Inpatient hospital stays 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. For each Medicare covered stay: Days 1- 60 $1316 deductible Days 61-90 $329 co-pay per day Days 91 and beyond: $658 per lifetime reserve day For each Medicare covered stay: Days 1- 60: $1316 deductible Days 61-90 $329 co-pay per day Days 91 and beyond: $658 per lifetime reserve day These are 2017 amounts which may change for 2018. Part D prescription drug coverage (See Section 1.6 for details.) Deductible: $400 Coinsurance during the Initial Coverage Stage: Drug Tier 1: 25% Deductible: $405 Coinsurance during the Initial Coverage Stage: Drug Tier 1: 25% Annual Notice of Changes for 2018 Table of Contents Summary of Important Costs for 2018 1 SECTION 1 Changes to Benefits and Costs for Next Year 4 Section 1.1 – Changes to the Monthly Premium 4 Section 1.2 – Changes to Your Maximum Out-of-Pocket Amount 4 Section 1.3 – Changes to the Provider Network 4 Section 1.4 – Changes to the Pharmacy Network 5 Section 1.5 – Changes to Benefits and Costs for Medical Services 5 Section 1.6 – Changes to Part D Prescription Drug Coverage 7
SECTION 1 Changes to Benefits and Costs for Next Year Section 1.1 – Changes to the Monthly Premium Cost 2017 (this year) 2018 (next year) Monthly premium (You must also continue to pay your Medicare Part B premium.) $33.20 $30.70 Section 1.2 – Changes to Your Maximum Out-of-Pocket Amount To protect you, Medicare requires all health plans to limit how much you pay “out-of-pocket” during the year. This limit is called the “maximum out-of-pocket amount.” Once you reach this amount, you generally pay nothing for covered Part A and Part B services for the rest of the year. Cost 2017 (this year) 2018 (next year) Maximum out-of-pocket amount Your costs for covered medical services (such as copays and deductibles) count toward your maximum out-of-pocket amount. Your plan premium and your costs for prescription drugs do not count toward your maximum amount. $6,700 $6,700 Once you have paid $6,700 out-of-pocket for covered Part A and Part B services, you will pay nothing for your covered Part A and Part B services for the rest of the calendar year. Section 1.3 – Changes to the Provider Network There are changes to our network of providers for next year. An updated Provider Directory is located on our website at www.pphealthplan.com. You may also call Member Services for updated provider information or to ask us to mail you a Provider Directory. Please review the 2018 Provider Directory to see if your providers (primary care provider, specialists, hospitals, etc.) are in our network.
SECTION 10 How other insurance works with our plan Section 10.1 Which plan pays first when you have other insurance? When you have other insurance (like employer group health coverage), there are rules set by Medicare that decide whether our plan or your other insurance pays first. The insurance that pays first is called the “primary payer” and pays up to the limits of its coverage. The one that pays second, called the “secondary payer,” only pays if there are costs left uncovered by the primary coverage. The secondary payer may not pay all of the uncovered costs. These rules apply for employer or union group health plan coverage: If you have retiree coverage, Medicare pays first. If your group health plan coverage is based on your or a family member’s current employment, who pays first depends on your age, the number of people employed by your employer, and whether you have Medicare based on age, disability, or End-Stage Renal Disease (ESRD): If you’re under 65 and disabled and you or your family member is still working, your group health plan pays first if the employer has 100 or more employees or at least one employer in a multiple employer plan that has more than 100 employees. If you’re over 65 and you or your spouse is still working, your group health plan pays first if the employer has 20 or more employees or at least one employer in a multiple employer plan that has more than 20 employees. If you have Medicare because of ESRD, your group health plan will pay first for the first 30 months after you become eligible for Medicare. These types of coverage usually pay first for services related to each type: No-fault insurance (including automobile insurance) Liability (including automobile insurance) Black lung benefits Workers’ compensation Medicaid and TRICARE never pay first for Medicare-covered services. They only pay after Medicare, employer group health plans, and/or Medigap have paid. If you have other insurance, tell your doctor, hospital, and pharmacy. If you have questions about who pays first, or you need to update your other insurance information, call Member Services (phone numbers are printed on the back cover of this booklet). You may need to give your plan member ID number to your other insurers (once you have confirmed their identity) so your bills are paid correctly and on time.
Annual wellness visit If you’ve had Part B for longer than 12 months, you can get an annual wellness visit to develop or update a personalized prevention plan based on your current health and risk factors. This is covered once every 12 months. Note: Your first annual wellness visit can’t take place within 12 months of your “Welcome to Medicare” preventive visit. However, you don’t need to have had a “Welcome to Medicare” visit to be covered for annual wellness visits after you’ve had Part B for 12 months. There is no coinsurance, copayment, or deductible for the annual wellness visit. Bone mass measurement For qualified individuals (generally, this means people at risk of losing bone mass or at risk of osteoporosis), the following services are covered every 24 months or more frequently if medically necessary: procedures to identify bone mass, detect bone loss, or determine bone quality, including a physician’s interpretation of the results. There is no coinsurance, copayment, or deductible for Medicare-covered bone mass measurement. Breast cancer screening (mammograms) Covered services include: One baseline mammogram between the ages of 35 and 39 One screening mammogram every 12 months for women age 40 and older Clinical breast exams once every 24 months There is no coinsurance, copayment, or deductible for covered screening mammograms. Cardiac rehabilitation services Comprehensive programs of cardiac rehabilitation services that include exercise, education, and counseling are covered for members who meet certain conditions with a doctor’s order. The plan also covers intensive cardiac rehabilitation programs that are typically more rigorous or more intense than cardiac rehabilitation programs. 20% of the cost for Medicare covered services
Colorectal cancer screening For people 50 and older, the following are covered: Flexible sigmoidoscopy (or screening barium enema as an alternative) every 48 months One of the following every 12 months: Guaiac-based fecal occult blood test (gFOBT) Fecal immunochemical test (FIT) DNA based colorectal screening every 3 years For people at high risk of colorectal cancer, we cover: Screening colonoscopy (or screening barium enema as an alternative) every 24 months For people not at high risk of colorectal cancer, we cover: Screening colonoscopy every 10 years (120 months), but not within 48 months of a screening sigmoidoscopy There is no coinsurance, copayment, or deductible for a Medicare-covered colorectal cancer screening exam. Dental services In general, preventive dental services (such as cleaning, routine dental exams, and dental x-rays) are not covered by Original Medicare. We cover: Dental services that are an integral part either of a covered procedure or for extractions done in preparation for radiation treatment for neoplastic devices involving the jaw. Other limited coverage may apply for Medicare covered services. Our plan pays up to $100 every year for preventative dental cleanings and exams and $500 every year for comprehensive dental. 20% of the cost for Medicare covered services Depression screening We cover one screening for depression per year. The screening must be done in a primary care setting that can provide follow-up treatment and referrals. There is no coinsurance, copayment, or deductible for an annual depression screening visit.
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 You pay a $329 copay per day for days 61-90 You pay a $658 per lifetime reserve day 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 diagnostic tests and therapeutic services and supplies Covered services include, but are not limited to: X-rays Radiation (radium and isotope) therapy including technician materials and supplies Surgical supplies, such as dressings Splints, casts and other devices used to reduce fractures and dislocations Laboratory tests Blood - including storage and administration. Coverage of whole blood and packed red cells begins only with the fourth pint of blood that you need - you must either pay the costs for the first 3 pints of blood you get in a calendar year or have the blood donated by you or someone else. All other components of blood are covered beginning with the first pint used. Other outpatient diagnostic tests A 20% of the cost for Medicare covered services A separate facility charge could apply for the facility in which the services are received. In addition, DME, Part B drugs, physicians’ services and doctor’s office visit cost share may also apply
Section 8.2 What if you don’t have your membership card with you? 108 SECTION 9 Part D drug coverage in special situations 108 Section 9.1 What if you’re in a hospital or a skilled nursing facility for a stay that is covered by the plan? 108 Section 9.2 What if you’re a resident in a long-term care (LTC) facility? 108 Section 9.3 What if you’re also getting drug coverage from an employer or retiree group plan? 109 Section 9.4 What if you’re in Medicare-certified hospice? 109 SECTION 10 Programs on drug safety and managing medications 110 Section 10.1 Programs to help members use drugs safely 110 Section 10.2 Medication Therapy Management (MTM) program to help members manage their medications 111 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.)
Stage 1 Yearly Deductible Stage Stage 2 Initial Coverage Stage Stage 3 Coverage Gap Stage Stage 4 Catastrophic Coverage Stage You begin in this payment stage when you fill your first prescription of the year. During this stage, you pay the full cost of your drugs. You stay in this stage until you have paid $405 for your drugs ($405 is the amount of your deductible). (Details are in Section 4 of this chapter.) During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost. You stay in this stage until your year-to-date “total drug costs” (your payments plus any Part D plan’s payments) total $3,750 OR costs. (Details are in Section 5 of this chapter.) During this stage, you pay 35% of the price for brand name drugs (plus a portion of the dispensing fee) and 44% of the price for generic drugs. You stay in this stage until your year-to-date costs” (your payments) reach a total of $5,000 This amount and rules for counting costs toward this amount have been set by Medicare. (Details are in Section 6 of this chapter.) During this stage, the plan will pay most of the cost of your drugs for the rest of the calendar year (through December 31, 2018). (Details are in Section 7 of this chapter.)