Summary Of Benefits
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User Manual: SummaryOfBenefits
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SECTION I INTRODUCTION TO SUMMARY OF BENEFITS GuildNet Health Advantage (HMO-POS SNP) January 1,2013 - December 31,2013 Bronx, Kings, New York, Queens, Nassau, Suffolk Thank you for your interest in GuildNet Health Advantage (HMO-POS SNP). Our plan is offered by GUILDNET, INC.GuildNet, a Medicare Advantage Health Maintenance Organization (HMO) Special Needs Plan (SNP), with a point-of-service option (POS) that contracts with the Federal government. This plan is designed for people who meet specific enrollment criteria. You may be eligible to join this plan if you receive assistance from the state and Medicare. All cost sharing in this summary of benefits is based on your level of Medicaid eligibility. Please call GuildNet Health Advantage (HMO-POS SNP) to find out if you are eligible to join. Our number is listed at the end of this introduction. This Summary of Benefits tells you some features of our plan. It doesn’t list every service we cover or list every limitation or exclusion. To get a complete list of our benefits, please call GuildNet Health Advantage (HMO-POS SNP) and ask for the Evidence of Coverage. YOU HAVE CHOICES IN YOUR HEALTH CARE As a Medicare beneficiary, you can choose from different Medicare options. One option is the Original (fee-for-service) Medicare Plan. Another option is a Medicare health plan, like GuildNet Health Advantage (HMO-POS SNP). You may have other options too. You make the choice. No matter what you decide, you are still in the Medicare Program. If you are eligible for both Medicare and Medicaid (dual eligible) you may join or leave a plan at any time. Please call GuildNet Health Advantage (HMO-POS SNP) at the number listed at the end of this introduction or 1-800-MEDICARE (1-800-633-4227) for more information. TTY/TDD users should call 1-877-486-2048. You can call this number 24 hours a day, 7 days a week. HOW CAN I COMPARE MY OPTIONS? You can compare GuildNet Health Advantage (HMO-POS SNP) and the Original Medicare Plan using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can see what our plan covers and what the Original Medicare Plan covers. Our members receive all of the benefits that the Original Medicare Plan offers. We also offer more benefits, which may change from year to year. 1 WHERE IS GuildNet Health Advantage (HMO-POS SNP) AVAILABLE? The service area for this plan includes: Bronx, Kings, Nassau, New York, Queens, Suffolk Counties, NY. You must live in one of these areas to join the plan. WHO IS ELIGIBLE TO JOIN GuildNet Health Advantage (HMO-POS SNP)? You can join GuildNet Health Advantage (HMO-POS SNP) if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, individuals with End-Stage Renal Disease generally are not eligible to enroll in GuildNet Health Advantage (HMO-POS SNP) unless they are members of our organization and have been since their dialysis began. You must also receive assistance from the state to join this plan. Please call the plan to see if you are eligible to join. CAN I CHOOSE MY DOCTORS? GuildNet Health Advantage (HMO-POS SNP) has formed a network of doctors, specialists, and hospitals. You can use any doctor who is part of our network. In some cases, you may also go to doctors outside of our network. The health providers in our network can change at any time. You can ask for a current provider directory. For an updated list, visit us at www.guildnetny.org. Our customer service number is listed at the end of this introduction. WHAT HAPPENS IF I GO TO A DOCTOR WHO’S NOT IN YOUR NETWORK? Generally, you are restricted to a doctor who is part of your network. However, we will cover your care from any provider for emergency or urgently needed care. Also, our point of service benefit allows you to get care from providers not in your network under certain conditions. For more information, please call the customer service number listed at the end of this introduction. WHERE CAN I GET MY PRESCRIPTIONS IF I JOIN THIS PLAN? 2 GuildNet Health Advantage (HMO-POS SNP) has formed a network of pharmacies. You must use a network pharmacy to receive plan benefits. We may not pay for your prescriptions if you use an out-of-network pharmacy, except in certain cases. The pharmacies in our network can change at any time. You can ask for a pharmacy directory or visit us at http://www.guildnetny.org. Our customer service number is listed at the end of this introduction. DOES MY PLAN COVER MEDICARE PART B OR PART D DRUGS? GuildNet Health Advantage (HMO-POS SNP) does cover both Medicare Part B prescription drugs and Medicare Part D prescription drugs. WHAT IS A PRESCRIPTION DRUG FORMULARY? GuildNet Health Advantage (HMO-POS SNP) uses a formulary. A formulary is a list of drugs covered by your plan to meet patient needs. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary change that limits our members’ ability to fill their prescriptions, we will notify the affected members before the change is made. We will send a formulary to you and you can see our complete formulary on our Web site at http://www.guildnetny.org. If you are currently taking a drug that is not on our formulary or subject to additional requirements or limits, you may be able to get a temporary supply of the drug. You can contact us to request an exception or switch to an alternative drug listed on our formulary with your physician’s help. Call us to see if you can get a temporary supply of the drug or for more details about our drug transition policy. HOW CAN I GET EXTRA HELP WITH MY PRESCRIPTION DRUG PLAN COSTS OR GET EXTRA HELP WITH OTHER MEDICARE COSTS? You may be able to get extra help to pay for your prescription drug premiums and costs as well as get help with other Medicare costs. To see if you qualify for getting extra help, call: 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7 days a week and see www.medicare.gov ‘Programs for People with Limited Income and Resources’ in the publication Medicare You. The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY/TDD users should call 1-800-325-0778 or Your State Medicaid Office. WHAT ARE MY PROTECTIONS IN THIS PLAN? All Medicare Advantage Plans agree to stay in the program for a full calendar year at a time. Plan benefits and cost-sharing may change from calendar year to calendar year. Each year, plans can decide whether to continue to participate with Medicare Advantage. A plan may continue in their entire service area (geographic area where the plan accepts members) or choose to continue only in certain areas. Also, Medicare may decide to end a contract with a plan. Even if your Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue for an additional calendar year, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area. As a member of GuildNet Health Advantage (HMO-POS SNP), you have the right to request an organization determination, which includes the right to file an appeal if we deny coverage for an item or service, and the right to file a grievance. You have the right to request an organization determination if you want us to provide or pay for an item or service that you believe should be covered. If we deny coverage for your requested item or service, you have the right to appeal and ask us to review our decision. You may ask us for an expedited (fast) coverage determination or 3 appeal if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision. Finally, you have the right to file a grievance with us if you have any type of problem with us or one of our network providers that does not involve coverage for an item or service. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information. As a member of GuildNet Health Advantage (HMO-POS SNP), you have the right to request a coverage determination, which includes the right to request an exception, the right to file an appeal if we deny coverage for a prescription drug, and the right to file a grievance. You have the right to request a coverage determination if you want us to cover a Part D drug that you believe should be covered. An exception is a type of coverage determination. You may ask us for an exception if you believe you need a drug that is not on our list of covered drugs or believe you should get a non-preferred drug at a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such as a limit on the quantity of a drug. If you think you need an exception, you should contact us before you try to fill your prescription at a pharmacy. Your doctor must provide a statement to support your exception request. If we deny coverage for your prescription drug(s), you have the right to appeal and ask us to review our decision. Finally, you have the right to file a grievance if you have any type of problem with us or one of our network pharmacies that does not involve coverage for a prescription drug. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information. WHAT IS A MEDICATION THERAPY MANAGEMENT (MTM) PROGRAM? A Medication Therapy Management (MTM) Program is a free service we offer. You may be invited to participate in a program designed for your specific health and pharmacy needs. You may decide not to participate but it is recommended that you take full advantage of this covered service if you are selected. Contact GuildNet Health Advantage (HMO-POS SNP) for more details. WHAT TYPES OF DRUGS MAY BE COVERED UNDER MEDICARE PART B? 4 Some outpatient prescription drugs may be covered under Medicare Part B. These may include, but are not limited to, the following types of drugs. Contact GuildNet Health Advantage (HMO-POS SNP) for more details. -- Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision. -- Osteoporosis Drugs: Injectable osteoporosis drugs for some women. -- Erythropoietin (Epoetin Alfa or Epogen®): By injection if you have end-stage renal disease (permanent kidney failure requiring either dialysis or transplantation) and need this drug to treat anemia. -- Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia. -- Injectable Drugs: Most injectable drugs administered incident to a physician’s service. -- Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the transplant took place in a Medicare-certified facility and was paid for by Medicare or by a private insurance company that was the primary payer for Medicare Part A coverage. -- Some Oral Cancer Drugs: If the same drug is available in injectable form. -- Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen. -- Inhalation and Infusion Drugs administered through Durable Medical Equipment. WHERE CAN I FIND INFORMATION ON PLAN RATINGS? The Medicare program rates how well plans perform in different categories (for example, detecting and preventing illness, ratings from patients and customer service). If you have access to the web, you may use the web tools on www.medicare.gov and select Health and Drug Plans then Compare Drug and Health Plans to compare the plan ratings for Medicare plans in your area. You can also call us directly to obtain a copy of the plan ratings for this plan. Our customer service number is listed below. Please call GuildNet for more information about GuildNet Health Advantage (HMO-POS SNP). Visit us at www.guildnetny.org or, call us: Customer Service Hours for October 1 – February 14: Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 8:00 p.m. Eastern Customer Service Hours for February 15 – September 30: Monday, Tuesday, Wednesday, Thursday, Friday, 8:00 a.m. - 8:00 p.m. Eastern Current and Prospective members should call toll-free (800)-815-0000 for questions related to the Medicare Advantage Program. (TTY/TDD (800)-662-1220) Current members should call toll-free (877)-444-3973 for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD (866)-248-0640) Prospective members should call toll-free (800)-815-0000 for questions related to the Medicare Part D Prescription Drug program. (TTY/TDD (800)-662-1220) For more information about Medicare, please call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 days a week. Or, visit www.medicare.gov on the web. This document may be available in other formats such as Braille, large print or other alternate formats. This document may be available in a non-English language. For additional information, call customer service at the phone number listed above. Esta información esta disponible en otros idiomas. Por favor llame a Servicios a los Clientes, al 1-800-815-0000 por información adicional. If you have any questions about this plan’s benefits or costs, please contact GuildNet for details. 5 SECTION II SUMMARY OF BENEFITS Benefit Original Medicare GuildNet Health Advantage (HMO-POS SNP) IMPORTANT INFORMATION 1 - Premium and Other Important Information 2 - Doctor and Hospital Choice (For more information, see Emergency Care - #15 and Urgently Needed Care - #16.) 6 The Medicare cost sharing amount may vary based General on your level of Medicaid eligibility. * Depending on your level of Medicaid eligibility, you may not have any cost-sharing responsibility for original Medicare services $0 monthly plan premium in addition to your monthly In 2012 the monthly Part B Premium was $0 or $99.90 and may change for 2013 and the annual Medicare Part B premium.* Part B deductible amount was $0 or $140 and may change for 2013.* In-Network $3,400 out-of-pocket limit. All plan services included.* If a doctor or supplier does not accept assignment, In and Out-of-Network their costs are often higher, which means you pay $3,400 out-of-pocket limit. All plan services included.* more. You may go to any doctor, specialist or hospital In-Network that accepts Medicare. No referral required for network doctors, specialists, and hospitals. Benefit Original Medicare GuildNet Health Advantage (HMO-POS SNP) INPATIENT CARE 3 - Inpatient Hospital Care In 2012 the amounts for each benefit period were $0 or: Days 1 - 60: $1156 deductible* Days 61 - 90: $289 per day* Days 91 - 150: $578 per lifetime reserve day* (includes Substance Abuse and Rehabilitation Services) 4 - Inpatient Mental Health Care In-Network You are covered up to 365 days per year (366 in a leap year). $0 copay Call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days. Lifetime reserve days can only be used once. A “benefit period” starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. In 2012 the amounts for each benefit period were $0 or: Days 1 - 60: $1156 deductible* Days 61 - 90: $289 per day* Days 91 - 150: $578 per lifetime reserve day* You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. In-Network You are covered up to 365 days per year (366 in a leap year). $0 copay Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. 7 Benefit Original Medicare GuildNet Health Advantage (HMO-POS SNP) 5 - Skilled Nursing Facility (SNF) In 2012 the amounts for each benefit period after at least a 3-day covered hospital stay were: Days 1 - 20: $0 per day* Days 21 - 100: $0 or $144.50 per day* General Authorization rules may apply. (in a Medicare-certified skilled nursing facility) In-Network Plan covers up to 100 days each benefit period No prior hospital stay is required. $0 copay of the cost for each Medicare-covered SNF stay.* 6 - Home Health Care (includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.) 7 - Hospice 100 days for each benefit period. A “benefit period” starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have. $0 copay. You pay part of the cost for outpatient drugs and you may pay part of the cost for inpatient respite care. General Authorization rules may apply. In-Network $0 copay for Medicare-covered home health visits* General You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice. You must get care from a Medicare-certified hospice. OUTPATIENT CARE 8 - Doctor Office Visits 8 0% or 20% coinsurance In-Network $0 copay of the cost for each Medicare-covered primary care doctor visit.* 0% of the cost for each Medicare-covered specialist visit.* Benefit Original Medicare GuildNet Health Advantage (HMO-POS SNP) 9 - Chiropractic Services 10 - Podiatry Services 11 - Outpatient Mental Health Care Supplemental routine care not covered General Authorization rules may apply. 0% or 20% coinsurance for manual manipulation In-Network of the spine to correct subluxation (a displacement $0 copay of the cost for each Medicare-covered or misalignment of a joint or body part) if you get it chiropractic visit* from a chiropractor or other qualified providers. Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor. Supplemental routine care not covered. In-Network $0 copay of the cost for each Medicare-covered podiatry visit* 0% or 20% coinsurance for medically necessary Medicare-covered podiatry visits are for medicallyfoot care, including care for medical conditions necessary foot care. affecting the lower limbs. 0% or 35% coinsurance for most outpatient mental General health services Authorization rules may apply. 0% or 35% coinsurance of the Medicare-approved In-Network $0 copay of the cost for each Medicare-covered individual amount for each service you get from a qualified therapy visit* professional as part of a Partial Hospitalization Program. $0 copay of the cost for each Medicare-covered group “Partial hospitalization program” is a structured program of active outpatient psychiatric treatment therapy visit* that is more intense than the care received in your doctor’s or therapist’s office and is an alternative to inpatient hospitalization. $0 copay of the cost for each Medicare-covered individual therapy visit with a psychiatrist* $0 copay of the cost for each Medicare-covered group therapy visit with a psychiatrist* $0 copay of the cost for Medicare-covered partial hospitalization program services* 9 Benefit Original Medicare GuildNet Health Advantage (HMO-POS SNP) 12 - Outpatient Substance Abuse Care 0% or 20% coinsurance General Authorization rules may apply. In-Network $0 copay of the cost for Medicare-covered individual substance abuse outpatient treatment visits* 0% of the cost for Medicare-covered group substance abuse outpatient treatment visits* 13 - Outpatient Services 0% or 20% coinsurance for the doctor’s services General Authorization rules may apply. Specified copayment for outpatient hospital facility In-Network services Copay cannot exceed the Part A inpatient $0 copay of the cost for each Medicare-covered ambulatory surgical center visit* hospital deductible. 0% or 20% coinsurance for ambulatory surgical $0 copay of the cost for each Medicare-covered outpatient center facility services hospital facility visit* 14 - Ambulance Services 0% or 20% coinsurance General Authorization rules may apply. (medically necessary In-Network ambulance services) $0 copay of the cost for Medicare-covered ambulance benefits.* If you are admitted to the hospital, you pay $0 for Medicare-covered ambulance benefits. 0% or 20% coinsurance for the doctor’s services General 15 - Emergency Care $0 copay of the cost for Medicare-covered emergency (You may go to any emergency room visits* room if you reasonably believe you need emergency care.) Specified copayment for outpatient hospital facility Worldwide coverage. emergency services. If you are admitted to the hospital within 24-hour(s) for Emergency services copay cannot exceed Part A inpatient hospital deductible for each service the same condition, you pay $0 for the emergency room provided by the hospital. visit. You don’t have to pay the emergency room copay if you are admitted to the hospital as an inpatient for the same condition within 3 days of the emergency room visit. Not covered outside the U.S. except under limited 10 circumstances. Benefit Original Medicare GuildNet Health Advantage (HMO-POS SNP) 16 - Urgently Needed Care 0% or 20% coinsurance (This is NOT emergency care, NOT covered outside the U.S. except under limited and in most cases, is out of the circumstances. service area.) 17 - Outpatient Rehabilitation 0% or 20% coinsurance Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy) OUTPATIENT MEDICAL SERVICES AND SUPPLIES 18 - Durable Medical 0% or 20% coinsurance Equipment (includes wheelchairs, oxygen, etc.) 19 - Prosthetic Devices 0% or 20% coinsurance (includes braces, artificial limbs and eyes, etc.) 20 - Diabetes Programs and Supplies 0% or 20% coinsurance for diabetes self-management training 0% or 20% coinsurance for diabetes supplies 21 - Diagnostic Tests, X-Rays, Lab Services, and Radiology Services 0% or 20% coinsurance for diabetic therapeutic shoes or inserts 0% or 20% coinsurance for diagnostic tests and x-rays General $0 copay of the cost for Medicare-covered urgently-needed-care visits* If you are admitted to the hospital within 24-hour(s) for the same condition, you pay $0 for the urgently-neededcare visit. General Authorization rules may apply. In-Network $0 copay of the cost for Medicare-covered Occupational Therapy visits* 0% of the cost for Medicare-covered Physical Therapy and/ or Speech and Language Pathology visits* General Authorization rules may apply. In-Network $0 copay of the cost for Medicare-covered durable medical equipment* General Authorization rules may apply. In-Network $0 copay of the cost for Medicare-covered prosthetic devices* In-Network $0 copay for Medicare-covered Diabetes self-management training* $0 copay of the cost for Medicare-covered Diabetes monitoring supplies* $0 copay of the cost for Medicare-covered Therapeutic shoes or inserts* General Authorization rules may apply. 11 Benefit Original Medicare GuildNet Health Advantage (HMO-POS SNP) $0 copay for Medicare-covered lab services Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most supplemental routine screening tests, like checking your cholesterol. 22 - Cardiac and Pulmonary Rehabilitation Services 0% or 20% coinsurance for Cardiac Rehabilitation services In-Network $0 copay of the cost for Medicare-covered lab services* $0 copay of the cost for Medicare-covered diagnostic procedures and tests* $0 copay of the cost for Medicare-covered X-rays* $0 copay of the cost for Medicare-covered diagnostic radiology services (not including X-rays)* $0 copay of the cost for Medicare-covered therapeutic radiology services* General Authorization rules may apply. 0% or 20% coinsurance for Pulmonary Rehabilitation services 0% or 20% coinsurance for Intensive Cardiac Rehabilitation services This applies to program services provided in a doctor’s office. Specified cost sharing for program services provided by hospital outpatient departments. In-Network $0 copay of the cost for Medicare-covered Cardiac Rehabilitation Services* $0 copay of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services* $0 copay of the cost for Medicare-covered Pulmonary Rehabilitation Services* 12 Benefit Original Medicare GuildNet Health Advantage (HMO-POS SNP) PREVENTIVE SERVICES, WELLNESS/EDUCATION AND OTHER SUPPLEMENTAL BENEFIT PROGRAMS 23 -Preventive Services, No coinsurance, copayment or deductible for the General $0 copay for all preventive services covered under Original Wellness/Education and other following: Medicare at zero cost sharing. Supplemental Benefit Any additional preventive services approved by Medicare Programs mid-year will be covered by the plan or by Original Medicare. In-Network The plan covers the following supplemental education/ wellness programs: - Health Education -Nutritional Education - Additional Smoking and Tobacco Use Cessation Visits 24 - Kidney Disease and 0% or 20% coinsurance for renal dialysis In-Network Conditions $0 copay of the cost for Medicare-covered renal dialysis* 0% or 20% coinsurance for kidney disease $0 copay for Medicare-covered kidney disease education education services services* PRESCRIPTION DRUG BENEFITS Drugs covered under Medicare Part B 25 - Outpatient Prescription Most drugs are not covered under Original Drugs Medicare. You can add prescription drug coverage General $0 yearly deductible for Medicare Part B drugs.* to Original Medicare by joining a Medicare Prescription Drug Plan, or you can get all your Medicare coverage, including prescription drug coverage, by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage. $0 copay of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.* Drugs covered under Medicare Part D General This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www. guildnetny.org on the web. 13 Benefit Original Medicare GuildNet Health Advantage (HMO-POS SNP) Different out-of-pocket costs may apply for people who -have limited incomes, -live in long term care facilities, or -have access to Indian/Tribal/Urban (Indian Health Service) providers. The plan offers national in-network prescription coverage (i.e., this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan’s service area (for instance when you travel). Total yearly drug costs are the total drug costs paid by you, the plan, and Medicare. The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. Some drugs have quantity limits. Your provider must get prior authorization from GuildNet Health Advantage (HMO-POS SNP) for certain drugs. You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan’s website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount. In-Network You pay a $0 annual deductible. 14 Benefit Original Medicare GuildNet Health Advantage (HMO-POS SNP) Initial Coverage Depending on your income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either: - A $0 copay or - A $1.15 copay or - A $2.65 copay For all other drugs, either: - A $0 copay or - A $3.50 copay or - A $6.60 copay. Retail Pharmacy You can get drugs the following way(s): - one-month (30-day) supply - three-month (90-day) supply Not all drugs are available at this extended day supply. Please contact the plan for more information. Long Term Care Pharmacy You can get drugs the following way(s): - one-month (31-day) supply of generic drugs - 31-day supply of brand drugs. Please note that brand drugs must be dispensed incrementally in long-term care facilities. Generic drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/collection when less than a one-month supply is dispensed. Mail Order You can get drugs the following way(s): - three-month (90-day) supply 15 Benefit Original Medicare GuildNet Health Advantage (HMO-POS SNP) Not all drugs are available at this extended day supply. Please contact the plan for more information. Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,750, you pay a $0 copay. Out-of-Network Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan’s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy’s full charge for the drug and submit documentation to receive reimbursement from GuildNet Health Advantage (HMO-POS SNP). You can get out-of-network drugs the following way: - one-month (30-day) supply Out-of-Network Initial Coverage Depending on your income and institutional status, you will be reimbursed by GuildNet Health Advantage (HMO-POS SNP) up to the plan’s cost of the drug minus the following: For generic drugs purchased out-of-network (including brand drugs treated as generic), either: - A $0 copay or - A $1.15 copay or - A $2.65 copay For all other drugs purchased out-of-network, either: - A $0 copay or - A $3.50 copay or - A $6.60 copay. 16 Benefit Original Medicare GuildNet Health Advantage (HMO-POS SNP) Out-of-Network Catastrophic Coverage After your yearly out-of-pocket drug costs reach $4,750, you will be reimbursed in full for drugs purchased out-of-network. OUTPATIENT MEDICAL SERVICES AND SUPPLIES 26 - Dental Services Preventive dental services (such as cleaning) not covered. 27 - Hearing Services 28 - Vision Services Over-the-Counter Items Transportation (Routine) Supplemental routine hearing exams and hearing aids not covered. 0% or 20% coinsurance for diagnostic hearing exams. 0% or 20% coinsurance for diagnosis and treatment of diseases and conditions of the eye. In-Network In general, preventive dental benefits (such as cleaning) not covered. $0 copay of the cost for Medicare-covered dental benefits* In-Network In general, supplemental routine hearing exams and hearing aids not covered. $0 copay of the cost for Medicare-covered diagnostic hearing exams* In-Network $0 copay for up to 1 supplemental routine eye exam(s) every year - up to 1 pair(s) of glasses every year Supplemental routine eye exams and glasses not covered. Medicare pays for one pair of eyeglasses or contact - contacts lenses after cataract surgery. Annual glaucoma screenings covered for people at - $0 copay of the cost for one pair of Medicare-covered risk. eyeglasses or contact lenses after cataract surgery.* - $0 copay of the cost for Medicare-covered exams to diagnose and treat diseases and conditions of the eye.* $200 plan coverage limit for eye glasses (lenses and frames) every year. Not covered. General The plan does not cover Over-the-Counter items. Not covered. In-Network Please see Medicaid section of this Summary of Benefits, 17 Benefit Original Medicare CuildNet Health Advantage (HMO-POS SNP) Acupuncture Point of Service Not covered. In-Network This plan does not cover Acupuncture. Out-of-Network Point of Service coverage is available for the following benefits: Medicare-covered - Inpatient Hospital Acute - Inpatient Hospital Psychiatric - Skilled Nursing Facility (SNF) - Cardiac Rehabilitation Services - Partial Hospitalization - Home Health Services - Primary Care Physician Services - Chiropractic Services - Occupational Therapy Services - Physician Specialist Services - Mental Health Specialty Services - Podiatry Services - Other Health Care Professional - Psychiatric Services - Physical Therapy and Speech-Language Pathology Services - Outpatient Diagnostic Procedures/Tests/Lab Services - Diagnostic Radiological Services - Therapeutic Radiological Services - Outpatient X-Rays - Outpatient Hospital Services - Ambulatory Surgical Center (ASC) Services - Outpatient Substance Abuse - Outpatient Blood Services - Durable Medical Equipment (DME) - Prosthetics/Medical Supplies - Diabetic Supplies and Services - Medicare-covered Preventive Services - Kidney Disease Education Services - Diabetes Self-Management Training - Comprehensive Dental 18 Benefit Original Medicare CuildNet Health Advantage (HMO-POS SNP) $0 copay of the cost for Medicare-covered - Cardiac Rehabilitation Services - Partial Hospitalization - Primary Care Physician Services - Chiropractic Services - Occupational Therapy Services - Physician Specialist Services - Mental Health Specialty Services - Podiatry Services - Other Health Care Professional - Psychiatric Services - Physical Therapy and Speech-Language Pathology Services - Outpatient Diagnostic Procedures/Tests/Lab Services - Diagnostic Radiological Services - Therapeutic Radiological Services - Outpatient X-Rays - Outpatient Hospital Services - Ambulatory Surgical Center (ASC) Services - Outpatient Substance Abuse - Outpatient Blood Services - Durable Medical Equipment (DME) - Prosthetics/Medical Supplies - Diabetic Supplies and Services - Kidney Disease Education Services - Diabetes Self-Management Training - Comprehensive Dental -$0 copay for Medicare-covered - Home Health Services - Medicare-covered Preventive Services 19 MEDICAID BENEFITS This Section compares the benefits you get from NY Medicaid to the benefits you get from the plan. Benefit Transportation (Routine) Dental Services Medicaid $0 copay for Medicaid-covered services. $0 copay for Medicaid-covered services. GuildNet Health Advantage (HMO-POS SNP) $0 copay for In-Network Transportation essential to obtain necessary medical care and services. Includes ambulette, invalid coach, taxicab, livery, public transportation, or other appropriate means. Not covered in Nassau and Suffolk. You can use your Medicaid card and get these services from Medicaid providers. $0 copay for In-Network necessary preventive, prophylactic and other routine dental care, services and supplies, dental prosthetics to alleviate a serious health condition, and ambulatory or inpatient surgical dental services. Not covered in Nassau and Suffolk. You can use your Medicaid card and get these services from Medicaid providers. Private Duty Nursing $0 copay for Medicaid-covered services. $0 copay for In-Network medically necessary private duty nursing services provided by a registered physician assistant or certified nurse when required by the written treatment plan. The following services are covered under Medicaid fee for service using your New York State issued Medicaid. GuildNet can help you coordinate these services. Nutrition 20 $0 copay for Medicaid-covered services. Not covered. You can use your Medicaid card and get these services from Medicaid providers. Benefit Personal Care Services Certain Mental Health Services Rehabilitation Services Provided to Residents of OMH Licensed Community Residences (CRs) and Family Based Treatment Programs Office for People With Developmental Disabilities (OPWDD) Services Home and Community Based Services (HCBS) Waiver Program Medicaid GuildNet Health Advantage (HMO-POS SNP) $0 copay for Medicaid covered services.Includes some or total assistance woth personal hygiene, dressing and feeding and nutritional and environmeal support(meaql preparation and housekeeping). Services must be ordered by a physician with evidence of medical necessity.Services rendered by Licensed home care service agencies are approved.Services ordered by approved personal care agencies are not approved $0 copay for Medicaid covered services.Including Intensive Psychiatric Rehabilitation Treatment Programs (IPRT),Day Treatment,Continuing Day Treatment,Case Management for Seriously and Persistently Mentally Ill (Sponsored by State or Local Mental Health Units),Partial Hospitalization Not Covered by Medicare,Assertive Community Treatment (ACT),Personalized Recovery Oriented Services (PROS) $0 copay for Medicaid covered services.Including Office of Mental Health (OMH) Licensed CR's and Family-Based Treatment $0 copay for Medicaid covered services.Including services provided for Long Term Therapy Services; Day treatment Medicaid Service Coordination $0 copay for Medicaid covered services.Includes the Long Term Home Health Care Program; Traumatic Brain Injury (TBI) Program; the ICF/MR Waiver, as well as Medicaid Care at Home HCBS Programs and OPWDD Care at Home Programs. Comprehensive Medicaid Case $0 copay for Medicaid covered services. Includes Management (CMCM) social work referral services to targeted population (teens, mentally ill) Not covered by the plan. Please use your New York State Medicaid issued card to obtain services Not covered by the plan. Please use your New York State Medicaid issued card to obtain services Not covered by the plan. Please use your New York State Medicaid issued card to obtain services Not covered by the plan. Please use your New York State Medicaid issued card to obtain services Not covered by the plan. Please use your New York State Medicaid issued card to obtain services Not covered by the plan. Please use your New York State Medicaid issued card to obtain services 21 Benefit Directly Observed Therapy for Tuberculosis Disease AIDS Adult Day Health Care HIV COBRA Case Management Methadone Maintenance Treatment Programs Skilled Nursing Facility Personal Emergency Response Services (PERS) Hearing Services Vision Services 22 Medicaid GuildNet Health Advantage (HMO-POS SNP) $0 copay for Medicaid covered services. Includes observation of oral ingestion of TB medications to assure patient compliance with the physician's prescribed medication regimen $0 copay for Medicaid covered services. Includes providing assistance to people with HIV disease to live more independently in the community or eliminate the need to residential health care services $0 copay for Medicaid covered services.Includes family-centered case management and community follow-up activities by case managers, case management technicians, and community follow-up workers. $0 copay for Medicaid covered services. Includes drug detoxification, drug dependence counceling and rehabilitation services. $0 copay for Medicaid covered services.Covers services in excess of Medicare first 100 days of the benefit period $0 copay for Medicaid covered services. $0 copay for Medicaid-covered services. $0 copay for Medicaid-covered services. Not covered by the plan. Please use your New York State Medicaid issued card to obtain services( Not covered by the plan. Please use your New York State Medicaid issued card to obtain services Not covered by the plan. Please use your New York State Medicaid issued card to obtain services Not covered by the plan. Please use your New York State Medicaid issued card to obtain services Not covered by the plan. Please use your New York State Medicaid issued card to obtain services Not covered by the plan. Please use your New York State Medicaid issued card to obtain services See Section 27 for more information. See Section 28 for more information. 23
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