Sunshine Health Medicare Advantage (HMO)...2017/01/01 · Sunshine Health Medicare Advantage (HMO)...

2017 Summary of Benefits

Sunshine Health Medicare Advantage (HMO)

Miami-Dade County

H9276, Plan 004

H9276-004_2017_SB_Accepted_09062016

Summary of Benefits

January 1, 2017 – December 31, 2017 This is a summary of drug and health services covered by Sunshine Health Medicare Advantage (HMO).

Sunshine Health Medicare Advantage is contracted with Medicare for HMO and HMO SNP plans, and with the Florida Medicaid program. Enrollment in Sunshine Health Medicare Advantage depends on contract renewal.

The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the “Evidence of Coverage.”

Who can join? To join Sunshine Health Medicare Advantage (HMO), you must:

have both Medicare A and Medicare Part B

be a United States citizen or are lawfully present in the United States

live in our service area

Our service area includes the following counties in Florida:

Miami-Dade County

Which doctors, hospitals and pharmacies can I use? Sunshine Health Medicare Advantage (HMO) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. You can view our provider & pharmacy directory on our website, https://advantage.sunshinehealth.com.

This plan’s phone numbers and website:

If you are a member of this plan, call toll-free: 1-844-293-2636. (TTY users, please call 711.)

If you are not a member of this plan, call toll-free: 1-877-826-3692. (TTY users, please call 711.)

Our website: https://advantage.sunshinehealth.com

Hours of Operation: From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. On weekends and holidays, an automated system will handle your call. This document is available in other formats such as Braille, large print or audio. This information is available for free in other languages. Please call our Member Services number at 1-844-293-2636. TTY: 711. October 1 – February 14, 7 days a week, 8 a.m. to 8 p.m.; February 15 – September 30, Monday – Friday, 8 a.m. to 8 p.m. Esta información está disponible gratis en otros idiomas. Por favor llame a nuestro de Servicios al Afiliado al 1-844-293-2636. TTY: 711. 1 de octubre - 14 de febrero, 7 días a la semana, 8 a. m. - 8 p. m.; 15 de febrero – 30 de septiembre, lunes - viernes, 8 a. m. – 8 p. m.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums, and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.

SUMMARY OF BENEFITS January 1, 2017 – December 31, 2017

Premiums and Benefits


What you should know

Monthly Plan Premium

$0 You must continue to pay your Medicare Part B premium.

Deductible You pay nothing

Maximum Out-of-Pocket Responsibility

(does not include prescription drugs)

Your yearly limit(s) in this plan:

$3,400 for services you receive from in-network providers

Please note: You will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.

Inpatient Hospital Coverage

You pay nothing For more information on “benefit periods” and “lifetime reserve days,” please see the plan’s Evidence of Coverage (EOC).

Prior authorization (approval in advance) may be required. Please contact the plan for details. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 “lifetime reserve days.”

Doctor Visits

o Primary o Specialists

You pay nothing A referral may be required for specialist visits. Please contact the plan for details.

Preventive Care You pay nothing

Please see the plan’s Evidence of Coverage (EOC) for a full list of preventive care services that the plan covers.

Any additional preventive services approved by Medicare during the contract year will be covered.




Emergency Care $50 copay per visit

If you are admitted to the hospital within three days, you do not have to pay your share of the cost for emergency care.

Urgently Needed Services

You pay nothing

Diagnostic Services/Labs/ Imaging

Diagnostic tests and procedures: $25 copay Lab services: You pay nothing Diagnostic radiological services: $25 copay Therapeutic radiology services (such as radiation treatment for cancer): 20% of the total cost Outpatient x-ray services: $25 copay

Prior authorization (approval in advance) may be required. Please contact the plan for details.

Hearing Services

Routine hearing exam: You pay nothing for up to 1 every calendar year

Hearing aid fitting/evaluation: You pay nothing for up to 1 every calendar year Hearing aid: You pay nothing for 1 hearing aid every calendar year Medicare-covered services: You pay nothing

This plan pays up to $750 for one hearing aid (for either the left or right ear). Medicare-covered services include an exam to diagnose and treat hearing and balance issues.

Dental Services

Medicare-covered dental services: 20% of the total cost

Medicare-covered dental includes limited dental services (this does not include services in connection with




Dental Services (cont.)

Preventive dental services: Oral exam (for up to 2 every calendar year): You pay nothing Cleaning (for up to 2 every calendar year): You pay nothing Dental x-ray (for up to 1 every calendar year): You pay nothing Comprehensive dental services: Diagnostic services: You pay nothing Restorative services: You pay nothing Endodontics/periodontics/extractions: You pay nothing Prosthodontics, other oral/maxillofacial surgery, other services: You pay nothing

care, treatment, filling, removal or replacement of teeth. Dental x-rays include bitewing series only. This plan offers additional, supplemental comprehensive dental benefits (maximum plan benefit coverage amount of $2,000).

Vision Services

Routine eye exam (for up to 1 year): You pay nothing Contact lenses: You pay nothing Eyeglasses (frames and lenses): You pay nothing Medicare-covered services: You pay nothing

Medicare-covered services includes an exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) and eyeglasses or contact lenses after cataract surgery.

The plan pays for up to $275 for contact lenses and/or eyeglasses (frames and lenses).

Mental Health Services

You pay nothing Prior authorization (approval in




Mental Health Services (cont.)

For more information on “benefit periods” and “lifetime reserve days,” please see the plan’s Evidence of Coverage (EOC). Outpatient group therapy visit: You pay nothing Outpatient individual therapy visit: You pay nothing

advance) may be required. Please contact the plan for details. Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 “lifetime reserve days.”

Skilled Nursing Facility (SNF)

For each benefit period, you pay:

You pay nothing for days 1 - 20

$25 copay per day for days 21 - 100

For more information on “benefit periods” and “lifetime reserve days,” please see the plan’s Evidence of Coverage (EOC).

Prior authorization (approval in advance) may be required. Please contact the plan for details. Our plan covers up to 100 days in a SNF.

Rehabilitation Services

Cardiac rehab services: You pay nothing Occupational therapy visit: You pay nothing Physical therapy and speech and language therapy visit: You pay nothing

Prior authorization (approval in advance) may be required. Please contact the plan for details. Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks)

Ambulance

$225 copay

Prior authorization (approval in advance) is required for non-emergency ambulance services. Please




Ambulance (cont.)

contact the plan for details.

Transportation You pay nothing for unlimited one-way trips per year

You must: Use this plan’s contracted transportation providers Go to and from this plan’s network providers and facilities within the service area Schedule your trip 48 hours in advance

Foot Care (podiatry services)

Medicare-covered podiatry services: You pay nothing Routine foot care (for unlimited visits every year): You pay nothing

Medicare-covered podiatry services include foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions.

Medical Equipment/Supplies

Durable Medical Equipment (DME) (e.g., wheelchairs, oxygen): 20% of the total cost Prosthetics (e.g., braces, artificial limbs): 20% of the total cost Medical supplies: 20% of the total cost Diabetes monitoring supplies: 20% of the total cost Therapeutic shoes or inserts: 20% of the total cost


Wellness Programs (e.g., fitness)

Fitness program: You pay nothing

The plan covers a basic fitness




Wellness Programs (e.g., fitness) (cont.)

24-hour nurse advice line: You pay nothing

membership at participating fitness facilities. Members can also request an in-home fitness program.

You can call the nursing hotline 24 hours a day, 365 days a year with questions about your health.

Medicare Part B Drugs

Chemotherapy drugs: 20% of the total cost Other Part B drugs: 20% of the total cost


Over-the-Counter (OTC) Items

You pay nothing The plan covers $20 per month for items available via mail order. Any unused plan benefit amounts do not carry forward into the next month. Please visit the plan’s website to see the list of covered over-the-counter items.

Outpatient Prescription Drugs

Deductible Phase Because there is no deductible for this plan, this payment phase does not apply to you.

Initial Coverage Phase

If you reside in a long-term care facility, you pay the same as at a retail pharmacy.

You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.

You begin in this phase when you fill your first prescription of the year. During this phase, the plan pays its share of the cost of your Part D drugs and you pay your share of the cost. You generally stay in this phase until your year-to-date “total drug costs” (your payments plus any payments by the plan) reach $3,700. Once your “total drug costs” reach $3,700 you move to the next phase (Coverage Gap).

Retail and Mail-Order Cost Sharing

One-month supply including Mail Order

Two-month supply including Mail Order

Three-month including Mail Order

Tier 1 (Preferred Generic): $0 copay



Tier 2 (Generic): $0 copay



Tier 3 (Preferred Brand): $0 copay



Tier 4 (Non-Preferred Brand): $35 copay



Tier 5 (Specialty): 33% of the total cost



Tier 6 (Select Care): $0 copay



You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website at https://advantage.sunshinehealth.com. For certain kinds of drugs, you can use the plan’s network mail order services. Generally, the drugs provided through mail order are drugs that you take on a regular

basis, for a chronic or long-term medical condition. The drugs available through our plan’s mail order service are marked as “MO” drugs in our Drug List.

Coverage Gap Phase

During this phase, for Tier 6 (Select Care drugs), you continue to pay $0. For Tier 1 (Preferred generic drugs) and Tier 2 (Generic drugs), you pay your copayment or coinsurance. For generic drugs on all other tiers, you pay 51% of the price. For brand name drugs on all other tiers, you pay 40% of the price (plus a portion of the dispensing fee).

You generally stay in this phase until your year-to-date “out-of-pocket costs” reaches $4,950. Once your “out-of-pocket costs” reach $4,950, you move to the next phase (Catastrophic Coverage).

Catastrophic Phase

During this phase, the plan pays most of the cost for your covered drugs. For each prescription, you pay the greater of:

5% of the cost – OR –

$3.30 copay for a generic drug (or a drug that is treated like a generic)

$8.25 copay for all other drugs.

Multi-language Interpreter Services

English: ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-844-293-2636 (TTY: 711). Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-844-293-2636 (TTY: 711).

Chinese Mandarin: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電1-844-293-2636 (TTY: 711)。

Chinese Cantonese:

注意：如果您說英文，您可獲得免費的語言協助服務。請致電1-844-293-2636（聽障專線：711)。

Tagalog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-844-293-2636 (TTY: 711).

French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-844-293-2636 (ATS : 711).

Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-844-293-2636 (TTY: 711).

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-844-293-2636 (TTY: 711).

Korean:

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-844-293-2636

(TTY: 711) 번으로 전화해 주십시오.

Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-844-293-2636 (телетайп: 711).

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Arabic: )رقم هاتف الصم والبكم: 1-448-392-6362ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم

711.)

Hindi:

ध्यान दें: यदद आप बोलते हैं तो आपके ललए मुफ्त में भाषा सहायता सेवाएं उपलब्ध हैं। 1-844-293-

2636 (TTY: 711) पर कॉल करें।

Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-844-293-2636 (TTY: 711).

Portugués: ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-844-293-2636 (TTY: 711).

French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-844-293-2636 (TTY: 711).

Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-844-293-2636 (TTY: 711).

Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-844-293-2636 (TTY: 711)

まで、お電話にてご連絡ください。

Navajo:

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

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 Sunshine Health Medicare Advantage’s Member Services at 1-844-293-2636 (TTY: 711). If you believe that Sunshine Health Medicare Advantage 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; Sunshine Health Medicare Advantage’s 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 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.


Sunshine Health Medicare Advantage 1301 International Parkway, Suite 400 Sunrise, FL 33323

Current members should call 1-844-293-2636 (TTY: 711) Prospective members should call 1-877-826-3692 (TTY: 711)

From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. On weekends and holidays, an automated system will handle your call. You can see our plan’s provider and pharmacy directory at http://advantage.sunshinehealth.com

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 https://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.

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Sunshine Health Medicare Advantage (HMO)...2017/01/01 · Sunshine Health Medicare Advantage (HMO)...

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