community health plan of washington tm€¦ · total drug cost paid by you and part d plan. stage...

2021 Summary of Benefits

Get More Than Original Medicare

H5826_MA_197_2021_SB_Plan2_M

Community Health Plan of Washington Medicare Advantage Plan 2 (HMO)

MEDICARE ADVANTAGE COMMUNITY HEALTH PLANof WashingtonTM

The power of community

1H5826_MA_197_2021_SB_Plan2_M

Get More From Your Medicare Plan

100% covered preventive care services

Prescription drug coverage with a large network of

local pharmacies

Eye exam (1 per year) and eyewear up to $150

(every 2 years)

$0 copay for unlimited preventive

dental services

Free home fitness kit and fitness center membership

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Monthly Plan Premium $26.50 per month

In addition, you must keep paying your Medicare Part B Premium.

Note: Depending on your level of "Extra Help" subsidy, your $26.50 premium may be reduced to as low as $0.

Deductible This plan does not have a deductible

Maximum Out-of-Pocket Responsibility (does not include prescription drugs)

Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers. If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your share of the cost of your Part D prescription drugs.

Inpatient Hospital Our plan covers an unlimited number of days for an inpatient hospital stay.

· $450 copay per day for days 1 through 4 · $0 copay days 5 through 90

Each new inpatient stay begins with a new day 1

Services with a 1 may require prior authorization. Services with a 2 may require a referral from your doctor.

Section ll Summary of Premiums & BenefitsCHPW Medicare Advantage Plan 2

Your benefits at a glance

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If you have any questions about this plan's benefits or costs, please contact one of our Medicare experts at 1-800-944-1247 TTY Relay: Dial 711

Outpatient Hospital $275 copay for Medicare-covered outpatient hospital observation services.

$275 copay for Medicare-covered outpatient hospital surgery and other services.

Doctor Visits

(Primary care and Specialists1,2)Primary care physician visit*: $10 copay

Specialist visit*: $45 copay

*Including telehealth visits

Preventive Care2 $0 copay for preventive services, such as flu shots, and yearly "Wellness" visits

Any additional preventive services approved by Medicare during the contract year will be covered. Eight counseling calls per year and Nicotine Replacement Therapy of up to 12 weeks are also available. Please call for more details.

Emergency Care $90 copay

If you are admitted to the hospital within 24 hours, you pay the inpatient hospital copay instead of the Emergency copay. See “Inpatient Hospital Care” section of this booklet for other costs.

Urgently Needed Services $10 copay for Medicare-covered urgently-needed care visits.

If additional services are provided, cost sharing may apply. For urgently needed services received outside of the U.S. and its territories, please see “Worldwide emergency/urgent care.”

Diagnostic Services/Labs/Imaging1 Diagnostic radiology services (such as MRIs, CT scans): 20% of the cost

Diagnostic tests and procedures: 20% of the cost

Lab services: $0 copay

Outpatient X-rays: $15 copay

Therapeutic radiology services, such as radiation treatment for cancer: 20% of the cost

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Hearing Services1,2 Medicare-covered diagnostic hearing exams.: 20% of the cost

Routine hearing exams and hearing aids are not covered

Dental Services1 Dental Services: 20% of the cost for Medicare-covered dental benefits.

Dental Services (supplemental): $0 copay for unlimited preventive dental services. Our supplemental benefit includes preventive dental benefits not generally covered by Medicare. Our supplemental preventive dental benefits include:

· oral exams · cleanings

· fluoride treatments · preventive dental X-rays

Comprehensive dental services are not covered.

Vision Services Vision services: 20% of the cost for Medicare-covered exams to diagnose and treat diseases and conditions of the eye.

Vision services (supplemental): (Through the Vision Service Plan (VSP) Choice Network) · $0 copay for one WellVision exam every year.

· Up to $150 benefit limit every two years for supplemental vision hardware.

Outside of the VSP Choice network: · 100% of the cost over the plan benefit limit.


Section ll Summary of Premiums & BenefitsCHPW Medicare Advantage Plan 2

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Mental Health Services1,2 Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.

For Medicare-covered inpatient psychiatric hospital stays: · $310 copay per day for days 1 through 5 · $0 copay per day for days 6 through 90

Outpatient group and/or individual therapy visit: $30 copay

If additional services are provided, cost sharing may apply.

Skilled Nursing Facility (SNF)1,2 Our plan covers up to 100 days in a SNF.· $0 copay per day for days 1 through 20 · $160 copay per day for days 21 through 100

Physical Therapy $40 copay for each Medicare-covered outpatient visit

Ambulance1 $325 copay for one-way, Medicare-covered ambulance benefits.

Transportation Not covered

Medicare Part B Drugs For Part B drugs such as chemotherapy drugs1: 20% of the cost

Other Part B drugs1: 20% of the cost

For part D drug coverage please see the next section.

Ambulatory Surgery Center $275 copay


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Section lll Summary of Drug CoverageCHPW Medicare Advantage Plan 2

Medicare Part D Drugs Deductible No Deductible

Coverage for your medicines

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You may get your drugs at network retail pharmacies and mail order pharmacies.

Retail cost sharing

Preferred Pharmacy Standard Pharmacy

Tier 30 Day supply 90 Day supply 30 Day supply 90 Day supply

Tier 1: Preferred Generic $0 copay $0 copay $5 copay $10 copay

Tier 2: Generic $10 copay $20 copay $15 copay $30 copay

Tier 3: Preferred Brand $42 copay $125 copay $47 copay $140 copay

Tier 4: Non-preferred Drug 50% of the cost 50% of the cost 50% of the cost 50% of the cost

Tier 5: Speciality Tier 33% of the cost Not covered Not covered Not covered

Standard Mail Order Cost-Sharing

Tier 90 Day supply

Tier 1: Preferred Generic $0 copay

Tier 2: Generic $20 copay

Tier 3: Preferred Brand $125 copay 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 at a standard retail pharmacy.

Stage 1: Initial Coverage

You pay the cost share for Tier 1, Tier 2, Tier 3, Tier 4, and Tier 5 Part D prescription drug until your yearly drug costs reach $4,130. Total yearly drug costs are the total drug cost paid by you and Part D plan.

Stage 2: Coverage Gap

After your total drug costs reach $4,130, you will pay no more than 25% coinsurance for generic drugs or 25% coinsurance for brand name drugs, for any drug tier during that coverage gap between the True-Out-Of-Pocket (TrOOP) costs $4,130 to $6,550.

Stage 3: Catastrophic Coverage

After your yearly our-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $6,550, you pay the greater of:

· 5% coinsurance, or

· $3.70 copay for generic (including brand drugs treated as generic) or $9.20 copay for all other drugs.

Note: Depending on your level of "Extra Help" subsidy, your pharmacy cost-shares may be reduced

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Alternative Medicine1,2

(Acupuncture, Chiropractic and Naturopathy)Chiropractic Services: $20 for each Medicare-covered visit. Manual manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position)

Chiropractic Services (Supplemental): $0 copay. Covered services include routine chiropractic visits combined with acupuncture and naturopathic visits up to the plan maximum of 12 visits per calendar year combined.

These services must be performed by a state certified practitioner.


Section lV Summary of Other BenefitsCHPW Medicare Advantage Plan 2

Extra benefits for you

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Telehealth Services We cover telehealth services, including virtual visits with:

· Primary care provider

· Specialist

· Urgent Care

· Individual and group sessions for outpatient mental health, psychiatric, and substance abuse

You pay the same as you would for an in-person visit.

Diabetic Supplies/Diabetes Supplies and Services

$0 for the cost of Medicare-covered diabetic self-management, diabetes services and supplies. Diabetic medication, such as insulin, injected by syringe is typically covered by your Part D prescription drug coverage.

Durable Medical Equipment 1 20% of the cost for Medicare-covered durable medical equipment.

Fitness Program $0 copay for the following: · Home fitness kit (options include activity tracker, videos, · and exercise equipment) · Membership at a participating fitness center · Online and smartphone fitness app tools


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Foot Care1,2

(podiatry services)Podiatry Services: $0 copay for each Medicare-covered podiatry visit.

Covered services include: · Diagnosis and the medical or surgical treatment of injuries · and diseases of the feet (such as hammer toe or heel spurs) · Routine foot care for members with certain medical · conditions affecting the lower limbs.

Podiatry Services (supplemental): $0 copay for each supplemental podiatry visit. Our supplemental benefit includes up to four (4) visits per year for non-Medicare covered foot care from a Medicare-approved foot care provider.

Home Health Care1,2 $0 copay for Medicare-covered home health visits.

Hospice When you enroll in a Medicare-certified hospice program, your hospice services and your Part A and Part B services related to your terminal prognosis are paid for by Original Medicare, not Community Health Plan of Washington Medicare Advantage.

Meals You pay nothing for covered meals up to the maximum benefit.Benefit includes 2 meals per day for up to 14 days post discharge from each hospital admission or skilled nursing facility admission. Meal program limited to 6 times per calendar year.


Section lV Summary of Other BenefitsCHPW Medicare Advantage Plan 2

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Outpatient Substance Abuse1,2 Group therapy visit: 20% of the cost

Individual therapy visit: 20% of the cost

Over the Counter Benefit Not covered

Prosthetic Devices1 (Braces, artificial limbs, etc.)

Medicare-covered:

Prosthetic Devices 20% of the cost

Medical Supplies 20% of the cost

Renal Dialysis1 20% of the cost

Worldwide Emergency/Urgent Care 20% of the cost for worldwide emergency/urgent care up to the coverage limit of $25,000 per year.

This plan covers supplemental emergency services, urgent services, and emergency transportation received outside of the U.S. and its territories up to a plan coverage limit. This does not apply to the Maximum Out-of-Pocket.

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Coinsurance The percentage you pay as your share of the cost for medical services or prescription drugs. For example, if you have 20 percent coinsurance, you pay 20 percent of the cost of your medical bill.

Copay The fixed amount you pay as your share of the cost of a medical service or supply. For example, you might have a $20 copay every time you see your primary care doctor.

Deductible The amount you pay for health care services or prescriptions before your insurance begins to pay.

Extra Help A Medicare program to help people with limited income and resources pay prescription drug program costs, like premiums, deductibles, and coinsurance.

Long-term care Services and support for people who can’t perform basic activities of daily living, like dressing and bathing. Medicare and most health insurance plans do not pay for long-term care.

Medicaid A state and federal program that provides health coverage to low-income people.

Medicare Advantage Also known as Part C. A type of Medicare plan offered by a private company approved by Medicare. A Medicare Advantage plan is an alternative to Original Medicare. It provides all of your Part A and Part B benefits and often offers extra benefits, like dental and vision care.

Original Medicare Medicare Part A (hospital insurance) and Part B (medical insurance). Most people get it when they turn 65. The federal government manages Original Medicare.

Out-of-pocket maximum The most you have to pay for covered services in one year. Once you reach this amount, your insurance covers 100 percent of your medically necessary care for the rest of the year.

Premium The money you pay monthly to Medicare or a health care plan for coverage.

Preventive services Health care to prevent or detect illness at an early stage. Most health plans must cover some important preventive services, like flu shots and blood pressure screening, at no cost to you.

Notes

Section V Glossary Terms and Notes

MEDICARE ADVANTAGE COMMUNITY HEALTH PLANof WashingtonTM

The power of community

1111 3rd Ave, Suite 400

Seattle, WA 98101-3207

medicare.chpw.org

Prospective Members: 1-800-944-1247

Current Members: 1-800-942-0247

TTY Relay: Dial 711

8:00 a.m. to 8:00 p.m. 7 days a week

Contact us

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