summary of benefits · summary of benefits 2020 h1587_003sb20_m member services: 1-877-372-1033...

SUMMARY OF BENEFITS2020

H1587_003SB20_M

Member Services: 1-877-372-1033 (TTY users call 711)8:00 a.m. to 8:00 p.m., 7 days a weekSuperiorSelectMedicare.com

Summary of Benefits Plan Year 2020 This is a summary of drug and health services covered by

Tribute Select (HMO-POS I-SNP) January 1, 2020 – December 31, 2020

Tribute Select (HMO-POS I-SNP) is a Medicare Advantage HMO plan with a Medicare contract. Enrollment in the Plan 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. A complete list of services can be found in the “Evidence of Coverage” (EOC) which can be accessed from our website, www.SuperiorSelectMedicare.com, or you can call and request one be mailed to you. To join Tribute Select (HMO-POS I-SNP), you must reside in Arkansas and require institutional level of care and live in the community or within a contracted long-term care facility.

Tribute Select (HMO-POS I-SNP) 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.

For further questions regarding Tribute Select, contact Member Services at: 1-877-372-1033

Calls to this number are free. Hours are 8:00 a.m.-8:00 p.m. seven (7) days a week. TTY call 711 (This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking).

Or visit our website, www.SuperiorSelectMedicare.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 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.

1

Premiums and Benefits Tribute Select (HMO-POS I-SNP) Monthly Premium $0-25 depending on your level of assistance

You must continue to pay your Medicare Part B premium or ensure that your coverage continues.

Deductible Original Medicare Part A deductible amount applies. For Plan Year 2020, this amount is $1,408.

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

$6700 annually

Inpatient Hospital Coverage $1,408 deductible for each benefit period Days 1-60: $0 coinsurance Days 61-90: $352 coinsurance Days 91 and beyond: $704 coinsurance per each “lifetime reserve day” (up to 60 days over your lifetime) Beyond lifetime reserve days: all costs Prior Authorization is required

Outpatient Hospital Coverage 20% coinsurance

Doctor Visits • Primary • Specialist

20% coinsurance 20% coinsurance

Preventative Care You pay nothing

Emergency Care 20% coinsurance Urgently Needed Services 20% coinsurance Diagnostic Services/Imaging

• Diagnostic radiology service (ex. MRI)

• Diagnostic tests and procedures

• Outpatient x-rays

20% coinsurance

Lab Services 0% coinsurance Dental Services 20% coinsurance on Medicare covered services

2

Premiums and Benefits Tribute Select (HMO-POS I-SNP) Hearing Services $1,000 annual benefit for hearing services includes:

hearing exam and hearing aid Vision Services $50 annual benefit for vision exam

$75 annual benefit for eyeglasses (lens and frames) Mental Health Services

• Outpatient group therapy visit

Outpatient individual therapy visit

20% coinsurance Prior Authorization is required

Skilled Nursing Facility $0 per day for days 1-20 $176 per day for days 21-100 Zero hospital days required prior to SNF admission Prior Authorization may be required

Rehabilitation Services • Occupational therapy visit • Physical therapy and speech

and language therapy visit

20% coinsurance Prior Authorization is required

Ambulance 20% coinsurance Prior Authorization is required for non-emergency ambulance transport

Transportation Not covered Medicare Part B Drugs 20% coinsurance

Prior Authorization may be required

Ambulatory Surgery Center 20% coinsurance Prior Authorization is required

Medical Equipment/Supplies • Durable Medical Equipment

(ex. Wheelchairs, oxygen) • Prosthetics (ex. Braces,

artificial limbs) • Diabetes Supplies

20% coinsurance DME services may be provided prior to qualification under Medicare coverage rules if determined to be in members best interest for the prevention of medical condition decline. Prior Authorization may be required

Depending on your level of Medicaid enrollment, your out of pocket costs for services listed above may be $0 as Medicaid will pay your

share of the charge

3

Outpatient Prescription Drugs

Stage 1

Yearly Deductible Stage

Stage 2

Initial Coverage Stage

Stage 3

Coverage Gap Stage

Stage 4

Catastrophic Coverage Stage

What You Should Know

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 $435 for your drugs ($435 is the amount of your deductible).

Depending on your extra help, your deductible may be lower

During this stage, the plan pays its share of the cost of your drugs and you (or others on your behalf) 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 $4,020.

During this stage, you pay 25% of the price for brand name drugs and 25% of the price for generic drugs.

You stay in this stage until your year-to-date “out-of-pocket costs” (your payments) reach a total of $6,350. This amount and rules for counting costs toward this amount have been set by Medicare.

During this stage, the plan pays most of the cost for your covered drugs. (through December 31, 2020)

For each prescription, you pay whichever of these is larger: a payment equal to 5% of the cost of the drug (this is called “coinsurance”), or a copayment ($3.60 for a generic drug or a drug that is treated like a generic, $8.95 for all other drugs)

Cost-Sharing may change depending on when you enter another phase of the Part D benefit. For more information on the additional pharmacy specific cost-sharing and the phases of the benefit, please call us or access our Evidence of Coverage online.

4

Cost-Sharing for One-Month Supply of Part D Prescription Drugs*

Standard Retail cost-sharing (in-

network) (up to 30-day

supply)

Preferred Retail cost-sharing (in-network)

(up to 30-day supply)

Mail-Order cost-sharing


Long-term care (LTC) cost-sharing


Out-of-Network cost-sharing

(coverage limited to certain

situations; see EOC for details.)

(Up to 30-day supply)

25% 25% 25% 25% 25%

*Depending on your “Extra Help”, income and institutional status, you pay the following: For generic drugs (including brand drugs treated as generic), either:

For all other drugs, either:

• $0 copay; or • $1.30 copay; or • $3.60 copay; or • 15%

• $0 copay; or • $3.90 copay; or • $8.95 copay; or • 15%

Tribute Health Plans PO Box 3630

Little Rock, AR 72202 SuperiorSelectMedicare.com

Anti-Discrimination Notice as defined in Section 1557 of the Affordable Care Act of 2010

English Tribute Health Plans complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, gender or sex. Superior Select Health Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Tribute Health Plans: • Provides free aids and services to people with disabilities to communicate

effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic

formats, other formats)• Provides free language services to people whose primary language is not English,

such as: Qualified interpreters Information written in other languages

If you need these services, contact Paige Harrington. If you believe that Tribute Health Plans 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 with:

Paige Harrington, Corporate Compliance Officer 1 Riverfront Place, Suite 615 North Little Rock, AR 72114

1-877-372-1033, (TTY: 711), [email protected].

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Paige Harrington, Corporate Compliance Director 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, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

H1587_ANTIDISCRIM20_C

mailto:[email protected]

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

Tribute Health Plans PO Box 3630 | Little Rock, AR 72202

Phone: 877‐372‐1033 | Fax: 866‐705‐3652 SuperiorSelectMedicare.com

H1587_003MULTILANG20_C

English Non-Discrimination Statement

Tribute Select (HMO-POS I-SNP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, gender or sex. Español (Spanish)

Si us ted, o alguien a quien usted está ayudando, tiene preguntas acerca de Tribute Select (HMO-POS I-SNP), tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame al 1-877-372-1033 (TTY:711). (Chinese)

如果您，或是您正在協助的對象，有關於[插⼊SBM項⽬的名稱 Tribute Select (HMO-POS

I-SNP), ⽅⾯的問，您有權利免費以您的⺟語得到幫助和訊息。洽詢⼀位翻譯員，請撥電話在此插⼊數字1-877-372-1033 (TTY:711)。

Tiếng Việt (Vietnamese)

Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Tribute Select (HMO-POS I-SNP), quý vịsẽcó uyền được giúp và có thêm thông tin bằng ngôn ngữcủa mình miễn phí. Đểnói chuyện với mộ thông ịch viên, xin gọi 1-877-372-1033 (TTY:711). (Laotian)

ຖ້າທ່ານ, ຫືຼຄົນທ່ທ່ານກໍາລັງຊ່ວຍເຫືຼອ, ມຄໍາຖາມກ່ຽວກັບ Tribute Select (HMO-POS I-SNP), ານມສິດທ່ຈະໄດ້ຮັບການຊ່ວຍເຫືຼອແລະຂ້ໍມູນຂ່າວສານທ່ເປັນພາສາຂອງທ່ານບ່ໍມຄ່າໃຊ້ຈ່າຍ. ການໂອ້ລົມກັບນາຍພາສາ, ໃຫ້ໂທຫາ1-877-372-1033 (TTY:711). (Tagalog)

Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Tribute Select (HMO-POS I-SNP), may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1-877-372-1033 (TTY:711). Arabic

بخصوص أسئلة تساعده شخص لدى أو كلدي كان إن Tribute Select (HMO-POS I-SNP) ، والمعلومات المساعدة على الحصول في الحق فلديك

اتصل مترجم مع للتحدث. تكلفة اية دون من بلغتك الضرورية - TTY:711) 1033 372-877-1




German

Falls Sie oder jemand, dem Sie helfen, Fragen zum Tribute Select (HMO-POS I-SNP) haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-877-372-1033 (TTY:711). an. Korean

만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Tribute Select (HMO-POS I-SNP) 에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1-877-372-1033 (TTY:711) 로 전화하십시오. Hmong

Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Tribute Select (HMO-POS I-SNP), koj muaj cai kom lawv muab cov ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu rau 1-877-372-1033 (TTY:711). Hindi

ियद आपके ,या आप ◌ारा सहायता ककए जा रहे ककसी त के Tribute Select (HMO-POS I-SNP) के बारे म ह ,तो आपके पास अपनी भाषा म मु म सहायता और सूचना ा करने का िअधकार है। ककसी ि◌◌◌◌ुभाषषए से बात करने के ि◌लए , 1-877-372-1033 (TTY:711). पर कॉि◌◌ कर । Japanese

ご本⼈様、またはお客様の⾝の回りの⽅でも、Tribute Select (HMO-POS I-SNP) ついてご質問がございましたら、ご希望の⾔語でサポートを受けたり、情報を⼊⼿したりすることができます。料⾦はかかりません。通訳とお話される場合、1-877-372-1033

(TTY:711) までお電話ください。

French

Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Tribute Select (HMO-POS I-SNP), vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun coût. Pour parler à un interprète, appelez 1-877-372-1033 (TTY:711). an.




Portuguese

Se você, ou alguém a quem você está ajudando, tem perguntas sobre o Tribute Select (HMO-POS I-SNP), você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para falar com um intérprete, ligue para 1-877-372-1033 (TTY:711). Gujarati

જો તમે અથવા તમે કોઇને મદદ કરી રહ્◌◌ા◌◌ા◌◌ં તેમ ◌◌ા◌◌ંથી કોઇને [એસબીએમ ક ય મન ◌◌ા◌◌ં ન મ મ કો] િ◌વશે ◌ો હોર્ તો તમને મદદ અને મ હહતી મેિ◌િળ◌ નો િઅવક ર છે. તે ખય િ◌વન તમ રી ભ ષ મ ◌◌ા◌◌ં કરી શક ર્ છે. દ ભ વષર્◌◌ો િ◌◌ ત િકર મ ટે,આ [અહી ંદ ખલ કરો નાંબર ] પર કોલ કરો. Tribute Select (HMO-POS I-SNP) 1-877-372-1033 (TTY:711) Telugu

� �ఎవ � � గర�సహ రయం� ం న �వయ �Tribute Select (HMO-POS I-SNP రం �పష న �ఉం , � � ష �ఏ�ఖ � ం �సహ రయం�మర �

స రం�పం ట �అ రం�ఉం . వ యఖయత � ట డ క�1-877-372-1033 (TTY:711) డయల� యం .

Member Services: 1-877-372-1033 (TTY users call 711)8:00 a.m. to 8:00 p.m., 7 days a weekSuperiorSelectMedicare.com

summary of benefits · summary of benefits 2020 h1587_003sb20_m member services: 1-877-372-1033...

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