2020 UMHA Summary of Benefits - ummedicareadvantage.org...This is a summary of drug and health services covered by University of Maryland Health Advantage Dual . Prime from January

2020 Summary of Benefits

H8854_20_1099_OE_M ACCEPTED: 9/17/2019

Call 1-844-331-6334 (TTY:711) Dual Prime (HMO-SNP)

2020 Summary of BenefitsDual Prime (HMO-SNP) H8854, Plan 002

This is a summary of drug and health services covered by University of Maryland Health Advantage Dual Prime from January 1, 2020 – December 31, 2020. University of Maryland Health Advantage is a HMO-SNP with a Medicare contract and a State of Maryland Medicaid contract. Enrollment in University of Maryland Health Advantage depends on contract renewal.

The benefit information provided 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.”

To join Dual Prime, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, have Medical Assistance from the State of Maryland, and live in our service area. Our service area includes the following counties in Maryland: Anne Arundel, Baltimore, Baltimore City, Caroline, Carroll, Cecil, Charles, Dorchester, Harford, Howard, Kent, Montgomery, Prince George’s, Queen Anne’s, and Talbot. Except in emergency situations, if you use the providers that are not in our network, we may not pay for these services. For coverage and costs of Original Medicare, look in your current “Medicare & You” handbook. View it online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227).TTY users should call 1-877-486-2048. This document is available in other formats such as Braille or large print. For more information, please call us at 1-844-331-6334 (TTY users should call 711), or visit us at www.UMMedicareAdvantage.org.

DUAL PRIME (HMO-SNP)*

PLAN HIGHLIGHTSMonthly Premium:

$0 - $28.40 (based on your level of “extra help”)

Doctor Visits:$0 PCP / $0 Specialist

Generic Prescriptions:As low as $0Dental Care:

Preventive, Comprehensive, & Dentures Vision Services:

$0 copay for a routine exam $150 allowance towards eyewear annually

Hearing Services:$0 copay for a routine exam

Up to $1,350 allowance every 3 years for hearing aids

Over-the-Counter (OTC) Items:$150 quarterly allowance

Transportation:$0 copay 36 one-way trips per year

Meals for Members with a Chronic Condition:

$0 copay for up to 14 per 1 week periodRoutine Foot Care (Podiatry Services)

$0 copay for 4 visits per yearRoutine Chiropractic Care$0 copay for 4 visits per year

Health & Wellness:$0 copay for 1 unique at-home

fitness kit per quarterBathroom Safety Devices

$0 copay for 2 devices each year

DUAL PRIME (HMO-SNP)

Summary of Benefits

BENEFITS DUAL PRIME / HEALTH BENEFITS*Monthly Plan Premium

$0 - $28.40 (based on your level of “extra help”)

Deductible Part C (Medical): $0 Maximum Out-of-Pocket (MOOP)

$6,700 annually (This is the most you pay for copays, coinsurance, and other costs for medical services for the year)

Inpatient Hospital Coverage 1

• Days 1 - 5: $0 per day• Days 6 - 90: $0 per day

Outpatient Hospital Coverage 1

• Ambulatory surgical center: $0 copay• Outpatient hospital: $0 copayThese copays apply to surgical procedures only

Doctor Visits • Primary care physician visit: $0 copay• Specialist visit: $0 copay

Preventive Care $0 copayEmergency Care $0 copayUrgently Needed Services

$0 copay

Diagnostic Tests, Lab and Radiology Services, and X-Rays 1

• Diagnostic radiology services (such as MRIs, CT scans): $0 copay• Diagnostic test and procedures: $0 copay• Lab services: $0 copay• Outpatient x-rays: $0 copay• Therapeutic radiology services (such as radiation treatment for cancer): $0 copay

Hearing Services • Medicare-coved exam to diagnose and treat hearing and balance issues: $0 copay• Routine hearing exam (1 per year): $0 copay• 1 fitting and evaluation with 3 follow up visits within the first year from date of

initial fitting: $0 copay• Our plan pays up to $1,350 every 3 years for hearing aids

*If your Medicaid status changes from Full Benefit Dual Eligible (FBDE) or Qualified Medicare Beneficiary (QMB), your copays and coinsurances may increase to 20% of the total cost for your medical benefits, the applicable Medicare Part A cost-shares, and 25% of the total cost of your Part D prescription drugs.

1 May require prior authorization



Summary of Benefits

BENEFITS DUAL PRIME / HEALTH BENEFITS*

Dental Services Preventive Dental Services: $0 copay• Oral exam & cleaning: every 6 months• Comprehensive oral exam: every

36 months• Fluoride treatment: every 6 months • Palliative treatment: 3 per 12 months

Comprehensive Dental Services: $0 copay and an $800 annual allowance. Member is responsible for all costs over the $800 annual allowance. • Restorative services: 1 per tooth once every 24 months• Endodontics: 1 per lifetime, per patient, per tooth• Crowns: once per tooth per 60 months• Simple Extractions• Periodontics: 1 per quadrant of scaling every 36 months• Periodontal maintenance: once every 3 months • Dentures: once every 60 months (not included under $800 dental allowance)• Denture repairs: once every 12 months• Denture relines/rebase: once every 36 months• Denture adjustments: 2 per 12 months

Vision Services • Medicare-covered exam to diagnose and treat diseases and the conditions of the eye including glaucoma screening: $0 copay

• Medicare-covered eye wear: $0 copay (Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery)

• Routine eye exam: $0 copay - Limited to 1 exam per year• $150 annual allowance towards eyewear, includes contact lenses, eyeglass frames

and lenses

• Bitewing x-ray: once per 12 months• Panoramic x-ray: once every 36 months• Vertical bitewing x-ray: once every 36

months• Intraoral imaging: once every 36 months



Summary of Benefits

BENEFITS DUAL PRIME / HEALTH BENEFITS*

Mental Health Services 1

Inpatient: • Days 1 - 5: $0 per day• Days 6 - 90: $0 per dayOutpatient: • Group therapy visit: $0 copay• Individual therapy visit: $0 copay

Skilled Nursing Facility (SNF)1


Physical Therapy 1 $0 copayAmbulance 1 $0 copay (Prior Authorization on non-emergent rides)Transportation $0 copay for 36 one-way trips per yearMedicare Part B Drugs 1

$0 copay

BENEFITS DUAL PRIME / PRESCRIPTION DRUG BENEFITS*

Deductible Does not applyInitial Coverage Period(30 and 90-day supply available retail or mail order)

For generic drugs (including brand drugs treated as generic), either:$0 copay / $1.30 copay / $3.60 copay (depending on your level of “extra help”)For all other drugs, either:$0 copay / $3.90 copay / $8.95 copay (depending on your level of “extra help”)

Catastrophic Coverage

For generic drugs (including brand drugs treated as generic), you paythe greater of 5% of the cost, or $3.60 For all other drugs, you pay the greater of 5% of the cost, or $8.95




Summary of Benefits

BENEFITS DUAL PRIME / ADDITIONAL HEALTH BENEFITS*

Outpatient Rehabilitation 1

• Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions over a period of up to 36 weeks): $0 copay

• Occupational therapy visit: $0 copay• Speech and language therapy visit: $0 copay

Durable Medical Equipment 1

$0 copay

Home Health Care 1 $0 copayChiropractic Care 1 • Medicare-covered visit: manual manipulation of the spine to correct

subluxation: $0 copay• Routine visit: Treatment of neuromusculoskeletal disorders, including but not

limited to the manual manipulation of the spine, neck, lower back, shoulder, elbow, wrist/hand/finger, hip, ankle/foot/toe: $0 copay - Limited to 4 visits per year

Foot Care (Podiatry Services)

• Medicare-covered services: $0 copay• Routine foot care: the cutting or removal of corns and calluses; the trimming,

cutting, clipping or debriding of nails; and other hygienic and preventive maintenance care: $0 copay - Limited to 4 visits per year

Meals1 Up to 14 meals per 1 week period for members with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), or Diabetes: $0 copay - Limited to 8 benefit periods per year

Over-the-Counter (OTC) Items

$150 quarterly allowance through the plan’s catalog

Bathroom Safety Devices

$0 copay - Limited to 2 devices each year through the plan’s catalog

Health & Wellness Program

1 unique at-home fitness kit per quarter: $0 copay - Limited to 1 kit per quarter

Healthy Rewards Program

Members can receive $15 reward cards for completing select preventive screenings and tests




Statement of Maryland Medical Assistance (Medicaid) Benefits and Cost-Sharing

EligibilityThe Dual Prime plan is available to anyone with both Medicare Parts A and B and who receives Medical Assistance from the state Medicaid program to cover Medicare cost-sharing.

• Dual Prime members with Full Benefit Dual Eligible (FBDE) and Qualified Medicare Beneficiary (QMB) are covered by the state Medicaid program for their Medicare cost sharing.

Cost Sharing and Protection for MembersIn the Dual Prime plan, the state Medicaid program pays the cost sharing for Medicare covered medical services you receive. You pay no cost sharing for the Medicare covered benefits described in the Covered Medical and Hospital Benefits section of this Summary of Benefits. You will pay small copayments for prescriptions covered under the Medicare Part D prescription drug benefit. These small copayments only apply as long as you are receiving “extra help.” When you receive covered health care services, the network provider should bill Dual Prime first and then Maryland Medical Assistance second. Network providers are not permitted to balance bill you for services that are covered by both Dual Prime and Medicaid.

If you receive care from a non-network provider, the provider may not understand Dual Prime or these billing rules. If you receive a bill from a provider for Medicare covered services, please notify Member Services so we can help you. Please see chapter 7, “Asking us to pay our share of a bill you have received for covered medical services or drugs”, of your Dual Prime Evidence of Coverage for more information.

The benefits described are covered by Maryland Medical Assistance (Medicaid). The benefits described in the Covered Medical and Hospital Benefits section of the Summary of Benefits are covered by Medicare. For each benefit listed, you can see what Maryland Medical Assistance covers and what our plan covers. What you pay for these covered services may depend on your level of Medicaid eligibility.


Maryland Medical Assistance (Medicaid) Program Benefits

Depending on your Medicaid category, you may have to make a small co-payment when you receive your medical care, but Medicaid will pay most or all of the bill.

BENEFITS

MARYLAND MEDICAID DUAL PRIME

Ambulance Services

For dual-eligible members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted.

$0 copay

Ambulatory Surgical Services


Ambulatory surgical center: $0 copay

Dental Services Medicaid covers certain emergency dental care for adults.

Preventive dental care, fillings and oral surgery for children.

Preventive Dental Services: $0 copay• Oral exams & cleaning: every 6 months• Comprehensive oral exam: every 36 months• Fluoride treatment: every 6 months • Palliative treatment: 3 per 12 months• Bitewing x-ray: once per 12 months• Panoramic x-ray: once every 36 months• Vertical bitewing x-ray: once every 36 months• Intraoral imaging: once every 36 months




BENEFITS


Dental Services Medicaid covers certain emergency dental care for adults.

Preventive dental care, fillings and oral surgery for children.

Comprehensive Dental Services: $0 copay and an $800 annual allowance. Member is responsible for all costs over the $800 annual allowance. • Restorative services: 1 per tooth once every 24 months• Endodontics: 1 per lifetime, per patient, per tooth• Crowns: once per tooth per 60 months• Simple Extractions• Periodontics: 1 per quadrant of scaling every 36 months• Periodontal maintenance: once every 3 months • Dentures: once every 60 months (not included under $800

dental allowance)• Denture repairs: once every 12 months• Denture relines/rebase: once every 36 months• Denture adjustments: 2 per 12 months

Diagnostic Tests, Lab and Radiology Services, and X-Rays


*Not covered: portable X-ray services; services provided in facilities not meeting the definition of an independent laboratory or X-ray.

• Diagnostic radiology services (such as MRIs, CT scans): $0 copay

• Diagnostic test and procedures: $0 copay• Lab services: $0 copay• Outpatient x-rays: $0 copay• Therapeutic radiology services (such as radiation treatment

for cancer): $0 copay




BENEFITS


Doctor Visits For dual-eligible members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted.

• Primary care physician visit: $0 copay• Specialist visit: $0 copay

Home Health Services(Includes medically necessary intermittent skilled nursing care, home health aide services, and rehabilitation services, etc.)

For dual-eligible members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted.*Not covered: social services, chore services, meals on wheels, audiology services.

$0 copay

Hospice Services

For dual-eligible members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted.*Available to Members certified as being terminally ill and having a medical prognosis of life expectancy of six (6) months or less.

You pay nothing for hospice care from a Medicare certified hospice. You may have to pay part of the costs for drugs and respite care. Hospice is covered outside of our plan. Please contact us for more details.

Inpatient Hospital Coverage (Includes Substance Abuse and Rehabilitation Services)






BENEFITS


Durable Medical Equipment


$0 copay

Mental Health Services


Inpatient • Days 1-5: $0 per day• Days 6-90: $0 per dayOutpatient • Group therapy visit: $0 copay• Individual therapy visit: $0 copay

Outpatient Hospital Coverage


Outpatient hospital: $0 copay

Podiatry Services (Foot Care)

For dual-eligible members, Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted.*Not covered: services for flatfoot; subluxation; routine foot care, supportive devices; vitamin B-12 injections.

Medicare-covered services: $0 copay

Routine foot care: $0 copay - Limited to 4 visits per year




BENEFITS


Prescription Drugs


Initial Coverage Period:

For generic drugs (including brand drugs treated as generic), either: $0 copay/ $1.30 copay/ $3.60 copay(depending on your level of “extra help”)For all other drugs, either: $0 copay/ $3.90 copay/ $8.95 copay(depending on your level of “extra help”)

Catastrophic Coverage:

For generic drugs (including brand drugs treated as generic), you pay the greater of 5% of the cost, or $3.60(depending on your level of “extra help”)For all other drugs, you pay the greater of 5% of the cost, or $8.95(depending on your level of “extra help”)




BENEFITS


Skilled Nursing Facility (SNF)


• Days 1-20: $0 per day• Days 21-100: $0 per day

Transportation(Non-Emergency)

Medicaid covers NET emergency transportation as medically necessary.

$0 copay for 36 one-way trips per year

Vision Services Medically necessary diagnostic services may be covered. Services may only be covered if performed for medical reasons and not for refractive purposes for members twenty-one (21) years of age or older.

• Medicare-covered exam to diagnose and treat diseases and the conditions of the eye including glaucoma screening: $0 copay

• Medicare-covered eye wear: $0 copay (Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery)

• Routine eye exam: $0 copay - Limited to 1 exam per year• $150 annual allowance towards eyewear, includes

contact lenses, eyeglass frames and lenses.

You can access the Evidence of Coverage (EOC), which provides a full listing of our plan’s benefits and services, on our website at www.UMMedicareAdvantage.org, or by calling the telephone number listed below. You may view our plan’s Provider Directory at our website at www.UMMedicareAdvantage.org/Find-a-Doctor. You can see our plan’s Pharmacy Directory at our website at www.UMMedicareAdvantage.org/Find-a-Medication-Pharmacy. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website at www.UMMedicareAdvantage.org/Find-a-Medication-Pharmacy.

1-844-331-6334 (TTY:711)

Hours of Operation:October 1 – March 31

8 am – 8 pm ET | 7 days a weekApril 1 – September 30

8 am – 8 pm ET | Monday - Friday

www.UMMedicareAdvantage.org


Documents

2020 UMHA Summary of Benefits - ummedicareadvantage.org...This is a summary of drug and health services covered by University of Maryland Health Advantage Dual . Prime from January