Fresenius Total Health (PPO SNP) - Fresenius … · All of Your Coverage under one roof Fresenius...
Transcript of Fresenius Total Health (PPO SNP) - Fresenius … · All of Your Coverage under one roof Fresenius...
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H9312_002_FSB17 Additional SA/LIS Submission 11/16/2016
2017California
Medicare Designed bythe Dialysis Experts
Fresenius Total Health (PPO SNP)
This is a summary of drug and health services covered for residents of San Diego County, CA.
January 1, 2017 - December 31, 2017
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All of Your Coverageunder one roof
Fresenius Health Plans
If dialysis is a part of your life, you know the many challenges that can come along with it. Getting the healthcare you need shouldnt be one of them. Thats why Fresenius Health Plans created a new Medicare Advantage plan just for people on dialysis. Fresenius Total Health makes it easier to get the care you need by providing all of your healthcare coverage under one roof. It combines three types of Medicare coverage into one plan - Part A (hospital), Part B (doctors), and Part D (drugs). Plus, it gives you bonus benefits that Original Medicare doesnt, like vision and dental care. And since Fresenius Total Health is from the same people you know and trust as the experts in kidney care, you can count on it for coverage tailored to your health needs like:
$0 Nephrologist office visits $0 Renal Vitamins and 24/7 access to specialized dialysis
nurses & service coordinators!
Do I Qualify?In order to join Fresenius Health Plans you must: Have End Stage Renal Disease requiring dialysis Have both Medicare Part A and B Live in San Diego County Be a U.S. citizen or lawfully present in the country
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Benefits What Fresenius Total Health Covers
Premiums andBenefits
What youshould know
Coverage Details Premiums and Benefits What youshould know Coverage Details
Monthly Plan Premium You pay $17.80 You must continue to pay your Medicare Part B premium.
Deductible The deductible is $183 per year for outpatient services Applies to services you get in-network or out-of-network.
Maximum Out-of-Pocket $6,700 per year for in-network services The most you pay for Responsibility (does not copays, coinsurance and include prescription drugs) $10,000 per year for out-of-network services other costs for medical
services for the year.
Inpatient Hospital In-network: Authorization is required. Coverage $1,316 deductible for days 1 through 60 Our plan also covers 60
$329 copay per day for days 61 through 90 lifetime reserve days. $658 copay per day for 60 lifetime reserve days If your hospital stay is
Out-of-network: 30% of the cost per stay longer than 90 days you can use these extra days.
Doctor Visits You do not need a Primary In-network you pay $0 referral to see an
Out-of-network you pay 30% in-network specialist. Specialists In-network you pay 0-20% depending on the service
Out-of-network you pay 30%
Nephrologist Office Visit In-network you pay $0 Out-of-network you pay 30%
Preventive Care In-network you pay $0 Out-of-network you pay 30%
Any additional preventive services approved by Medicare during the contract year will be covered.
Emergency Care You pay 20% of the cost up to $75 If you are admitted to the hospital within 24 hours, you do not have to pay your share of the cost for emergency care.
Urgently Needed Services You pay 20% of the cost up to $65
Diagnostic Services/Labs/ Imaging Diagnostic radiology
service (e.g., MRI) Lab services Diagnostic tests and
procedures Outpatient x-rays
In-network you pay 20% of the cost Out-of-network you pay 30% of the cost
Prior authorization & referral are required for some services. Please contact the plan for more information.
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Premiums and Benefits
What youshould know
Coverage Details
Hearing Exams In-network you pay 20% of the cost Out-of-network you pay 30% of the cost
Dental Services The plan covers up to Exam & Cleaning
(every 6 months) In-network you pay $0. Out-of-network you pay 50% of the cost.
$1,500 a year in dental services.
Comprehensive Dental In-network you pay $5. Out-of-network you pay 50% (e.g. fillings and dentures) of the cost.
Vision Services Exams (1 per year) Glasses or Contacts
(1 per year)
In-network you pay $0 towards exams and eyeglasses or contacts from the Davis Vision Collection. Out-of-network you pay 50% of the cost.
The plan covers up to $175 per year towards frames or contacts out-side of the Collection.
Mental Health Services In-network: The plan covers up to Inpatient visit $1,316 deductible for days 1 through 60
$329 copay per day for days 61 through 90 $658 copay per day for 60 lifetime reserve days
Out-of-network: 30% of the cost per stay
190 days in a lifetime for inpatient mental health care in a psychiatric hos-pital. Prior authorization
Outpatient therapy visit In-network you pay 20% of the cost is required. (group or individual) Out-of-network you pay 30% of the cost
Skilled Nursing Facility In-network: You pay nothing for days 1 through 20 $164.50 copay per day for days 21 through 100
Out-of-network: 30% of the cost per stay
Our plan covers up to 100 days in a SNF. Prior authorization is required.
Rehabilitation Services In-network you pay 20% of the cost Prior authorization is Occupational Out-of-network you pay 30% of the cost required.
therapy visit
Physical therapy and speech and language therapy visit
Ambulance In-network you pay 20% of the cost Out-of-network you pay 30% of the cost
May require prior authorization.
Transportation In-network you pay $0 for 30 one-way trips to covered medical appointments each year
Rides must be scheduled through Care Navigation.
Foot Care (podiatry In-network you pay 20% of the cost services) Foot exams and
treatment Routine foot care
Out-of-network you pay 30% of the cost
Medical Equipment/Supplies Durable Medical
Equipment (e.g., wheelchairs, oxygen)
Prosthetics (e.g., braces, artificial limbs)
In-network you pay 20% of the cost Out-of-network you pay 30% of the cost
Prior authorization is required.
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Benefits What Fresenius Total Health Covers Premiums andBenefits
What youshould know
Coverage Details Premiums and Benefits What youshould know Coverage Details
Diabetic Supplies In-network you pay $0Out-of-network you pay 30% of the cost
Health & Wellness Education Kidney Disease Diabetes
You pay $0 Prior authorization & referral may be required.
Medicare Part B Drugs In-network you pay 20% of the cost Out-of-network you pay 30% of the cost
Generally, drugs covered under Part B are ones you wouldnt give to yourself, like those you get at a doctors office or hospital outpatient setting.
Over-the-Counter Items (OTC)
Get $20 each month to spend on OTC items inlcuding bandages, cough drops and pain relievers.
A list of covered items is available at www.esrdplans.com
Renal Vitamins You pay $0 for OTC renal vitamins through Fresenius Rx. Receive up to four 90-day supplies of one renal vitamin per year.
Choose from an eligible list of nephrologist evaluated products.
Outpatient Prescription Drugs (Part D)
Part D Deductible: $400 After the deductible, cost sharing is:
Retail RX 30-day supply
Cost of Retail RX 30-day supply with Extra Help
Tier 1: Preferred Generic You pay $0 You pay $0 Tier 2: Generic You pay 25% $0, $1.20, $3.30
Tier 3: Preferred Brand You pay 25% $0, $3.70, $8.25 Tier 4: Non-Preferred Brand You pay 25% $0, $3.70, $8.25
Tier 5: Speciality Tier You pay 25% $0, $3.70, $8.25
What you should know
Cost-Sharing may change depending on the pharmacy you choose and when you enter another phase of the Part D benefit. For more information on the additional cost-sharing and the phases of the benefit, please call us or access our Evidence of Coverage (EOC) online.
Visit us online at www.esrdplans.com to find: The provider & pharmacy directories The Formulary (list of covered drugs) The EOC - a complete list of benefits
If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.
http://www.medicare.govhttp://www.esrdplans.com
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Multi-language Interpreter Services
Spanish: ATENCIN: si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. Llame al 1-855-598-6774 (TTY: 1-844-209-9094)
Chinese: . 1-855-598-6774 (TTY: 1-844-209-9094).
Vietnamese: CH : Nu b n ni Tin g Vi t , c cc d c h v h tr ngn ng min phdnh cho b n . Gi s 1-855-598-6774 (TTY: 1-844-209-9094). Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-598-6774 (TTY: 1-844-209-9094).
Korean: : , . 1-855-598-6774 (TTY: 1-844-209-9094) .
Armenian: , : 1-855-598-6774 (TTY () 1-844-209-9094):
Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sawika nang walang bayad. Tumawag sa 1-855-598-6774 (TTY: 1-844-209-9094).
Farsi: . :
1-855-598-6774 (TTY: 1-844-209-9094) . Russian: : , . 1-855-598-6774 (: 1-844-209-9094).
Japanese: .1-855-598-6774TTY:1-844-209-9094
Arabic: ( 6774-598-855-1 . :9094-209-844-1). :
Panjabi: : , 1-855-598-6774 (TTY: 1-844-209-9094) '
Thai: : 1-855-598-6774 (TTY: 1-844-209-9094).
Hmong: LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-855-598-6774 (TTY: 1-844-209-9094).
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Spanish: ATENCIN: si habla espaol, tiene a su disposicin servicios gratuitos de asistencia lingstica. Llame al 1-855-598-6774 (TTY: 1-844-209-9094)
Chinese: . 1-855-598-6774 (TTY: 1-844-209-9094).
Vietnamese: CH : Nu bn ni Tin g Vi t , c cc d c h v h tr ngn ng min ph dnh cho bn . Gi s 1-855-598-6774 (TTY: 1-844-209-9094).Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-598-6774 (TTY: 1-844-209-9094).
Korean: : , . 1-855-598-6774 (TTY: 1-844-209-9094) .
Armenian: , : 1-855-598-6774 (TTY () 1-844-209-9094):
Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sawika nang walang bayad. Tumawag sa 1-855-598-6774 (TTY: 1-844-209-9094).
Farsi:
Russian: : , . 1-855-598-6774 (: 1-844-209-9094).
Japanese: .1-855-598-6774TTY:1-844-209-9094
Arabic:
Panjabi: : , 1-855-598-6774 (TTY: 1-844-209-9094) '
Cambodian: , 1-855-598-6774 (TTY: 1-844-209-9094)
Thai: : 1-855-598-6774 (TTY: 1-844-209-9094).
Hmong: LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau1-855-598-6774 (TTY: 1-844-209-9094).
Hindi: : 1-855-598-6774 (TTY: 1-844-209-9094)
Multi-language Interpreter Services
: . (TTY: 1-844-209-9094) 6774-598-855-1 .
: . 6774-598-855-1 ( : 1-844-209-9094).
Plan NoticesFresenius Total Health is a PPO SNP offered by Fresenius Health Plans Insurance Company. Fresenius Health Plans is a PPO with a Medicare contract. Enrollment in Fresenius Health Plans depends on contract renewal. To join Fresenius Total Health (PPO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, be diagnosed with end stage renal disease requiring dialysis (any mode of dialysis) and live in our service area. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits, premium and/or copayments/coinsurance may change on Jan-uary 1 of each year. You must continue to pay your Medicare Part B premium. Out-of-network/non-contracted providers are under no obligation to treat Fresenius Total Health members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask us for a pre-service organization determination before you receive the service. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
Fresenius Health Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Fresenius Health Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Fresenius Health Plans:
Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages
If you need these services, contact Member Services. If you believe that Fresenius Health Plans has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Utilization Management, Appeals & Grievances, P.O. Box 162487, Austin, TX 78716, 1-844-609-7746, Fax: 1-855-850-5930, Email: [email protected]. You can file a griev-ance in person or by mail, fax, or email. If you need help filing a grievance, Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services, 200 Indepen-dence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019, 800-537-7697 (TDD). Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.
http://www.hhs.gov/ocr/office/file/index.htmlhttps://ocrportal.hhs.gov/ocr/portal/lobby.jsf
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FRESENIUS TOTAL HEALTH www.esrdplans.com
Member Services:1-855-598-6774 / TTY 1-844-209-9094
Hours:February 15 September 30: Monday Friday, 8am 11pm ET
October 1 February 14: 7 days a week, 8am 11pm ET
http://www.esrdplan.com