Health Net Seniority Plus Amber II (HMO SNP) …...2019/01/01 · 2019 Health Net Seniority Plus...

2019

Health Net Seniority Plus Amber II (HMO SNP)

H0562: 110-001

Fresno, Los Angeles, Orange, San Diego, and

San Francisco Counties, CA

H0562_19_7874SB_110_001_M_Accepted 09072018

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This booklet provides you with a summary of what we cover and your cost-sharing responsibilities. It

doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of

services we cover, please call us at the number listed on the last page, and ask for the "Evidence of

Coverage" (EOC), or you may access the EOC on our website at, ca.healthnetadvantage.com.

You are eligible to enroll in Health Net Seniority Plus Amber II (HMO SNP) if:

You are entitled to Medicare Part A and enrolled in Medicare Part B. Members must continue to pay

their Medicare Part B p remium if not otherwise paid for under Medicaid or by another third party.

You must be a United States citizen, or are lawfully present in the United States and permanently

reside in the service area of the plan (in other words, your permanent residence is within the Health

Net Seniority Plus Amber II (HMO SNP) service area counties). Our service area includes the

following counties in California: Fresno, Los Angeles, Orange, San Diego, and San Fran cisco.

You do not have end-stage renal disease (ESRD). (Exceptions may apply for individuals who develop

ESRD while enrolled in a Health Net commercial or group health plan, or a Medicaid plan.)

For Health Net Seniority Plus Amber II (HMO SNP), you must also be enrolled in the California

Medicaid plan. Premiums, copays, coinsurance, and deductibles may vary based on your Medicaid

eligibility category and/or the level of Extra Help you receive. Your Part B premium is paid by the State

of California for full-dual enrollees. Please contact the plan for further details.

The Health Net Seniority Plus Amber II (HMO SNP) plan gives you access to our network of highly

skilled medical providers in your area. You can look forward to choosing a primary care provider (PCP)

to work with you and coordinate your care. You can ask for a current provider directory or, for an up-to-

date list of network providers, visit ca.healthnetadvantage.com. (Please note that, except for

emergency care, urgently needed care when you are out of the network, out-of-area dialysis services,

and cases in which our plan authorizes use of out-of-network providers, if you obtain medical care from

out-of-plan providers, neither Medicare nor Health Net Seniority Plus Amber II (HMO SNP) will be

responsible for the costs.)

This Health Net Seniority Plus Amber II (HMO SNP) plan also includes Part D coverage, which

provides you with the ease of having both your medical and prescription drug needs coordinated

through a single convenient source.

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http://ca.healthnetadvantage.com


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Summary of Benefits JANUARY 1, 2019–DECEMBER 31, 2019

Benefits Health Net Seniority Plus Amber II (HMO SNP)

H0562: 110-001

Premiums / Copays / Coinsurance

With Health Net Seniority Plus Amber II , Medicare and full Medicaid/ Medi-Cal eligibility, you pay

With Health Net Seniority Plus Amber II and Medicare only, you pay

Premiums, copays, coinsurance, and deductibles may vary based on your Medicaid eligibility

category and/or the level of Extra Help you receive.

Monthly Plan Premium $0

Your premium is based on your low income subsidy status.

$34.80

Your premium is based on your low income subsidy status.

Deductible $0 deductible for covered medicalservices

$0 - $85 deductible for Part D prescription drugs (applies todrugs on Tiers 2, 3, 4 and 5)

$0 deductible for inpatienthospital stay

$0 deductible for cov ered medicalservices

$300 deductible for Part Dprescription drugs (applies todrugs on Tiers 2, 3, 4 and 5)

$1,340 deductible for inpatienthospital stay

Maximum Out-of-Pocket

Responsibility

(does not include

prescription drugs)

$4,950 annually

This is the most you will pay in copays and coinsurance for medical services for the year.

$4,950 annually

This is the most you will pay in copays and coinsurance for medical services for the year.

Inpatient Hospital

Coverage*

$0 copay In 2018, the amounts for each benefit period were:

$ 1,340 hospital deductible eachbenefit period

$0 copay per days 1 through 60

$ 335 copay per day for days 61through 90

$ 670 copay per day per lifetimereserve day (may change in2019)

Outpatient Hospital* Outpatient Hospital (includes ambulatory surgical center and observation services): 0% coinsurance per visit

Outpatient Hospital (includes ambulatory surgical center and observation services): 20% coinsurance per visit

Services with an * (asterisk) may require prior authorization and / or a referral from your doctor.

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H0562: 110-001




Doctor Visits* Primary Care: $0 copay per visit

Specialist: $0 copay per visit

Primary Care: $0 copay per visit

Specialist: $0 copay per visit

Preventive Care*

(e.g. flu vaccine, diabetic screening)

$0 copay for Medicare-covered preventive services

Other preventive services are available.

$0 copay for Medicare-covered preventive services

Other preventive services are available.

Emergency Care 0% coinsurance per visit 20% coinsurance (up to $90) per visit

You do not have to pay the copay if admitted to the hospital immediately.

Urgently Needed Services 0% coinsurance per visit 20% coinsurance (up to $65) per visit

Diagnostic Services/Labs/

Imaging*

Lab services: $0 copay

Diagnostic tests and procedures:0% coinsurance

Outpatient X-ray services: 0%coinsurance

Diagnostic Radiological services:0% coinsurance

Lab services: $0 copay

Diagnostic tests and procedures:20% coinsurance

Outpatient X-ray services: 20%coinsurance

Diagnostic Radiological services:20% coinsurance

Hearing Services* Hearing exam (Medicare-covered): 0% coinsurance

Routine hearing exam: $0 copay(1 every calendar year)

Hearing aid: $0 copay (2 hearingaids every year)

Hearing exam (Medicare-covered): 20% coinsurance

Routine hearing exam: $0 copay(1 every calendar year)

Hearing aid: $0 copay (2 hearingaids every year)

Dental Services* Dental services (Medicarecovered): 0% coinsurance pervisit

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Preventive Dental Services: $0copay (including oral exams,cleanings, fluoride treatment andX-rays)

Comprehensive dental s ervices: Additional comprehensive dental benefits are available

Dental services (Medicare-covered): 20% coinsurance pervisit

Preventive Dental Services: $0copay (including oral exams,cleanings, fluoride treatment, andX-rays

Comprehensive dental s ervices: Additional comprehensive dental benefits are available.


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H0562: 110-001




Vision Services* Vision exam (Medicare-covered):0% coinsurance per visit

Routine eye exam: $0 copay pervisit (up to 1 every calendar year)

Routine eyewear: up to $250allowance every 2 calendar years

Vision exam (Medicare-covered):20% coinsurance per visit

Routine eye exam: $0 copay pervisit (up to 1 every calendar year)

Routine eyewear: up to $250allowance every 2 cal endar years

Mental Health Services* Individual and group therapy: 0% coinsurance per visit

Individual and group therapy: 20% coinsurance per visit

Skilled Nursing Facility * $0 copay

In 2018, the amounts for eachbenefit period were:

$0 copay per day, days 1 through20

$167.50 copay per day, days 21through 100 (may change for2019)

Physical Therapy* $0 copay per visit 20% coinsurance per visit

Ambulance* 0% coinsurance (per one-way trip 20% coinsurance (per one-way trip)

Transportation* $0 copay for each one-way trip $0 copay for each one-way trip

(up to 20 one-way trips to plan approved locations each calendar year)

Medicare Part B Drugs* Chemotherapy drugs: 0%coinsurance

Other Part B d rugs: 0%coinsurance

Chemotherapy drugs:20%coinsurance

Other Part B d rugs:20%coinsurance


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Part D Prescription Drugs

Deductible Phase $0 - $300 deductible

(Deductible does not apply to Tiers 1 and 6.)

Initial Coverage Phase

(after you pay your Part D

deductible, if applicable)

Standard Retail

Rx 30-day supply

Mail-Order

Rx 90-day supply

Tier 1: Preferred Generic $0 or $1.25 or $3.40 copay $0 copay

Tier 2: Generic $0 or $3.80 or $8.50 copay $60 copay

Tier 3: Preferred Brand $0 or $3.80 or $8.50 copay $141 copay

Tier 4: Non-Preferred Drug $0 or $3.80 or $8.50 copay $300 copay

Tier 5: Specialty $0 or $1.25 or $3.40 copay Not available

Tier 6: Select Care Drugs $0 or $3.80 or $8.50 copay $0 copay

Important Info: Cost-sharing may change depending on the level of help you receive, the pharmacy you choose (such as Standard Retail, Mail-Order, Long-Term Care or Home Infusion) and when you enter another of the four phases of the Part D benefit.

For more information about the costs for Long-Term Supply, Home Infusion, or additional pharmacy-specific cost-sharing and the phases of the benefit, please call us or access our EOC online.

Low income subsidy (LIS) is extra help you receive from Medicare. To find out if you qualify, visit Medicare.gov or call Member Services at 1-800-431-9007 (TTY: 711).

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http://Medicare.gov

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Additional Covered Benefits

Benefits Health Net Seniority Plus Amber II (HMO SNP) H0562: 110-001


With Health Net Seniority Plus Amber II, Medicare and full Medicaid/ Medi-Cal eligibility, you pay

With Health Net Seniority Plus Amber II an d Medicare only, you pay

Chiropractic Care* Chiropractic services (Medicare-covered): 0% coinsurance per visit

Chiropractic services (Medicare-covered): 20% coinsurance per visit

Medical Equipment/

Supplies*

Durable Medical Equipment(e.g., wheelchairs, oxygen): 0%coinsurance

Prosthetics (e.g., braces,artificial limbs): 0% coinsurance

Diabetic supplies: 0%coinsurance

Durable Medical Equipment(e.g., wheelchairs, oxygen):20% coinsurance

Prosthetics (e.g., braces,artificial limbs): 20%coinsurance

Diabetic supplies: 20%coinsurance

Foot Care *

(Podiatry Services)

Foot exams and treatment (Medicare-covered): 0% coinsurance per visit

Routine foot care: $0 copay pervisit (12 visits per year.)

Foot exams and treatment(Medicare-covered): 20%coinsurance

Routine foot care: $0 copay pervisit (12 visits per year.)

Wellness Programs Fitness program: $0 copay

24-hour nurse advice line: $0copay

For a detailed list of wellness program benefits offered, please refer to the EOC.

Fitness program: $0 copay

24-hour nurse advice line: $0copay

For a detailed list of wellness program benefits offered, please refer to the EOC.


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Comprehensive Written Statement for Prospective Enrollees

The benefits described in the Premium and Benefit section of the Summary of Benefits are covered by our Medicare Advantage plan. For each benefit listed, you can see what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. Coverage of the benefits described in this Summary of Benefits depends upon your level of Medicaid eligibility. No matter what your level of Medicaid eligibility is, Health Net Seniority Plus Amber II (HMO SNP) will cover the benefits described in the Premium and Benefit section of the Summary of Benefits. If you have questions about your Medicaid eligibility and what benefits you are entitled to, call California Health Advocates toll-free at 1-800-434-0222.

Our source of information for Medicaid benefits is cahealthadvocates.org. All Medicaid covered

services are subject to change at any time. For the most current California Medicaid coverage

information, please visit cahealthadvocates.org or call Member Services for assistance. A de tailed

explanation of California Medicaid benefits can be found in the California Summary of Services online

at cahealthadvocates.org.

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http://cahealthadvocates.org



Section 1557 Non-Discrimination Language Notice of Non-Discrimination

Health Net complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Net does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Health Net:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats).

• Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages.

If you need these services, contact Health Net’s Customer Contact Center at California: 1-800-431-9007 (Jade, Sapphire, Amber, and HMO SNP), 1-800-275-4737 (all other HMO); Oregon: 1-888-445-8913 (HMO and PPO) (TTY: 711).

From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays.

If you believe that Health Net 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 by calling the number above and telling them you need help filing a grievance; Health Net’s Customer Contact Center 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 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, 1-800-368-1019 (TDD: 1-800-537-7697).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

Health Net is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Health Net depends on contract renewal.

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http://www.hhs.gov/ocr/office/file/index.html

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Section 1557 Non-Discrimination LanguageMulti-Language Interpreter Services

ARABIC

ARMENIAN

CHINESE

CUSHITE

FRENCH

GERMAN

HINDI

HMONG

JAPANESE

KOREAN

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MON-KHMER CAMBODIAN

PERSIAN

PUNJABI

ROMANIAN

RUSSIAN

SPANISH

TAGALOG

THAI

UKRAINIAN

VIETNAMESE

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For more information, please contact:

Health Net Seniority Plus Amber II (HMO SNP)

PO Box 10420

Van Nuys, CA 91410-0420

ca.healthnetadvantage.com

Current members should call: 1-800-431-9007 (TTY: 711)

Prospective members should call: 1-800-977-6738 (TTY: 711)

From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 to

September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is

used after hours, weekends, and on federal holidays.

If you want to know more about the coverage and costs of Original Medicare, look in your current

“Medicare & Y ou” handbook. View it online at 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. This plan is available to anyone who has both Medical Assistance from the State and Medicare.

This information is not a complete description of benefits. Call 1-800-431-9007 (TTY: 711) for more

information.

“Coinsurance” is the percentage you pay of the total cost of certain medical services.

The Formulary, pharmacy network, and/or provider network may change at any time. You will receive

notice when necessary.

This document is available in other formats such as Braille, large print or audio.

Health Net is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state

Medicaid programs. Enrollment in Health Net depends on contract renewal.

SBS020832EK00_A (07/18)

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http://www.medicare.gov


Health Net Seniority Plus Amber II (HMO SNP) …...2019/01/01 · 2019 Health Net Seniority Plus...

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