Stage 2017 (this year) 2018 (next year) Stage 2: Initial Coverage Stage Once you pay the yearly deductible, you move to the 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; or for prescriptions, look in Chapter 6, Section 5 of your Evidence of Coverage. Your cost for a one-month supply filled at a network pharmacy with standard cost-sharing: Tier 1: You pay 25% of the total cost. Once your total drug costs have reached $3,700, you will move to the next stage (the Coverage Gap Stage). Your cost for a one-month supply filled at a network pharmacy with standard cost-sharing: Tier 1: You pay 25% of the total cost. Once your total drug costs have reached $3,750, 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.
Chapter 1. Getting started as a member SECTION 1 Introduction 6 Section 1.1 You are enrolled in Provider Partners Pennsylvania Advantage (HMO SNP), which is a Medicare HMO Error! Bookmark not defined. Section 1.1 You are currently enrolled in Provider Partners Pennsylvania Advantage (HMO SNP), which is a specialized Medicare Advantage Plan (“Special Needs Plan”) 6 Section 1.2 What is the Evidence of Coverage booklet about? 6 Section 1.3 Legal information about the Evidence of Coverage 7 SECTION 2 What makes you eligible to be a plan member? 7 Section 2.1 Your eligibility requirements 7 Section 2.2 What are Medicare Part A and Medicare Part B? 8 Section 2.3 Here is the plan service area for Provider Partners Pennsylvania Advantage (HMO SNP) 8 Section 2.4 U.S. Citizen or Lawful Presence 9 SECTION 3 What other materials will you get from us? 9 Section 3.1 Your plan membership card – Use it to get all covered care and prescription drugs 9 Section 3.2 The Provider Directory: Your guide to all providers in the plan’s network 10 Section 3.3 The Pharmacy Directory: Your guide to pharmacies in our network 10 Section 3.4 The plan’s List of Covered Drugs (Formulary) 11 Section 3.5 The Part D Explanation of Benefits (the “Part D EOB”): Reports with a summary of payments made for your Part D prescription drugs 11 SECTION 4 Your monthly premium for Provider Partners Pennsylvania Advantage (HMO SNP) 11 Section 4.1 How much is your plan premium? 11 SECTION 5 Do you have to pay the Part D “late enrollment penalty”? 12 Section 5.1 What is the Part D “late enrollment penalty”? 12 Section 5.2 How much is the Part D late enrollment penalty? 13 Section 5.3 In some situations, you can enroll late and not have to pay the penalty 14 Section 5.4 What can you do if you disagree about your Part D late enrollment penalty? 14 SECTION 6 Do you have to pay an extra Part D amount because of your income? 15 Section 6.1 Who pays an extra Part D amount because of income? 15 .
studies and hospice services). Keep your red, white, and blue Medicare card if applicable, in a safe place in case you need it later. Here’s why this is so important: If you get covered services using your red, white, and blue Medicare card instead of using your Provider Partners Pennsylvania Advantage (HMO SNP) membership card while you are a plan member, you may have to pay the full cost yourself. If your plan membership card is damaged, lost, or stolen, call Member Services right away and we will send you a new card. (Phone numbers for Member Services are printed on the back cover of this booklet.) Section 3.2 The Provider Directory: Your guide to all providers in the plan’s network The Provider Directory lists our network providers and durable medical equipment suppliers. What are “network providers”? Network providers are the doctors and other health care professionals, medical groups, durable medical equipment suppliers, hospitals, and other health care facilities that have an agreement with us to accept our payment and any plan cost-sharing as payment in full. We have arranged for these providers to deliver covered services to members in our plan. The most recent list of providers and suppliers is available on our website at www.pphealthplanpa.com. Why do you need to know which providers are part of our network? It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed services when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Provider Partners Pennsylvania Advantage (HMO SNP) authorizes use of out-of-network providers. See Chapter 3 (Using the plan’s coverage for your medical services) for more specific information about emergency, out-of-network, and out-of-area coverage. If you don’t have your copy of the Provider Directory, you can request a copy from Member Services (phone numbers are printed on the back cover of this booklet). You may ask Member Services for more information about our network providers, including their qualifications. You can also see the Provider Directory at www.pphealthplanpa.com, or download it from this website. Both Member Services and the website can give you the most up-to-date information about changes in our network providers.
You think coverage for your hospital stay is ending too soon. You think coverage for your home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services are ending too soon. Method Livanta (Pennsylvania’s Quality Improvement Organization) CALL 588-1123, Monday through Friday 8:00 a.m. to 5:00 p.m.; Saturday and Sunday, 11:00 a.m. to 3:00 p.m. TTY 1-855-887-6668 This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking. WRITE Livanta LLC BFCC-QIO Area 5 9090 Junction Drive Suite 10 Annapolis Junction, MD 20701 WEBSITE SECTION 5 Social Security Social Security is responsible for determining eligibility and handling enrollment for Medicare. U.S. citizens and lawful permanent residents who are 65 or older, or who have a disability or End-Stage Renal Disease and meet certain conditions, are eligible for Medicare. If you are already getting Social Security checks, enrollment into Medicare is automatic. If you are not getting Social Security checks, you have to enroll in Medicare. Social Security handles the enrollment process for Medicare. To apply for Medicare, you can call Social Security or visit your local Social Security office. Social Security is also responsible for determining who has to pay an extra amount for their Part D drug coverage because they have a higher income. If you got a letter from Social Security telling you that you have to pay the extra amount and have questions about the amount or if your income went down because of a life-changing event, you can call Social Security to ask for reconsideration. If you move or change your mailing address, it is important that you contact Social Security to let them know.
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. For more assistance, contact Member Services at the number on the back cover of this book. Section 2.4 How to get care from out-of-network providers Under certain circumstances members may obtain services from out-of-network providers. Newly eligible members who are undergoing an existing course of treatment under the care of an out-of-network provider at the time of eligibility may continue to obtain services from that provider. Out-of-network providers with members under a current treatment plan must notify the health plan and request authorization of services as appropriate according to the Plan benefits. Once the health plan is notified that the member is under the care of an out-of-network provider, the provider must submit a request for authorization. All supporting clinical information must be provided to substantiate the continuation of the requested service(s). During this time existing care will not be interrupted until clinical information is reviewed for medical necessity and appropriateness. In the case where there may not be a network specialist available to the member, an out-of-network provider may be accessed at the discretion of the PCP. SECTION 3 How to get covered services when you have an emergency or urgent need for care or during a disaster Section 3.1 Getting care if you have a medical emergency What is a “medical emergency” and what should you do if you have one? 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. If you have a medical emergency: Get help as quickly as possible. Call 911 for help or go to the nearest emergency room or hospital. Call for an ambulance if you need it. You do not need to get approval or a referral first from your PCP.
Immunizations Covered Medicare Part B services include: Pneumonia vaccine Flu shots, once a year in the fall or winter Hepatitis B vaccine if you are at high or intermediate risk of getting Hepatitis B Other vaccines if you are at risk and they meet Medicare Part B coverage rules We also cover some vaccines under our Part D prescription drug benefit. There is no coinsurance, copayment, or deductible for the pneumonia, influenza, and Hepatitis B vaccines. Inpatient hospital care 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. Our plan covers 90 days for an inpatient hospital stay. Our plan covers 60 lifetime reserve days. Covered services include but are not limited to: Semi-private room (or a private room if medically necessary) Meals including special diets Regular nursing services Costs of special care units (such as intensive care or coronary care units) Drugs and medications Lab tests X-rays and other radiology services Necessary surgical and medical supplies Use of appliances, such as wheelchairs Operating and recovery room costs Physical, occupational, and speech language therapy Inpatient substance abuse services You pay a $1316 deductible for days 1-60. You pay a $329 copay per day for days 61-90. You pay $658 copay per lifetime reserve These are 2017 amounts which may change for 2018. Cost shares are applied starting on the first day of admission and do not include the date of discharge.
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). 20% of the cost for Medicare covered services Outpatient substance abuse services Non-residential ambulatory services provided for the treatment of drug or alcohol dependence without the use of pharmacotherapies. Services may include group or individual therapy. 20% of the cost for Medicare covered services 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.” 20% of the cost for Medicare covered services Partial services “Partial hospitalization” is a structured program of active psychiatric treatment provided as a hospital outpatient service or by a community mental health center, that is more intense than the care received in your doctor’s or therapist’s office and is an alternative to inpatient hospitalization. Note: Because there are no community mental health centers in our network, we cover partial hospitalization only as a hospital outpatient service.] 20% of the cost for Medicare covered services
Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) If you use tobacco, but do not have signs or symptoms of tobacco-related disease: We cover two counseling quit attempts within a 12-month period as a preventive service with no cost to you. Each counseling attempt includes up to four face-to-face visits. If you use tobacco and have been diagnosed with a disease or are taking medicine that may be affected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12-month period, however, you will pay the applicable cost-sharing. Each counseling attempt includes up to four face-to-face visits. ____________________________________________________ Transportation (Non-Emergent, Routine) Routine transportation services are covered for up to thirty-six (36) one-way trips per calendar area within the Plan’s Service Area. Please call Member Services for more details on how to use this service. Routine Transportation is a trip to a scheduled medical appointment within a defined service when the need for transport is not based on medical necessity and can be met through a van, sedan or other non-ambulance vehicle. Trip must be arranged through the contracted transportation vendor and must be scheduled 3 days in advance of needed services. There is no coinsurance, copayment, or deductible for the Medicare-covered smoking and tobacco use cessation preventive benefits. ______________________ $0 copay for up to 36 one- way trip(s) to plan approved locations every year Prior authorization may be required 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. Cost sharing for necessary urgently needed services furnished out-of-network is the same as for such services furnished Urgent care is covered within the United States and its territories but not worldwide. 20% of the cost for Medicare covered services (up to $65)
Section 8.2 What if you don’t have your membership card with you? 103 SECTION 9 Part D drug coverage in special situations 103 Section 9.1 What if you’re in a hospital or a skilled nursing facility for a stay that is covered by the plan? 103 Section 9.2 What if you’re a resident in a long-term care (LTC) facility? 103 Section 9.3 What if you’re also getting drug coverage from an employer or retiree group plan? 104 Section 9.4 What if you’re in Medicare-certified hospice? 105 SECTION 10 Programs on drug safety and managing medications 105 Section 10.1 Programs to help members use drugs safely 105 Section 10.2 Medication Therapy Management (MTM) program to help members manage their medications 106 Did you know there are programs to help people pay for their drugs? There are programs to help people with limited resources pay for their drugs. These include “Extra Help” and State Pharmaceutical Assistance Programs. OR The “Extra Help” program helps people with limited resources pay for their drugs. For more information, see Chapter 2, Section 7. Are you currently getting help to pay for your drugs? If you are in a program that helps pay for your drugs, some information in this Evidence of Coverage about the costs for Part D prescription drugs may not apply to you. We have included a separate insert, called the “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (also known as the “Low Income Subsidy Rider” or the “LIS Rider”), which tells you about your drug coverage. If you don’t have this insert, please call Member Services and ask for the “LIS Rider.” (Phone numbers for Member Services are printed on the back cover of this booklet.)
SECTION 6 Your Part D prescription drugs: How to ask for a coverage decision or make an appeal Have you read Section 4 of this chapter (A guide to “the basics” of coverage decisions and appeals)? If not, you may want to read it before you start this section. Section 6.1 This section tells you what to do if you have problems getting a Part D drug or you want us to pay you back for a Part D drug Your benefits as a member of our plan include coverage for many prescription drugs. Please refer to our plan’s List of Covered Drugs (Formulary). To be covered, the drug must be used for a medically accepted indication. (A “medically accepted indication” is a use of the drug that is either approved by the Food and Drug Administration or supported by certain reference books. See Chapter 5, Section 3 for more information about a medically accepted indication.) This section is about your Part D drugs only. To keep things simple, we generally say “drug” in the rest of this section, instead of repeating “covered outpatient prescription drug” or “Part D drug” every time. For details about what we mean by Part D drugs, the List of Covered Drugs (Formulary), rules and restrictions on coverage, and cost information, see Chapter 5 (Using our plan’s coverage for your Part D prescription drugs) and Chapter 6 (What you pay for your Part D prescription drugs). Part D coverage decisions and appeals As discussed in Section 4 of this chapter, a coverage decision is a decision we make about your benefits and coverage or about the amount we will pay for your drugs. Legal Terms An initial coverage decision about your Part D drugs is called a “coverage determination.” Here are examples of coverage decisions you ask us to make about your Part D drugs: You ask us to make an exception, including: Asking us to cover a Part D drug that is not on the plan’s List of Covered Drugs (Formulary) Asking us to waive a restriction on the plan’s coverage for a drug (such as limits on the amount of the drug you can get)
1. Read this notice carefully and ask questions if you don’t understand it. It tells you about your rights as a hospital patient, including: Your right to receive Medicare-covered services during and after your hospital stay, as ordered by your doctor. This includes the right to know what these services are, who will pay for them, and where you can get them. Your right to be involved in any decisions about your hospital stay, and know who will pay for it. Where to report any concerns you have about quality of your hospital care. Your right to appeal your discharge decision if you think you are being discharged from the hospital too soon. Legal Terms The written notice from Medicare tells you how you can “request an immediate review.” Requesting an immediate review is a formal, legal way to ask for a delay in your discharge date so that we will cover your hospital care for a longer time. (Section 7.2 below tells you how you can request an immediate review.) 2. You must sign the written notice to show that you received it and understand your rights. You or someone who is acting on your behalf must sign the notice. (Section 4 of this chapter tells how you can give written permission to someone else to act as your representative.) Signing the notice shows only that you have received the information about your rights. The notice does not give your discharge date (your doctor or hospital staff will tell you your discharge date). Signing the notice does not mean you are agreeing on a discharge date. 3. Keep your copy of the signed notice so you will have the information about making an appeal (or reporting a concern about quality of care) handy if you need it. If you sign the notice more than two days before the day you leave the hospital, you will get another copy before you are scheduled to be discharged. To look at a copy of this notice in advance, you can call Member Services (phone numbers are printed on the back cover of this booklet) or 1-800 MEDICARE 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. You can also see it online at .