Not included If you receive a prescription automatically by mail that you do not want, and you were not contacted to see if you wanted it before it shipped, you may be eligible for a refund.

If you used mail order in the past and do not want the pharmacy to automatically fill and ship each new prescription, please contact our mail order pharmacy directly. For further assistance, contact your Healthcare Concierge at 1-877-374-7993 (TTY users should call 711), October 1 - March 31, 8AM – 8PM Central, 7 days a week; April 1 - September 30, 8AM – 8PM Central, Monday through Friday.

If you have never used our mail order delivery and/or decide to stop automatic fills of new prescriptions, the pharmacy will contact you each time it gets a new prescription from a health care provider to see if you want the medication filled and shipped immediately. This will give you an opportunity to make sure that the pharmacy is delivering the correct drug (including strength, amount, and form) and, if necessary, allow you to cancel or delay the order before you are billed and it is shipped. It is important that you respond each time you are contacted by the pharmacy, to let them know what to do with the new prescription and to prevent any delays in shipping.

To opt out of automatic deliveries of new prescriptions received directly from your health care provider’s office, please contact our mail order pharmacy directly and ask to be removed from automatic filling and shipping of each new prescription, or contact your Healthcare Con- cierge at 1-877-374-7993 (TTY users should call 711), October 1 - March 31, 8AM – 8PM Central, 7 days a week; April 1 - September 30, 8AM – 8PM Central, Monday through Friday.


SECTION 4 Deadline for Changing Plans

If you want to change to a different plan or to Original Medicare for next year, you can do it from October 15 until December 7. The change will take effect on January 1, 2020.

Are there other times of the year to make a change?

In certain situations, changes are also allowed at other times of the year. For example, people with Medicaid, those who get “Extra Help” paying for their drugs, those who have or are leaving employer coverage, and those who move out of the service area may be allowed to make a change at other times of the year. For more information, see Chapter 10, Section 2.3 of the Evidence of Coverage.

Note: If you’re in a drug management program, you may not be able to change plans.

If you enrolled in a Medicare Advantage Plan for January 1, 2020, and don’t like your plan choice, you can switch to another Medicare health plan (either with or without Medicare prescription drug coverage) or switch to Original Medicare (either with or without Medicare prescription drug coverage) between January 1 and March 31, 2020. For more information, see Chapter 10, Section 2.2 of the Evidence of Coverage.

SECTION 5 Programs That Offer Free Counseling about Medicare

The State Health Insurance Assistance Program (SHIP) is a government program with trained counselors in every state. In Texas, the SHIP is called the Health Information Counseling and Advocacy Program (HICAP).

The Health Information Counseling and Advocacy Program (HICAP) is independent (not connected with any insurance company or health plan). It is a state program that gets money from the Federal government to give free local health insurance counseling to people with Medicare. The Health Information Counseling and Advocacy Program (HICAP) counselors can help you with your Medicare questions or problems. They can help you understand your Medicare plan choices and answer questions about switching plans. You can call the Health Information Counseling and Advocacy Program (HICAP) at 1-800-252-9240. You can learn more about the Health Insurance Information Counseling and Advocacy Program (HICAP) by visiting their website (http://www.tdi.texas.gov/consumer/hicap/).

SECTION 6 Programs That Help Pay for Prescription Drugs

You may qualify for help paying for prescription drugs. Below we list different kinds of help:

• “Extra Help” from Medicare. People with limited incomes may qualify for “Extra Help” to pay for their prescription drug costs. If you qualify, Medicare could pay up to 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and coinsurance. Additionally, those who qualify will not have a coverage gap or late enrollment penalty. Many people are eligible and don’t even know it. To see if you qualify, call:

http://www.tdi.texas.gov/consumer/hicap/


o 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7

days a week;

o The Social Security Office at 1-800-772-1213 between 7 am and 7 pm, Monday through Friday. TTY users should call 1-800-325-0778 (applications); or

o Your State Medicaid Office (applications).

• Help from your state’s pharmaceutical assistance program. Texas has a program called Texas Kidney Health Care Program (KHC) and the Texas HIV Medication Program that helps people pay for prescription drugs based on their financial need, age, or medical condition. To learn more about the program, check with your State Health Insurance Assistance Program (the name and phone numbers for this organization are in Section 4 of this booklet).

• Prescription Cost-sharing Assistance for Persons with HIV/AIDS. The AIDS Drug Assistance Program (ADAP) helps ensure that ADAP-eligible individuals living with HIV/AIDS have access to life-saving HIV medications. Individuals must meet certain criteria, including proof of State residence and HIV status, low income as defined by the State, and uninsured/under-insured status. Medicare Part D prescription drugs that are also covered by ADAP qualify for prescription cost-sharing assistance through the Texas HIV Medication Program (THMP). For information on eligibility criteria, covered drugs, or how to enroll in the program, please call 1-800-255-1090.

SECTION 7 Questions?

Section 7.1 – Getting Help from Care N’ Care Choice Premium (PPO)

Questions? We’re here to help. Please call your Healthcare Concierge at 1-877-374-7993. (TTY only, call 711.) We are available for phone calls October 1 - March 31, 8AM – 8PM Central, 7 days a week; April 1 - September 30, 8AM – 8PM Central, Monday through Friday.

Read your 2020 Evidence of Coverage (it has details about next year's benefits and costs)

This Annual Notice of Changes gives you a summary of changes in your benefits and costs for 2020. For details, look in the 2020 Evidence of Coverage for Care N’ Care Choice Premium (PPO). The Evidence of Coverage is the legal, detailed description of your plan benefits. It explains your rights and the rules you need to follow to get covered services and prescription drugs. A copy of the Evidence of Coverage is located on our website at https://www.cnchealthplan.com/search. You may also call your Healthcare Concierge to ask us to mail you a copy of the Evidence of Coverage.

Visit our Website

You can also visit our website at https://www.cnchealthplan.com. As a reminder, our website has the most up- to-date information about our provider network (Provider Directory) and our list of covered drugs (Formulary/Drug List).

https://www.cnchealthplan.com/search



Section 6.2 – Getting Help from Medicare

To get information directly from Medicare:

Call 1-800-MEDICARE (1-800-633-4227)

You can call 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1- 877-486-2048.

Visit the Medicare Website

You can visit the Medicare website (https://www.medicare.gov). It has information about cost, coverage, and quality ratings to help you compare Medicare health plans. You can find information about plans available in your area by using the Medicare Plan Finder on the Medicare website. (To view the information about plans, go to https://www.medicare.gov and click on “Find health & drug plans.”)

Read Medicare & You 2020

You can read Medicare & You 2020 Handbook. Every year in the fall, this booklet is mailed to people with Medicare. It has a summary of Medicare benefits, rights and protections, and answers to the most frequently asked questions about Medicare. If you don’t have a copy of this booklet, you can get it at the Medicare website (https://www.medicare.gov) or 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.




2020

Comprehensive Formulary (List of Covered Drugs)

If your plan includes prescription drug coverage and you have a question about covered drugs, please call your Healthcare Concierge at 1-877-374-7993 (TTY 711), October 1 - March 31, 8am - 8pm, CST, seven days a week or April 1 - September 30, 8am - 8pm Monday through Friday, CST, or visit www.cnchealthplan. com/2020- medication-look-up/ to access our on-line formulary.

The 2020 Comprehensive Formulary will be available October 15, 2019. If you would like a copy mailed to you, you may call your Healthcare Concierge at the number above, request one online at www.cnchealthplan. com/ members/ or email your Healthcare Concierge at [email protected] to request an electronic or hard copy.

Provider/Pharmacy Directory

Notice of How to Find or Request your Care N’ Care HMO or PPO:

If you need help finding a network provider, please call your Healthcare Concierge at 1-877-374-7993 (TTY 711), October 1 - March 31, 8am - 8pm, CST, seven days a week or April 1 - September 30, 8am - 8pm, CST, Monday through Friday, or visit www.cnchealthplan.com/search to access our online searchable Provider/ Pharmacy Directory.

The 2020 Provider/Pharmacy Directory will be available October 15, 2019. If you would like a copy mailed to you, you may call your Healthcare Concierge at the number above, request one online at www.cnchealthplan. com/members, or email your Healthcare Concierge at [email protected] to request an electronic or hard copy.

Evidence of Coverage

If you have a question about what is covered by the plan, please call your Healthcare Concierge at 1-877-374-7993 (TTY 711), October 1 - March 31, 8am - 8pm, CST, seven days a week or April 1 - September 30, 8am - 8pm Monday through Friday, CST, or visit www.cnchealthplan.com/2020-plan-documents/ to access the online Evidence of Coverage.

The 2020 Evidence of Coverage will be available October 15, 2019. If you would like a copy mailed to you, you may call your Healthcare Concierge at the number above, request one online at www.cnchealthplan. com/ members/ or email your Healthcare Concierge at [email protected] to request an electronic copy or hard copy.

Care N’ Care Insurance is an HMO and PPO plan with a Medicare contract. Enrollment in Care N’ Care depends on contract renewal. Y0107_20_006_C

http://thplan.com/2020-medication-look-up/

http://www.cnchealthplan.com/members/

mailto:[email protected]

http://www.cnchealthplan.com/search

http://www.cnchealthplan.com/members


http://www.cnchealthplan.com/2020-plan-documents/




http://www.cnchealthplan.com/members


http://thplan.com/2020-medication-look-up/

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