Upload
dinhnguyet
View
213
Download
0
Embed Size (px)
Citation preview
SUMMARY OF BENEFITS January 1 2016 - December 31 2016
Cigna-HealthSpringreg TotalCare (HMO SNP) H4513 - 010
copy 2015 Cigna H4513_16_32742 Accepted
SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS
This booklet gives you a summary of what we cover and what you pay It doesnrsquot list every service that we cover or list every limitation or exclusion To get a complete list of services we cover call us and ask for the ldquoEvidence of Coveragerdquo
You have choices about how to get your Medicare benefits
bull One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare) Original Medicare is run directly by the Federal government
bull Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Cigna-HealthSpring TotalCare (HMO SNP))
Tips for comparing your Medicare choices
This Summary of Benefits booklet gives you a summary of what Cigna-HealthSpring TotalCare (HMO SNP) covers and what you pay
bull If you want to compare our plan with other Medicare health plans ask the other plans for their Summary of Benefits booklets Or use the Medicare Plan Finder on httpwwwmedicaregov
Sections in this booklet
bull Things to Know About Cigna-HealthSpring TotalCare (HMO SNP)
bull Monthly Premium Deductible and Limits on How Much You Pay for Covered Services
bull Covered Medical and Hospital Benefits
bull Prescription Drug Benefits
bull If you want to know more about the coverage and costs of Original Medicare look in your current ldquoMedicare amp Yourdquo handbook View it online at httpwwwmedicaregov 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
This document is available in other formats such as Braille and large print
This document may be available in a non-English language For additional information call us at 1-800-668-3813
Este documento puede estar disponible en un idioma distinto al ingleacutes Para obtener informacioacuten adicional llaacutemenos al 1-800-668-3813
THINGS TO KNOW ABOUT CIGNA-HEALTHSPRING TOTALCARE (HMO SNP)
Hours of Operation Which doctors hospitals and pharmacies can I use
You can call us 7 days a week from 800 am to 800 pm Local time Cigna-HealthSpring TotalCare
(HMO SNP) has a network of doctors Cigna-HealthSpring TotalCare hospitals pharmacies and other (HMO SNP) Phone Numbers providers If you use the providers that and Website are not in our network the plan may not
pay for these services bull If you are a member of this plan
call toll-free 1-800-668-3813 You must generally use network pharmacies to fill your prescriptions
bull If you are not a member of this plan for covered Part D
call toll-free 1-800-846-2098 You can see our plans provider directory
bull Our website at our website
httpwwwcignahealthspringcom (wwwcignahealthspringcom) You can see our plans pharmacy directory at our
Who can join website (wwwcignahealthspringcom)
To join Cigna-HealthSpring TotalCare Or call us and we will send you a copy
(HMO SNP) you must be entitled to of the provider and pharmacy directories
Medicare Part A be enrolled in Medicare Part B and Texas Medicaid and live in our
What do we cover service area
Like all Medicare health plans we cover Our service area includes the following
everything that Original Medicare covers - counties in Texas Angelina Brazoria
and more Cameron Chambers El Paso Fort Bend Galveston Hardin Harris Hidalgo bull Our plan members get all of Jasper Jefferson Liberty Montgomery the benefits covered by Original Nacogdoches Newton Orange Polk San Medicare Jacinto Tyler Walker Waller Webb and
bull Our plan members also get Willacy more than what is covered by denotes partial county (77510 77511 Original Medicare Some of the 77517 77518 77539 77546 77549 extra benefits are outlined in 77563 77565 77568 77573 77574 this booklet 77590 77591 77592)
We cover Part D drugs In addition How will I determine my drug costs we cover Part B drugs such as
The amount you pay for drugs depends on chemotherapy and some drugs
the drug you are taking and what stage of administered by your provider
the benefit you have reached Later in this bull You can see the complete plan document we discuss the benefit stages
formulary (list of Part D that occur after you meet your deductible prescription drugs) and any Initial Coverage Coverage Gap and restrictions on our website Catastrophic Coverage httpwwwcignahealthspringcom
bull Or call us and we will send you a copy
of the formulary
SECTION II - SUMMARY OF BENEFITS
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Monthly Premium Deductible and Limits on How Much You Pay for Covered Services
How much is the $2800 per month In addition you must keep paying your Medicare Part B monthly premium premium
How much is the deductible $0 to $74 per year for Part D prescription drugs
Is there any limit on Yes Like all Medicare health plans our plan protects you by having yearly limits how much I will pay for on your out-of-pocket costs for medical and hospital care my covered services In this plan you will pay nothing for Medicare-covered services
Refer to the ldquoMedicare amp Yourdquo handbook for Medicare-covered services For Texas Medicaid-covered services refer to the Medicaid Coverage section in this document
Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs
Is there a limit on how Our plan has a coverage limit every year for certain in-network benefits much the plan will pay Contact us for the services that apply
Cigna-HealthSpring is contracted with Medicare for PDP plans HMO and PPO plans in select states and with select State Medicaid programs Enrollment in Cigna-HealthSpring depends on contract renewal
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Covered Medical and Hospital Benefits Note Services with a 1 may require prior authorization
Services with a 2 may require a referral from your doctor
Outpatient Care and Services
Acupuncture Not covered
Ambulance1 You pay nothing
Chiropractic Care2 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position) You pay nothing
Dental Services1 Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth) $0 copay
Preventive dental services bull Cleaning (for up to 1 every six months) $0 copay bull Dental x-ray(s) (for up to 1 every year) $0 copay bull Oral exam (for up to 1 every six months) $0 copay Comprehensive services bull Restorative ndash Fillings Crowns $0 copay bull Periodontics $0 copay bull Extractions $0 copay bull Prosthodontics $0 copay bull Oral Surgery $0 copay
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Diabetes Supplies and Services2
Diabetes monitoring supplies You pay nothing Diabetes self-management training You pay nothing Therapeutic shoes or inserts You pay nothing
Diagnostic Tests Lab and Radiology Services and X-Rays (Costs for these services may vary based on place of service)12
Diagnostic radiology services (such as MRIs CT scans) You pay nothing Diagnostic tests and procedures You pay nothing Lab services You pay nothing Outpatient x-rays You pay nothing Therapeutic radiology services (such as radiation treatment for cancer) You pay nothing
Doctorrsquos Office Visits12 Primary care physician visit You pay nothing Specialist visit You pay nothing
Durable Medical Equipment (wheelchairs oxygen etc)1
You pay nothing
Emergency Care You pay nothing
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Foot Care Foot exams and treatment if you have diabetes-related nerve damage andor (podiatry services)2 meet certain conditions You pay nothing
Hearing Services2 Exam to diagnose and treat hearing and balance issues $0 copay Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids Please see your EOC for plan coverage details
Home Health Care1 You pay nothing
Mental Health Care1 Inpatient visit
Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital
Our plan covers 90 days for an inpatient hospital stay
Our plan also covers 60 ldquolifetime reserve daysrdquo These are ldquoextrardquo days that we cover If your hospital stay is longer than 90 days you can use these extra days But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days bull You pay nothing per day for days 1 through 90
Outpatient group therapy visit You pay nothing
Outpatient individual therapy visit You pay nothing
Outpatient Rehabilitation12 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing Occupational therapy visit You pay nothing Physical therapy and speech and language therapy visit You pay nothing
Outpatient Group therapy visit You pay nothing Substance Abuse1 Individual therapy visit You pay nothing
Outpatient Surgery12 Ambulatory surgical center You pay nothing Outpatient hospital You pay nothing
Over-the-Counter Items Please visit our website to see our list of covered over-the-counter items Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Prosthetic Devices Prosthetic devices You pay nothing (braces artificial limbs etc)1 Related medical supplies You pay nothing
Renal Dialysis12 You pay nothing
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Transportation1 You pay nothing $0 copayment for unlimited one‑way trips to plan‑approved location ever year Please see your EOC for plan coverage details
Urgently Needed Services You pay nothing If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for urgently needed services See the ldquoInpatient Hospital Carerdquo section of this booklet for other costs
Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) $0 copay
Routine eye exam (for up to 1 every year) $0 copay
Contact lenses $0 copay
Eyeglasses (frames and lenses) (for up to 1 every year) $0 copay
Eyeglass frames (for up to 1 every year) $0 copay
Eyeglass lenses (for up to 1 every year) $0 copay
Eyeglasses or contact lenses after cataract surgery $0 copay
Our plan pays up to $250 every year for eyewear
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Preventive Care You pay nothing
Our plan covers many preventive services including
bull Abdominal aortic aneurysm screening
bull Alcohol misuse counseling
bull Bone mass measurement
bull Breast cancer screening (mammogram)
bull Cardiovascular disease (behavioral therapy)
bull Cardiovascular screenings
bull Cervical and vaginal cancer screening
bull Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
bull Depression screening
bull Diabetes screenings
bull HIV screening
bull Medical nutrition therapy services
bull Obesity screening and counseling
bull Prostate cancer screenings (PSA)
bull Sexually transmitted infections screening and counseling
bull Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
bull Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
bull ldquoWelcome to Medicarerdquo preventive visit (one-time)
bull Yearly ldquoWellnessrdquo visit
Any additional preventive services approved by Medicare during the contract year will be covered
Annual physical exam You pay nothing
Hospice You pay nothing for hospice care from a Medicare-certified hospice You may have to pay part of the cost for drugs and respite care Hospice is covered outside of our plan Please contact us for more details
Inpatient Care
Inpatient Hospital Care12 Our plan covers an unlimited number of days for an inpatient hospital stay
bull You pay nothing per day for days 1 through 90
bull You pay nothing per day for days 91 and beyond
Inpatient Mental Health Care For inpatient mental health care see the ldquoMental Health Carerdquo section of this booklet
Skilled Nursing Facility (SNF)1
Our plan covers up to 100 days in a SNF
bull You pay nothing per day for days 1 through 100
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Prescription Drug Benefits
How much do I pay For Part B drugs such as chemotherapy drugs1 You pay nothing Other Part B drugs1 You pay nothing
Initial Coverage Depending on your income and institutional status you pay the following For generic drugs (including brand drugs treated as generic) either
bull $0 copay or bull $120 copay or bull $295 copay
For all other drugs either bull $0 copay or bull $360 copay or bull $740 copay
You may get your drugs at network retail pharmacies and mail order pharmacies
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 an in-network pharmacy
Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Additional Plan Benefits
24-hour Nurse Line $0 copay for 24-hour Nurse Line
Caring registered nurses are available by phone 24 hours a day 7 days a week to answer your health questions in a confidential and convenient service
Fitness $0 copay for membership in Health ClubFitness Classes
Please see your EOC for plan coverage details
Home Safety $1500 allowance once per lifetime for the purchase and installation of approved safety devices in bathrooms Please see your EOC for plan coverage details
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H4513 PLAN 010
This section demonstrates the Medicaid Medicare Part A and B cost sharing when benefit package for full benefit dual-eligible the state is responsible for paying these recipients in the state of Texas The amounts For more information about your services offered in your Medicaid benefit Medicaid benefits and copayments please package are based on your Medicaid contact the State Medicaid Office eligibility level (Categorically Needy or
The benefits described below are covered Medically Needy) Medicare coverage must
by Medicaid The benefits described in the be used first and the Medicaid Program may
Covered Medical and Hospital Benefits cover payment of Medicare Part A and B
section of the Summary of Benefits are deductible and coinsurance for all Medicare
covered by Medicare For each benefit listed covered services The services listed below
below you can see what Texas Medicaid are available only to those SNP members
covers and what our plan covers What you eligible under Medicaid for medical services
pay for covered services may depend on If you are eligible for both Medicare and
your level of Medicaid eligibility Medicaid you will not be held liable for
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Important Information
Premium and other important information
Medicaid assistance with premium payment may vary based on your level of Medicaid eligibility
Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for Original Medicare services
$2800 monthly plan premium in addition to your monthly Medicare Part B premium
In-Network
In this plan you will have no cost-sharing responsibility for Medicare-covered services
Doctor and hospital choice (For more information see Emergency Care and Urgently Needed Care)
For those who meet QMB requirements Medicaid pays coinsurance copayments and deductibles for Medicare-covered services Members should follow Medicare guidelines related to hospital and doctor choice
$0 copay for Medicaid-covered services
In-Network
You must go to network doctors specialists and hospitals
Referral required for network hospitals and specialists (for certain benefits)
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Inpatient Care
Inpatient Hospital Care (Includes substance abuse and rehabilitation services)
Admissions for the single diagnosis of chemical dependency or abuse without an accompanying medical complication are not a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Our plan covers an unlimited number of days for an inpatient hospital stay
bull You pay nothing per day for days 1 through 90
bull You pay nothing per day for days 91 and beyond
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Inpatient Mental Health Care
Inpatient admissions to acute care hospitals for adults and children for psychiatric conditions are a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
You get up to 190 days of inpatient psychiatric hospital care in a lifetime Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met This limitation does not apply to inpatient psychiatric services furnished in a general hospital
bull You pay nothing per day for days 1 through 90
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Skilled Nursing Facility (SNF) (in a Medicare-certified skilled nursing facility)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Our plan covers up to 100 days in a SNF
bull You pay nothing per day for days 1 through 100
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Home Health Care (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
$0 copay for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered home health visits
Hospice 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 for Medicaid-covered services
You must get care from a Medicare-certified hospice
Your plan will pay for a consultative visit before you select hospice
Outpatient Care
Doctor Office Visits 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for each Medicare-covered primary care doctor visit
$0 copay for each Medicare-covered specialist visit
Chiropractic 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 for Medicaid-covered services
In-Network
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered chiropractic visits
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part)
Podiatry 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered podiatry visits Medicare-covered podiatry visits are for medically-necessary foot care
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient Mental For Dual-eligible Members Medicaid In-Network Health Care pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare $0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
therapy visit
bull each Medicare-covered group therapy visit
$0 copay for Medicare-covered partial hospitalization program services
Outpatient For Dual-eligible Members Medicaid In-Network Substance pays for this service if it is not covered Authorization rules may apply Abuse Care by Medicare or when the Medicare
$0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
substance abuse outpatient treatment visit
bull each Medicare-covered group substance abuse outpatient treatment visit
Outpatient For Dual-eligible Members Medicaid In-Network ServicesSurgery pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) is required
$0 copay for Medicaid-covered services $0 copay for each Medicare-covered ambulatory surgical center visit
$0 copay for each Medicare-covered outpatient hospital facility visit
Ambulance Services For Dual-eligible Members Medicaid In-Network (medically necessary pays for this service if it is not covered Authorization rules may apply ambulance services) by Medicare or when the Medicare
$0 copay per ground trip benefit is exhausted 0 coinsurance per air trip $0 copay for Medicaid-covered services
Emergency Care For Dual-eligible Members Medicaid $0 copay for Medicare-covered (you may go to any pays for this service if it is not covered emergency room visits emergency room if you by Medicare or when the Medicare $50000 plan coverage limit for reasonably believe you benefit is exhausted supplemental emergency services need emergency care) $0 copay for Medicaid-covered services outside the US and its territories every
year
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Urgently Needed Care (this is not emergency care and in most cases is out of the service area)
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 for Medicaid-covered services
$0 copay for Medicare-covered urgently-needed-care Visits
If you are admitted to the hospital within 24 hours for the same condition you pay $0 for the urgently-needed-care visit
Outpatient Rehabilitation Services (occupational therapy physical therapy speech and language therapy)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Medically necessary physical therapy occupational therapy and speech and language pathology services are covered
$0 copay for Medicare-covered Occupational Therapy visits
$0 copay for Medicare-covered Physical Therapy and or Speech and Language Pathology visits
Outpatient Medical Services and Supplies
Durable Medical Equipment (includes wheelchairs oxygen etc)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered durable medical equipment
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Prosthetic Devices For Dual-eligible Members under age 21 In-Network (includes braces (CCP) Medicaid pays for this service if it Authorization rules may apply artificial limbs is not covered by Medicare or when the
$0 copay for Medicare-covered and eyes etc) Medicare benefit is exhausted bull prosthetic devices For all Dual-eligible Members Medicaid
pays for breast prostheses if not covered bull medical supplies related to prosthetics by Medicare or when the Medicare splints and other devices benefit is exhausted Quantity limitations apply and vary with each device Prior authorization will NOT be required within limitations except for miscellaneous codes
$0 copay for Medicaid-covered services
Diabetes Programs For Dual-eligible Members Medicaid In-Network and Supplies pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered Diabetes self-management training
$0 copay for Medicare-covered
bull Diabetes monitoring supplies
bull Therapeutic shoes or inserts
Diabetic Supplies and Services are limited to specific manufacturers products andor brands Contact the plan for a list of covered supplies
Diagnostic Tests For Dual-eligible Members Medicaid In-Network X-rays Lab Services pays for this service if it is not covered Authorization rules may apply and Radiology by Medicare or when the Medicare
Referral from your Primary Care Services benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered
bull lab services
bull diagnostic procedures and tests
bull X-rays
bull diagnostic radiology services (not including X-rays)
bull therapeutic radiology services
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Cardiac and Pulmonary Rehabilitation Services
Outpatient cardiac rehabilitation is covered for members meeting specific diagnostic criteria for a limited number of sessions
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing $0 copay for Medicare-covered Pulmonary Rehabilitation Services
Preventive Services
Preventive Services bull Bone Mass Measurement Texas Medicaid covers only the Single Photon Absorptiometry Test
$0 copay for Medicaid-covered services
bull Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam for women with Medicare) 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 for Medicaid-covered services
bull Colorectal Cancer Screening (for people with Medicare age 50 and older) 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 for Medicaid-covered services
bull Immunization (Flu vaccine Hepatitis B Vaccine for people with Medicare who are at risk Pneumonia vaccine) 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 for Medicaid-covered services
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for all preventive services covered under Original Medicare at zero cost sharing
Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare
Plan covers a physical exam annually
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services bull Health Wellness Education (Written (continued) health education materials including
Newsletters Nutritional Training Additional Smoking Cessation other wellness benefits) This is not a Texas Medicaid benefit but is available in some of the pilot programs like the Diabetes and Asthma projects For Dual-eligible Members participating in the Diabetes and Asthma pilot program Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
bull Mammograms (Annual Screening ndash for women with Medicare age 40 and older) 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 for Medicaid-covered services
bull Physical Exams 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 for Medicaid-covered services
bull Prostate Cancer Screening Exams (for men with Medicare age 50 and older) 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 for Medicaid-covered services
bull Telemedicine 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 for Medicaid-covered services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services Assistive Communication Devices This (continued) is a benefit for clients in an ICF-MR For
Dual-eligible Members who meet the above criteria Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
Kidney Disease 0 or 20 coinsurance for renal dialysis In-Network and Conditions 0 or 20 coinsurance for kidney Authorization rules may apply
disease education services Referral by your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient For Dual-eligible Members Medicaid Drugs covered under Medicare Part B Prescription Drugs pays for this service if it is not covered $0 yearly deductible for Medicare Part B
by Medicare or when Medicare benefit is drugs exhausted
$0 copay for Medicare Part B drugs $0 copayment for Medicaid-covered
Drugs covered under Medicare Part D prescription drugs not covered by Medicare Part D In-Network
Deductible $0 to $74 per year for Part D prescription drugs
Initial Coverage
Depending on your income and institutional status you pay the following
For generic drugs (including brand drugs treated as generic) either bull A $0 copay or bull A $120 copay or bull A $295 copay
For all other drugs either bull A $0 copay or bull A $360 copay or bull A $740 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Dental Services This is a benefit only for Texas Health In-Network Steps eligible clients and for clients in an Authorization rules may apply ICF-MR who are 21 years of age and
Referral from your Primary Care older For Dual-eligible Members who Physician (PCP) may be required meet the above criteria Medicaid pays
for this service if it is not covered by $0 copay for Medicare-covered dental Medicare or when the Medicare benefit benefits is exhausted $0 copay for the following preventive $0 copay for Medicaid-covered services dental benefits
bull up to 1 oral exam(s) every six months bull up to 1 cleaning(s) every six months bull up to 1 dental X-ray every year
$0 copay for the following comprehensive services bull Restorative ndash Fillings Crowns bull Periodontics bull Extractions bull Prosthodontics bull Oral Surgery
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Hearing Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered Referral by your Primary Care Physician by Medicare or when the Medicare (PCP) may be required benefit is exhausted
Exam to diagnose and treat hearing and $0 copay for Medicaid-covered services balance issues $0 copay
Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids
Please see your EOC for plan coverage details
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at
risk
$0 copay for up to 1 supplemental routine eye exam every year
$0 copay for
bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
bull up to 1 pair of eyeglasses (lenses and frames) every year
bull contact lenses
bull up to 1 pair of eyeglass lenses every year
bull up to 1 eyeglass frame(s) every year
$250 plan coverage limit for eyewear every year
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs
bull 24 Hour Nurse Line
bull Gym membership
Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items
Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
SECTION I - INTRODUCTION TO SUMMARY OF BENEFITS
This booklet gives you a summary of what we cover and what you pay It doesnrsquot list every service that we cover or list every limitation or exclusion To get a complete list of services we cover call us and ask for the ldquoEvidence of Coveragerdquo
You have choices about how to get your Medicare benefits
bull One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare) Original Medicare is run directly by the Federal government
bull Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Cigna-HealthSpring TotalCare (HMO SNP))
Tips for comparing your Medicare choices
This Summary of Benefits booklet gives you a summary of what Cigna-HealthSpring TotalCare (HMO SNP) covers and what you pay
bull If you want to compare our plan with other Medicare health plans ask the other plans for their Summary of Benefits booklets Or use the Medicare Plan Finder on httpwwwmedicaregov
Sections in this booklet
bull Things to Know About Cigna-HealthSpring TotalCare (HMO SNP)
bull Monthly Premium Deductible and Limits on How Much You Pay for Covered Services
bull Covered Medical and Hospital Benefits
bull Prescription Drug Benefits
bull If you want to know more about the coverage and costs of Original Medicare look in your current ldquoMedicare amp Yourdquo handbook View it online at httpwwwmedicaregov 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
This document is available in other formats such as Braille and large print
This document may be available in a non-English language For additional information call us at 1-800-668-3813
Este documento puede estar disponible en un idioma distinto al ingleacutes Para obtener informacioacuten adicional llaacutemenos al 1-800-668-3813
THINGS TO KNOW ABOUT CIGNA-HEALTHSPRING TOTALCARE (HMO SNP)
Hours of Operation Which doctors hospitals and pharmacies can I use
You can call us 7 days a week from 800 am to 800 pm Local time Cigna-HealthSpring TotalCare
(HMO SNP) has a network of doctors Cigna-HealthSpring TotalCare hospitals pharmacies and other (HMO SNP) Phone Numbers providers If you use the providers that and Website are not in our network the plan may not
pay for these services bull If you are a member of this plan
call toll-free 1-800-668-3813 You must generally use network pharmacies to fill your prescriptions
bull If you are not a member of this plan for covered Part D
call toll-free 1-800-846-2098 You can see our plans provider directory
bull Our website at our website
httpwwwcignahealthspringcom (wwwcignahealthspringcom) You can see our plans pharmacy directory at our
Who can join website (wwwcignahealthspringcom)
To join Cigna-HealthSpring TotalCare Or call us and we will send you a copy
(HMO SNP) you must be entitled to of the provider and pharmacy directories
Medicare Part A be enrolled in Medicare Part B and Texas Medicaid and live in our
What do we cover service area
Like all Medicare health plans we cover Our service area includes the following
everything that Original Medicare covers - counties in Texas Angelina Brazoria
and more Cameron Chambers El Paso Fort Bend Galveston Hardin Harris Hidalgo bull Our plan members get all of Jasper Jefferson Liberty Montgomery the benefits covered by Original Nacogdoches Newton Orange Polk San Medicare Jacinto Tyler Walker Waller Webb and
bull Our plan members also get Willacy more than what is covered by denotes partial county (77510 77511 Original Medicare Some of the 77517 77518 77539 77546 77549 extra benefits are outlined in 77563 77565 77568 77573 77574 this booklet 77590 77591 77592)
We cover Part D drugs In addition How will I determine my drug costs we cover Part B drugs such as
The amount you pay for drugs depends on chemotherapy and some drugs
the drug you are taking and what stage of administered by your provider
the benefit you have reached Later in this bull You can see the complete plan document we discuss the benefit stages
formulary (list of Part D that occur after you meet your deductible prescription drugs) and any Initial Coverage Coverage Gap and restrictions on our website Catastrophic Coverage httpwwwcignahealthspringcom
bull Or call us and we will send you a copy
of the formulary
SECTION II - SUMMARY OF BENEFITS
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Monthly Premium Deductible and Limits on How Much You Pay for Covered Services
How much is the $2800 per month In addition you must keep paying your Medicare Part B monthly premium premium
How much is the deductible $0 to $74 per year for Part D prescription drugs
Is there any limit on Yes Like all Medicare health plans our plan protects you by having yearly limits how much I will pay for on your out-of-pocket costs for medical and hospital care my covered services In this plan you will pay nothing for Medicare-covered services
Refer to the ldquoMedicare amp Yourdquo handbook for Medicare-covered services For Texas Medicaid-covered services refer to the Medicaid Coverage section in this document
Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs
Is there a limit on how Our plan has a coverage limit every year for certain in-network benefits much the plan will pay Contact us for the services that apply
Cigna-HealthSpring is contracted with Medicare for PDP plans HMO and PPO plans in select states and with select State Medicaid programs Enrollment in Cigna-HealthSpring depends on contract renewal
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Covered Medical and Hospital Benefits Note Services with a 1 may require prior authorization
Services with a 2 may require a referral from your doctor
Outpatient Care and Services
Acupuncture Not covered
Ambulance1 You pay nothing
Chiropractic Care2 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position) You pay nothing
Dental Services1 Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth) $0 copay
Preventive dental services bull Cleaning (for up to 1 every six months) $0 copay bull Dental x-ray(s) (for up to 1 every year) $0 copay bull Oral exam (for up to 1 every six months) $0 copay Comprehensive services bull Restorative ndash Fillings Crowns $0 copay bull Periodontics $0 copay bull Extractions $0 copay bull Prosthodontics $0 copay bull Oral Surgery $0 copay
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Diabetes Supplies and Services2
Diabetes monitoring supplies You pay nothing Diabetes self-management training You pay nothing Therapeutic shoes or inserts You pay nothing
Diagnostic Tests Lab and Radiology Services and X-Rays (Costs for these services may vary based on place of service)12
Diagnostic radiology services (such as MRIs CT scans) You pay nothing Diagnostic tests and procedures You pay nothing Lab services You pay nothing Outpatient x-rays You pay nothing Therapeutic radiology services (such as radiation treatment for cancer) You pay nothing
Doctorrsquos Office Visits12 Primary care physician visit You pay nothing Specialist visit You pay nothing
Durable Medical Equipment (wheelchairs oxygen etc)1
You pay nothing
Emergency Care You pay nothing
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Foot Care Foot exams and treatment if you have diabetes-related nerve damage andor (podiatry services)2 meet certain conditions You pay nothing
Hearing Services2 Exam to diagnose and treat hearing and balance issues $0 copay Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids Please see your EOC for plan coverage details
Home Health Care1 You pay nothing
Mental Health Care1 Inpatient visit
Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital
Our plan covers 90 days for an inpatient hospital stay
Our plan also covers 60 ldquolifetime reserve daysrdquo These are ldquoextrardquo days that we cover If your hospital stay is longer than 90 days you can use these extra days But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days bull You pay nothing per day for days 1 through 90
Outpatient group therapy visit You pay nothing
Outpatient individual therapy visit You pay nothing
Outpatient Rehabilitation12 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing Occupational therapy visit You pay nothing Physical therapy and speech and language therapy visit You pay nothing
Outpatient Group therapy visit You pay nothing Substance Abuse1 Individual therapy visit You pay nothing
Outpatient Surgery12 Ambulatory surgical center You pay nothing Outpatient hospital You pay nothing
Over-the-Counter Items Please visit our website to see our list of covered over-the-counter items Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Prosthetic Devices Prosthetic devices You pay nothing (braces artificial limbs etc)1 Related medical supplies You pay nothing
Renal Dialysis12 You pay nothing
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Transportation1 You pay nothing $0 copayment for unlimited one‑way trips to plan‑approved location ever year Please see your EOC for plan coverage details
Urgently Needed Services You pay nothing If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for urgently needed services See the ldquoInpatient Hospital Carerdquo section of this booklet for other costs
Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) $0 copay
Routine eye exam (for up to 1 every year) $0 copay
Contact lenses $0 copay
Eyeglasses (frames and lenses) (for up to 1 every year) $0 copay
Eyeglass frames (for up to 1 every year) $0 copay
Eyeglass lenses (for up to 1 every year) $0 copay
Eyeglasses or contact lenses after cataract surgery $0 copay
Our plan pays up to $250 every year for eyewear
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Preventive Care You pay nothing
Our plan covers many preventive services including
bull Abdominal aortic aneurysm screening
bull Alcohol misuse counseling
bull Bone mass measurement
bull Breast cancer screening (mammogram)
bull Cardiovascular disease (behavioral therapy)
bull Cardiovascular screenings
bull Cervical and vaginal cancer screening
bull Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
bull Depression screening
bull Diabetes screenings
bull HIV screening
bull Medical nutrition therapy services
bull Obesity screening and counseling
bull Prostate cancer screenings (PSA)
bull Sexually transmitted infections screening and counseling
bull Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
bull Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
bull ldquoWelcome to Medicarerdquo preventive visit (one-time)
bull Yearly ldquoWellnessrdquo visit
Any additional preventive services approved by Medicare during the contract year will be covered
Annual physical exam You pay nothing
Hospice You pay nothing for hospice care from a Medicare-certified hospice You may have to pay part of the cost for drugs and respite care Hospice is covered outside of our plan Please contact us for more details
Inpatient Care
Inpatient Hospital Care12 Our plan covers an unlimited number of days for an inpatient hospital stay
bull You pay nothing per day for days 1 through 90
bull You pay nothing per day for days 91 and beyond
Inpatient Mental Health Care For inpatient mental health care see the ldquoMental Health Carerdquo section of this booklet
Skilled Nursing Facility (SNF)1
Our plan covers up to 100 days in a SNF
bull You pay nothing per day for days 1 through 100
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Prescription Drug Benefits
How much do I pay For Part B drugs such as chemotherapy drugs1 You pay nothing Other Part B drugs1 You pay nothing
Initial Coverage Depending on your income and institutional status you pay the following For generic drugs (including brand drugs treated as generic) either
bull $0 copay or bull $120 copay or bull $295 copay
For all other drugs either bull $0 copay or bull $360 copay or bull $740 copay
You may get your drugs at network retail pharmacies and mail order pharmacies
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 an in-network pharmacy
Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Additional Plan Benefits
24-hour Nurse Line $0 copay for 24-hour Nurse Line
Caring registered nurses are available by phone 24 hours a day 7 days a week to answer your health questions in a confidential and convenient service
Fitness $0 copay for membership in Health ClubFitness Classes
Please see your EOC for plan coverage details
Home Safety $1500 allowance once per lifetime for the purchase and installation of approved safety devices in bathrooms Please see your EOC for plan coverage details
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H4513 PLAN 010
This section demonstrates the Medicaid Medicare Part A and B cost sharing when benefit package for full benefit dual-eligible the state is responsible for paying these recipients in the state of Texas The amounts For more information about your services offered in your Medicaid benefit Medicaid benefits and copayments please package are based on your Medicaid contact the State Medicaid Office eligibility level (Categorically Needy or
The benefits described below are covered Medically Needy) Medicare coverage must
by Medicaid The benefits described in the be used first and the Medicaid Program may
Covered Medical and Hospital Benefits cover payment of Medicare Part A and B
section of the Summary of Benefits are deductible and coinsurance for all Medicare
covered by Medicare For each benefit listed covered services The services listed below
below you can see what Texas Medicaid are available only to those SNP members
covers and what our plan covers What you eligible under Medicaid for medical services
pay for covered services may depend on If you are eligible for both Medicare and
your level of Medicaid eligibility Medicaid you will not be held liable for
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Important Information
Premium and other important information
Medicaid assistance with premium payment may vary based on your level of Medicaid eligibility
Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for Original Medicare services
$2800 monthly plan premium in addition to your monthly Medicare Part B premium
In-Network
In this plan you will have no cost-sharing responsibility for Medicare-covered services
Doctor and hospital choice (For more information see Emergency Care and Urgently Needed Care)
For those who meet QMB requirements Medicaid pays coinsurance copayments and deductibles for Medicare-covered services Members should follow Medicare guidelines related to hospital and doctor choice
$0 copay for Medicaid-covered services
In-Network
You must go to network doctors specialists and hospitals
Referral required for network hospitals and specialists (for certain benefits)
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Inpatient Care
Inpatient Hospital Care (Includes substance abuse and rehabilitation services)
Admissions for the single diagnosis of chemical dependency or abuse without an accompanying medical complication are not a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Our plan covers an unlimited number of days for an inpatient hospital stay
bull You pay nothing per day for days 1 through 90
bull You pay nothing per day for days 91 and beyond
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Inpatient Mental Health Care
Inpatient admissions to acute care hospitals for adults and children for psychiatric conditions are a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
You get up to 190 days of inpatient psychiatric hospital care in a lifetime Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met This limitation does not apply to inpatient psychiatric services furnished in a general hospital
bull You pay nothing per day for days 1 through 90
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Skilled Nursing Facility (SNF) (in a Medicare-certified skilled nursing facility)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Our plan covers up to 100 days in a SNF
bull You pay nothing per day for days 1 through 100
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Home Health Care (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
$0 copay for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered home health visits
Hospice 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 for Medicaid-covered services
You must get care from a Medicare-certified hospice
Your plan will pay for a consultative visit before you select hospice
Outpatient Care
Doctor Office Visits 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for each Medicare-covered primary care doctor visit
$0 copay for each Medicare-covered specialist visit
Chiropractic 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 for Medicaid-covered services
In-Network
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered chiropractic visits
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part)
Podiatry 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered podiatry visits Medicare-covered podiatry visits are for medically-necessary foot care
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient Mental For Dual-eligible Members Medicaid In-Network Health Care pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare $0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
therapy visit
bull each Medicare-covered group therapy visit
$0 copay for Medicare-covered partial hospitalization program services
Outpatient For Dual-eligible Members Medicaid In-Network Substance pays for this service if it is not covered Authorization rules may apply Abuse Care by Medicare or when the Medicare
$0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
substance abuse outpatient treatment visit
bull each Medicare-covered group substance abuse outpatient treatment visit
Outpatient For Dual-eligible Members Medicaid In-Network ServicesSurgery pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) is required
$0 copay for Medicaid-covered services $0 copay for each Medicare-covered ambulatory surgical center visit
$0 copay for each Medicare-covered outpatient hospital facility visit
Ambulance Services For Dual-eligible Members Medicaid In-Network (medically necessary pays for this service if it is not covered Authorization rules may apply ambulance services) by Medicare or when the Medicare
$0 copay per ground trip benefit is exhausted 0 coinsurance per air trip $0 copay for Medicaid-covered services
Emergency Care For Dual-eligible Members Medicaid $0 copay for Medicare-covered (you may go to any pays for this service if it is not covered emergency room visits emergency room if you by Medicare or when the Medicare $50000 plan coverage limit for reasonably believe you benefit is exhausted supplemental emergency services need emergency care) $0 copay for Medicaid-covered services outside the US and its territories every
year
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Urgently Needed Care (this is not emergency care and in most cases is out of the service area)
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 for Medicaid-covered services
$0 copay for Medicare-covered urgently-needed-care Visits
If you are admitted to the hospital within 24 hours for the same condition you pay $0 for the urgently-needed-care visit
Outpatient Rehabilitation Services (occupational therapy physical therapy speech and language therapy)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Medically necessary physical therapy occupational therapy and speech and language pathology services are covered
$0 copay for Medicare-covered Occupational Therapy visits
$0 copay for Medicare-covered Physical Therapy and or Speech and Language Pathology visits
Outpatient Medical Services and Supplies
Durable Medical Equipment (includes wheelchairs oxygen etc)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered durable medical equipment
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Prosthetic Devices For Dual-eligible Members under age 21 In-Network (includes braces (CCP) Medicaid pays for this service if it Authorization rules may apply artificial limbs is not covered by Medicare or when the
$0 copay for Medicare-covered and eyes etc) Medicare benefit is exhausted bull prosthetic devices For all Dual-eligible Members Medicaid
pays for breast prostheses if not covered bull medical supplies related to prosthetics by Medicare or when the Medicare splints and other devices benefit is exhausted Quantity limitations apply and vary with each device Prior authorization will NOT be required within limitations except for miscellaneous codes
$0 copay for Medicaid-covered services
Diabetes Programs For Dual-eligible Members Medicaid In-Network and Supplies pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered Diabetes self-management training
$0 copay for Medicare-covered
bull Diabetes monitoring supplies
bull Therapeutic shoes or inserts
Diabetic Supplies and Services are limited to specific manufacturers products andor brands Contact the plan for a list of covered supplies
Diagnostic Tests For Dual-eligible Members Medicaid In-Network X-rays Lab Services pays for this service if it is not covered Authorization rules may apply and Radiology by Medicare or when the Medicare
Referral from your Primary Care Services benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered
bull lab services
bull diagnostic procedures and tests
bull X-rays
bull diagnostic radiology services (not including X-rays)
bull therapeutic radiology services
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Cardiac and Pulmonary Rehabilitation Services
Outpatient cardiac rehabilitation is covered for members meeting specific diagnostic criteria for a limited number of sessions
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing $0 copay for Medicare-covered Pulmonary Rehabilitation Services
Preventive Services
Preventive Services bull Bone Mass Measurement Texas Medicaid covers only the Single Photon Absorptiometry Test
$0 copay for Medicaid-covered services
bull Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam for women with Medicare) 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 for Medicaid-covered services
bull Colorectal Cancer Screening (for people with Medicare age 50 and older) 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 for Medicaid-covered services
bull Immunization (Flu vaccine Hepatitis B Vaccine for people with Medicare who are at risk Pneumonia vaccine) 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 for Medicaid-covered services
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for all preventive services covered under Original Medicare at zero cost sharing
Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare
Plan covers a physical exam annually
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services bull Health Wellness Education (Written (continued) health education materials including
Newsletters Nutritional Training Additional Smoking Cessation other wellness benefits) This is not a Texas Medicaid benefit but is available in some of the pilot programs like the Diabetes and Asthma projects For Dual-eligible Members participating in the Diabetes and Asthma pilot program Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
bull Mammograms (Annual Screening ndash for women with Medicare age 40 and older) 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 for Medicaid-covered services
bull Physical Exams 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 for Medicaid-covered services
bull Prostate Cancer Screening Exams (for men with Medicare age 50 and older) 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 for Medicaid-covered services
bull Telemedicine 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 for Medicaid-covered services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services Assistive Communication Devices This (continued) is a benefit for clients in an ICF-MR For
Dual-eligible Members who meet the above criteria Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
Kidney Disease 0 or 20 coinsurance for renal dialysis In-Network and Conditions 0 or 20 coinsurance for kidney Authorization rules may apply
disease education services Referral by your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient For Dual-eligible Members Medicaid Drugs covered under Medicare Part B Prescription Drugs pays for this service if it is not covered $0 yearly deductible for Medicare Part B
by Medicare or when Medicare benefit is drugs exhausted
$0 copay for Medicare Part B drugs $0 copayment for Medicaid-covered
Drugs covered under Medicare Part D prescription drugs not covered by Medicare Part D In-Network
Deductible $0 to $74 per year for Part D prescription drugs
Initial Coverage
Depending on your income and institutional status you pay the following
For generic drugs (including brand drugs treated as generic) either bull A $0 copay or bull A $120 copay or bull A $295 copay
For all other drugs either bull A $0 copay or bull A $360 copay or bull A $740 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Dental Services This is a benefit only for Texas Health In-Network Steps eligible clients and for clients in an Authorization rules may apply ICF-MR who are 21 years of age and
Referral from your Primary Care older For Dual-eligible Members who Physician (PCP) may be required meet the above criteria Medicaid pays
for this service if it is not covered by $0 copay for Medicare-covered dental Medicare or when the Medicare benefit benefits is exhausted $0 copay for the following preventive $0 copay for Medicaid-covered services dental benefits
bull up to 1 oral exam(s) every six months bull up to 1 cleaning(s) every six months bull up to 1 dental X-ray every year
$0 copay for the following comprehensive services bull Restorative ndash Fillings Crowns bull Periodontics bull Extractions bull Prosthodontics bull Oral Surgery
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Hearing Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered Referral by your Primary Care Physician by Medicare or when the Medicare (PCP) may be required benefit is exhausted
Exam to diagnose and treat hearing and $0 copay for Medicaid-covered services balance issues $0 copay
Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids
Please see your EOC for plan coverage details
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at
risk
$0 copay for up to 1 supplemental routine eye exam every year
$0 copay for
bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
bull up to 1 pair of eyeglasses (lenses and frames) every year
bull contact lenses
bull up to 1 pair of eyeglass lenses every year
bull up to 1 eyeglass frame(s) every year
$250 plan coverage limit for eyewear every year
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs
bull 24 Hour Nurse Line
bull Gym membership
Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items
Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
THINGS TO KNOW ABOUT CIGNA-HEALTHSPRING TOTALCARE (HMO SNP)
Hours of Operation Which doctors hospitals and pharmacies can I use
You can call us 7 days a week from 800 am to 800 pm Local time Cigna-HealthSpring TotalCare
(HMO SNP) has a network of doctors Cigna-HealthSpring TotalCare hospitals pharmacies and other (HMO SNP) Phone Numbers providers If you use the providers that and Website are not in our network the plan may not
pay for these services bull If you are a member of this plan
call toll-free 1-800-668-3813 You must generally use network pharmacies to fill your prescriptions
bull If you are not a member of this plan for covered Part D
call toll-free 1-800-846-2098 You can see our plans provider directory
bull Our website at our website
httpwwwcignahealthspringcom (wwwcignahealthspringcom) You can see our plans pharmacy directory at our
Who can join website (wwwcignahealthspringcom)
To join Cigna-HealthSpring TotalCare Or call us and we will send you a copy
(HMO SNP) you must be entitled to of the provider and pharmacy directories
Medicare Part A be enrolled in Medicare Part B and Texas Medicaid and live in our
What do we cover service area
Like all Medicare health plans we cover Our service area includes the following
everything that Original Medicare covers - counties in Texas Angelina Brazoria
and more Cameron Chambers El Paso Fort Bend Galveston Hardin Harris Hidalgo bull Our plan members get all of Jasper Jefferson Liberty Montgomery the benefits covered by Original Nacogdoches Newton Orange Polk San Medicare Jacinto Tyler Walker Waller Webb and
bull Our plan members also get Willacy more than what is covered by denotes partial county (77510 77511 Original Medicare Some of the 77517 77518 77539 77546 77549 extra benefits are outlined in 77563 77565 77568 77573 77574 this booklet 77590 77591 77592)
We cover Part D drugs In addition How will I determine my drug costs we cover Part B drugs such as
The amount you pay for drugs depends on chemotherapy and some drugs
the drug you are taking and what stage of administered by your provider
the benefit you have reached Later in this bull You can see the complete plan document we discuss the benefit stages
formulary (list of Part D that occur after you meet your deductible prescription drugs) and any Initial Coverage Coverage Gap and restrictions on our website Catastrophic Coverage httpwwwcignahealthspringcom
bull Or call us and we will send you a copy
of the formulary
SECTION II - SUMMARY OF BENEFITS
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Monthly Premium Deductible and Limits on How Much You Pay for Covered Services
How much is the $2800 per month In addition you must keep paying your Medicare Part B monthly premium premium
How much is the deductible $0 to $74 per year for Part D prescription drugs
Is there any limit on Yes Like all Medicare health plans our plan protects you by having yearly limits how much I will pay for on your out-of-pocket costs for medical and hospital care my covered services In this plan you will pay nothing for Medicare-covered services
Refer to the ldquoMedicare amp Yourdquo handbook for Medicare-covered services For Texas Medicaid-covered services refer to the Medicaid Coverage section in this document
Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs
Is there a limit on how Our plan has a coverage limit every year for certain in-network benefits much the plan will pay Contact us for the services that apply
Cigna-HealthSpring is contracted with Medicare for PDP plans HMO and PPO plans in select states and with select State Medicaid programs Enrollment in Cigna-HealthSpring depends on contract renewal
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Covered Medical and Hospital Benefits Note Services with a 1 may require prior authorization
Services with a 2 may require a referral from your doctor
Outpatient Care and Services
Acupuncture Not covered
Ambulance1 You pay nothing
Chiropractic Care2 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position) You pay nothing
Dental Services1 Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth) $0 copay
Preventive dental services bull Cleaning (for up to 1 every six months) $0 copay bull Dental x-ray(s) (for up to 1 every year) $0 copay bull Oral exam (for up to 1 every six months) $0 copay Comprehensive services bull Restorative ndash Fillings Crowns $0 copay bull Periodontics $0 copay bull Extractions $0 copay bull Prosthodontics $0 copay bull Oral Surgery $0 copay
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Diabetes Supplies and Services2
Diabetes monitoring supplies You pay nothing Diabetes self-management training You pay nothing Therapeutic shoes or inserts You pay nothing
Diagnostic Tests Lab and Radiology Services and X-Rays (Costs for these services may vary based on place of service)12
Diagnostic radiology services (such as MRIs CT scans) You pay nothing Diagnostic tests and procedures You pay nothing Lab services You pay nothing Outpatient x-rays You pay nothing Therapeutic radiology services (such as radiation treatment for cancer) You pay nothing
Doctorrsquos Office Visits12 Primary care physician visit You pay nothing Specialist visit You pay nothing
Durable Medical Equipment (wheelchairs oxygen etc)1
You pay nothing
Emergency Care You pay nothing
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Foot Care Foot exams and treatment if you have diabetes-related nerve damage andor (podiatry services)2 meet certain conditions You pay nothing
Hearing Services2 Exam to diagnose and treat hearing and balance issues $0 copay Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids Please see your EOC for plan coverage details
Home Health Care1 You pay nothing
Mental Health Care1 Inpatient visit
Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital
Our plan covers 90 days for an inpatient hospital stay
Our plan also covers 60 ldquolifetime reserve daysrdquo These are ldquoextrardquo days that we cover If your hospital stay is longer than 90 days you can use these extra days But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days bull You pay nothing per day for days 1 through 90
Outpatient group therapy visit You pay nothing
Outpatient individual therapy visit You pay nothing
Outpatient Rehabilitation12 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing Occupational therapy visit You pay nothing Physical therapy and speech and language therapy visit You pay nothing
Outpatient Group therapy visit You pay nothing Substance Abuse1 Individual therapy visit You pay nothing
Outpatient Surgery12 Ambulatory surgical center You pay nothing Outpatient hospital You pay nothing
Over-the-Counter Items Please visit our website to see our list of covered over-the-counter items Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Prosthetic Devices Prosthetic devices You pay nothing (braces artificial limbs etc)1 Related medical supplies You pay nothing
Renal Dialysis12 You pay nothing
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Transportation1 You pay nothing $0 copayment for unlimited one‑way trips to plan‑approved location ever year Please see your EOC for plan coverage details
Urgently Needed Services You pay nothing If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for urgently needed services See the ldquoInpatient Hospital Carerdquo section of this booklet for other costs
Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) $0 copay
Routine eye exam (for up to 1 every year) $0 copay
Contact lenses $0 copay
Eyeglasses (frames and lenses) (for up to 1 every year) $0 copay
Eyeglass frames (for up to 1 every year) $0 copay
Eyeglass lenses (for up to 1 every year) $0 copay
Eyeglasses or contact lenses after cataract surgery $0 copay
Our plan pays up to $250 every year for eyewear
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Preventive Care You pay nothing
Our plan covers many preventive services including
bull Abdominal aortic aneurysm screening
bull Alcohol misuse counseling
bull Bone mass measurement
bull Breast cancer screening (mammogram)
bull Cardiovascular disease (behavioral therapy)
bull Cardiovascular screenings
bull Cervical and vaginal cancer screening
bull Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
bull Depression screening
bull Diabetes screenings
bull HIV screening
bull Medical nutrition therapy services
bull Obesity screening and counseling
bull Prostate cancer screenings (PSA)
bull Sexually transmitted infections screening and counseling
bull Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
bull Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
bull ldquoWelcome to Medicarerdquo preventive visit (one-time)
bull Yearly ldquoWellnessrdquo visit
Any additional preventive services approved by Medicare during the contract year will be covered
Annual physical exam You pay nothing
Hospice You pay nothing for hospice care from a Medicare-certified hospice You may have to pay part of the cost for drugs and respite care Hospice is covered outside of our plan Please contact us for more details
Inpatient Care
Inpatient Hospital Care12 Our plan covers an unlimited number of days for an inpatient hospital stay
bull You pay nothing per day for days 1 through 90
bull You pay nothing per day for days 91 and beyond
Inpatient Mental Health Care For inpatient mental health care see the ldquoMental Health Carerdquo section of this booklet
Skilled Nursing Facility (SNF)1
Our plan covers up to 100 days in a SNF
bull You pay nothing per day for days 1 through 100
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Prescription Drug Benefits
How much do I pay For Part B drugs such as chemotherapy drugs1 You pay nothing Other Part B drugs1 You pay nothing
Initial Coverage Depending on your income and institutional status you pay the following For generic drugs (including brand drugs treated as generic) either
bull $0 copay or bull $120 copay or bull $295 copay
For all other drugs either bull $0 copay or bull $360 copay or bull $740 copay
You may get your drugs at network retail pharmacies and mail order pharmacies
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 an in-network pharmacy
Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Additional Plan Benefits
24-hour Nurse Line $0 copay for 24-hour Nurse Line
Caring registered nurses are available by phone 24 hours a day 7 days a week to answer your health questions in a confidential and convenient service
Fitness $0 copay for membership in Health ClubFitness Classes
Please see your EOC for plan coverage details
Home Safety $1500 allowance once per lifetime for the purchase and installation of approved safety devices in bathrooms Please see your EOC for plan coverage details
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H4513 PLAN 010
This section demonstrates the Medicaid Medicare Part A and B cost sharing when benefit package for full benefit dual-eligible the state is responsible for paying these recipients in the state of Texas The amounts For more information about your services offered in your Medicaid benefit Medicaid benefits and copayments please package are based on your Medicaid contact the State Medicaid Office eligibility level (Categorically Needy or
The benefits described below are covered Medically Needy) Medicare coverage must
by Medicaid The benefits described in the be used first and the Medicaid Program may
Covered Medical and Hospital Benefits cover payment of Medicare Part A and B
section of the Summary of Benefits are deductible and coinsurance for all Medicare
covered by Medicare For each benefit listed covered services The services listed below
below you can see what Texas Medicaid are available only to those SNP members
covers and what our plan covers What you eligible under Medicaid for medical services
pay for covered services may depend on If you are eligible for both Medicare and
your level of Medicaid eligibility Medicaid you will not be held liable for
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Important Information
Premium and other important information
Medicaid assistance with premium payment may vary based on your level of Medicaid eligibility
Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for Original Medicare services
$2800 monthly plan premium in addition to your monthly Medicare Part B premium
In-Network
In this plan you will have no cost-sharing responsibility for Medicare-covered services
Doctor and hospital choice (For more information see Emergency Care and Urgently Needed Care)
For those who meet QMB requirements Medicaid pays coinsurance copayments and deductibles for Medicare-covered services Members should follow Medicare guidelines related to hospital and doctor choice
$0 copay for Medicaid-covered services
In-Network
You must go to network doctors specialists and hospitals
Referral required for network hospitals and specialists (for certain benefits)
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Inpatient Care
Inpatient Hospital Care (Includes substance abuse and rehabilitation services)
Admissions for the single diagnosis of chemical dependency or abuse without an accompanying medical complication are not a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Our plan covers an unlimited number of days for an inpatient hospital stay
bull You pay nothing per day for days 1 through 90
bull You pay nothing per day for days 91 and beyond
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Inpatient Mental Health Care
Inpatient admissions to acute care hospitals for adults and children for psychiatric conditions are a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
You get up to 190 days of inpatient psychiatric hospital care in a lifetime Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met This limitation does not apply to inpatient psychiatric services furnished in a general hospital
bull You pay nothing per day for days 1 through 90
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Skilled Nursing Facility (SNF) (in a Medicare-certified skilled nursing facility)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Our plan covers up to 100 days in a SNF
bull You pay nothing per day for days 1 through 100
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Home Health Care (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
$0 copay for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered home health visits
Hospice 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 for Medicaid-covered services
You must get care from a Medicare-certified hospice
Your plan will pay for a consultative visit before you select hospice
Outpatient Care
Doctor Office Visits 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for each Medicare-covered primary care doctor visit
$0 copay for each Medicare-covered specialist visit
Chiropractic 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 for Medicaid-covered services
In-Network
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered chiropractic visits
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part)
Podiatry 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered podiatry visits Medicare-covered podiatry visits are for medically-necessary foot care
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient Mental For Dual-eligible Members Medicaid In-Network Health Care pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare $0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
therapy visit
bull each Medicare-covered group therapy visit
$0 copay for Medicare-covered partial hospitalization program services
Outpatient For Dual-eligible Members Medicaid In-Network Substance pays for this service if it is not covered Authorization rules may apply Abuse Care by Medicare or when the Medicare
$0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
substance abuse outpatient treatment visit
bull each Medicare-covered group substance abuse outpatient treatment visit
Outpatient For Dual-eligible Members Medicaid In-Network ServicesSurgery pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) is required
$0 copay for Medicaid-covered services $0 copay for each Medicare-covered ambulatory surgical center visit
$0 copay for each Medicare-covered outpatient hospital facility visit
Ambulance Services For Dual-eligible Members Medicaid In-Network (medically necessary pays for this service if it is not covered Authorization rules may apply ambulance services) by Medicare or when the Medicare
$0 copay per ground trip benefit is exhausted 0 coinsurance per air trip $0 copay for Medicaid-covered services
Emergency Care For Dual-eligible Members Medicaid $0 copay for Medicare-covered (you may go to any pays for this service if it is not covered emergency room visits emergency room if you by Medicare or when the Medicare $50000 plan coverage limit for reasonably believe you benefit is exhausted supplemental emergency services need emergency care) $0 copay for Medicaid-covered services outside the US and its territories every
year
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Urgently Needed Care (this is not emergency care and in most cases is out of the service area)
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 for Medicaid-covered services
$0 copay for Medicare-covered urgently-needed-care Visits
If you are admitted to the hospital within 24 hours for the same condition you pay $0 for the urgently-needed-care visit
Outpatient Rehabilitation Services (occupational therapy physical therapy speech and language therapy)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Medically necessary physical therapy occupational therapy and speech and language pathology services are covered
$0 copay for Medicare-covered Occupational Therapy visits
$0 copay for Medicare-covered Physical Therapy and or Speech and Language Pathology visits
Outpatient Medical Services and Supplies
Durable Medical Equipment (includes wheelchairs oxygen etc)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered durable medical equipment
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Prosthetic Devices For Dual-eligible Members under age 21 In-Network (includes braces (CCP) Medicaid pays for this service if it Authorization rules may apply artificial limbs is not covered by Medicare or when the
$0 copay for Medicare-covered and eyes etc) Medicare benefit is exhausted bull prosthetic devices For all Dual-eligible Members Medicaid
pays for breast prostheses if not covered bull medical supplies related to prosthetics by Medicare or when the Medicare splints and other devices benefit is exhausted Quantity limitations apply and vary with each device Prior authorization will NOT be required within limitations except for miscellaneous codes
$0 copay for Medicaid-covered services
Diabetes Programs For Dual-eligible Members Medicaid In-Network and Supplies pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered Diabetes self-management training
$0 copay for Medicare-covered
bull Diabetes monitoring supplies
bull Therapeutic shoes or inserts
Diabetic Supplies and Services are limited to specific manufacturers products andor brands Contact the plan for a list of covered supplies
Diagnostic Tests For Dual-eligible Members Medicaid In-Network X-rays Lab Services pays for this service if it is not covered Authorization rules may apply and Radiology by Medicare or when the Medicare
Referral from your Primary Care Services benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered
bull lab services
bull diagnostic procedures and tests
bull X-rays
bull diagnostic radiology services (not including X-rays)
bull therapeutic radiology services
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Cardiac and Pulmonary Rehabilitation Services
Outpatient cardiac rehabilitation is covered for members meeting specific diagnostic criteria for a limited number of sessions
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing $0 copay for Medicare-covered Pulmonary Rehabilitation Services
Preventive Services
Preventive Services bull Bone Mass Measurement Texas Medicaid covers only the Single Photon Absorptiometry Test
$0 copay for Medicaid-covered services
bull Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam for women with Medicare) 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 for Medicaid-covered services
bull Colorectal Cancer Screening (for people with Medicare age 50 and older) 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 for Medicaid-covered services
bull Immunization (Flu vaccine Hepatitis B Vaccine for people with Medicare who are at risk Pneumonia vaccine) 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 for Medicaid-covered services
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for all preventive services covered under Original Medicare at zero cost sharing
Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare
Plan covers a physical exam annually
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services bull Health Wellness Education (Written (continued) health education materials including
Newsletters Nutritional Training Additional Smoking Cessation other wellness benefits) This is not a Texas Medicaid benefit but is available in some of the pilot programs like the Diabetes and Asthma projects For Dual-eligible Members participating in the Diabetes and Asthma pilot program Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
bull Mammograms (Annual Screening ndash for women with Medicare age 40 and older) 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 for Medicaid-covered services
bull Physical Exams 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 for Medicaid-covered services
bull Prostate Cancer Screening Exams (for men with Medicare age 50 and older) 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 for Medicaid-covered services
bull Telemedicine 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 for Medicaid-covered services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services Assistive Communication Devices This (continued) is a benefit for clients in an ICF-MR For
Dual-eligible Members who meet the above criteria Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
Kidney Disease 0 or 20 coinsurance for renal dialysis In-Network and Conditions 0 or 20 coinsurance for kidney Authorization rules may apply
disease education services Referral by your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient For Dual-eligible Members Medicaid Drugs covered under Medicare Part B Prescription Drugs pays for this service if it is not covered $0 yearly deductible for Medicare Part B
by Medicare or when Medicare benefit is drugs exhausted
$0 copay for Medicare Part B drugs $0 copayment for Medicaid-covered
Drugs covered under Medicare Part D prescription drugs not covered by Medicare Part D In-Network
Deductible $0 to $74 per year for Part D prescription drugs
Initial Coverage
Depending on your income and institutional status you pay the following
For generic drugs (including brand drugs treated as generic) either bull A $0 copay or bull A $120 copay or bull A $295 copay
For all other drugs either bull A $0 copay or bull A $360 copay or bull A $740 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Dental Services This is a benefit only for Texas Health In-Network Steps eligible clients and for clients in an Authorization rules may apply ICF-MR who are 21 years of age and
Referral from your Primary Care older For Dual-eligible Members who Physician (PCP) may be required meet the above criteria Medicaid pays
for this service if it is not covered by $0 copay for Medicare-covered dental Medicare or when the Medicare benefit benefits is exhausted $0 copay for the following preventive $0 copay for Medicaid-covered services dental benefits
bull up to 1 oral exam(s) every six months bull up to 1 cleaning(s) every six months bull up to 1 dental X-ray every year
$0 copay for the following comprehensive services bull Restorative ndash Fillings Crowns bull Periodontics bull Extractions bull Prosthodontics bull Oral Surgery
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Hearing Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered Referral by your Primary Care Physician by Medicare or when the Medicare (PCP) may be required benefit is exhausted
Exam to diagnose and treat hearing and $0 copay for Medicaid-covered services balance issues $0 copay
Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids
Please see your EOC for plan coverage details
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at
risk
$0 copay for up to 1 supplemental routine eye exam every year
$0 copay for
bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
bull up to 1 pair of eyeglasses (lenses and frames) every year
bull contact lenses
bull up to 1 pair of eyeglass lenses every year
bull up to 1 eyeglass frame(s) every year
$250 plan coverage limit for eyewear every year
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs
bull 24 Hour Nurse Line
bull Gym membership
Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items
Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
We cover Part D drugs In addition How will I determine my drug costs we cover Part B drugs such as
The amount you pay for drugs depends on chemotherapy and some drugs
the drug you are taking and what stage of administered by your provider
the benefit you have reached Later in this bull You can see the complete plan document we discuss the benefit stages
formulary (list of Part D that occur after you meet your deductible prescription drugs) and any Initial Coverage Coverage Gap and restrictions on our website Catastrophic Coverage httpwwwcignahealthspringcom
bull Or call us and we will send you a copy
of the formulary
SECTION II - SUMMARY OF BENEFITS
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Monthly Premium Deductible and Limits on How Much You Pay for Covered Services
How much is the $2800 per month In addition you must keep paying your Medicare Part B monthly premium premium
How much is the deductible $0 to $74 per year for Part D prescription drugs
Is there any limit on Yes Like all Medicare health plans our plan protects you by having yearly limits how much I will pay for on your out-of-pocket costs for medical and hospital care my covered services In this plan you will pay nothing for Medicare-covered services
Refer to the ldquoMedicare amp Yourdquo handbook for Medicare-covered services For Texas Medicaid-covered services refer to the Medicaid Coverage section in this document
Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs
Is there a limit on how Our plan has a coverage limit every year for certain in-network benefits much the plan will pay Contact us for the services that apply
Cigna-HealthSpring is contracted with Medicare for PDP plans HMO and PPO plans in select states and with select State Medicaid programs Enrollment in Cigna-HealthSpring depends on contract renewal
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Covered Medical and Hospital Benefits Note Services with a 1 may require prior authorization
Services with a 2 may require a referral from your doctor
Outpatient Care and Services
Acupuncture Not covered
Ambulance1 You pay nothing
Chiropractic Care2 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position) You pay nothing
Dental Services1 Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth) $0 copay
Preventive dental services bull Cleaning (for up to 1 every six months) $0 copay bull Dental x-ray(s) (for up to 1 every year) $0 copay bull Oral exam (for up to 1 every six months) $0 copay Comprehensive services bull Restorative ndash Fillings Crowns $0 copay bull Periodontics $0 copay bull Extractions $0 copay bull Prosthodontics $0 copay bull Oral Surgery $0 copay
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Diabetes Supplies and Services2
Diabetes monitoring supplies You pay nothing Diabetes self-management training You pay nothing Therapeutic shoes or inserts You pay nothing
Diagnostic Tests Lab and Radiology Services and X-Rays (Costs for these services may vary based on place of service)12
Diagnostic radiology services (such as MRIs CT scans) You pay nothing Diagnostic tests and procedures You pay nothing Lab services You pay nothing Outpatient x-rays You pay nothing Therapeutic radiology services (such as radiation treatment for cancer) You pay nothing
Doctorrsquos Office Visits12 Primary care physician visit You pay nothing Specialist visit You pay nothing
Durable Medical Equipment (wheelchairs oxygen etc)1
You pay nothing
Emergency Care You pay nothing
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Foot Care Foot exams and treatment if you have diabetes-related nerve damage andor (podiatry services)2 meet certain conditions You pay nothing
Hearing Services2 Exam to diagnose and treat hearing and balance issues $0 copay Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids Please see your EOC for plan coverage details
Home Health Care1 You pay nothing
Mental Health Care1 Inpatient visit
Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital
Our plan covers 90 days for an inpatient hospital stay
Our plan also covers 60 ldquolifetime reserve daysrdquo These are ldquoextrardquo days that we cover If your hospital stay is longer than 90 days you can use these extra days But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days bull You pay nothing per day for days 1 through 90
Outpatient group therapy visit You pay nothing
Outpatient individual therapy visit You pay nothing
Outpatient Rehabilitation12 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing Occupational therapy visit You pay nothing Physical therapy and speech and language therapy visit You pay nothing
Outpatient Group therapy visit You pay nothing Substance Abuse1 Individual therapy visit You pay nothing
Outpatient Surgery12 Ambulatory surgical center You pay nothing Outpatient hospital You pay nothing
Over-the-Counter Items Please visit our website to see our list of covered over-the-counter items Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Prosthetic Devices Prosthetic devices You pay nothing (braces artificial limbs etc)1 Related medical supplies You pay nothing
Renal Dialysis12 You pay nothing
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Transportation1 You pay nothing $0 copayment for unlimited one‑way trips to plan‑approved location ever year Please see your EOC for plan coverage details
Urgently Needed Services You pay nothing If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for urgently needed services See the ldquoInpatient Hospital Carerdquo section of this booklet for other costs
Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) $0 copay
Routine eye exam (for up to 1 every year) $0 copay
Contact lenses $0 copay
Eyeglasses (frames and lenses) (for up to 1 every year) $0 copay
Eyeglass frames (for up to 1 every year) $0 copay
Eyeglass lenses (for up to 1 every year) $0 copay
Eyeglasses or contact lenses after cataract surgery $0 copay
Our plan pays up to $250 every year for eyewear
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Preventive Care You pay nothing
Our plan covers many preventive services including
bull Abdominal aortic aneurysm screening
bull Alcohol misuse counseling
bull Bone mass measurement
bull Breast cancer screening (mammogram)
bull Cardiovascular disease (behavioral therapy)
bull Cardiovascular screenings
bull Cervical and vaginal cancer screening
bull Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
bull Depression screening
bull Diabetes screenings
bull HIV screening
bull Medical nutrition therapy services
bull Obesity screening and counseling
bull Prostate cancer screenings (PSA)
bull Sexually transmitted infections screening and counseling
bull Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
bull Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
bull ldquoWelcome to Medicarerdquo preventive visit (one-time)
bull Yearly ldquoWellnessrdquo visit
Any additional preventive services approved by Medicare during the contract year will be covered
Annual physical exam You pay nothing
Hospice You pay nothing for hospice care from a Medicare-certified hospice You may have to pay part of the cost for drugs and respite care Hospice is covered outside of our plan Please contact us for more details
Inpatient Care
Inpatient Hospital Care12 Our plan covers an unlimited number of days for an inpatient hospital stay
bull You pay nothing per day for days 1 through 90
bull You pay nothing per day for days 91 and beyond
Inpatient Mental Health Care For inpatient mental health care see the ldquoMental Health Carerdquo section of this booklet
Skilled Nursing Facility (SNF)1
Our plan covers up to 100 days in a SNF
bull You pay nothing per day for days 1 through 100
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Prescription Drug Benefits
How much do I pay For Part B drugs such as chemotherapy drugs1 You pay nothing Other Part B drugs1 You pay nothing
Initial Coverage Depending on your income and institutional status you pay the following For generic drugs (including brand drugs treated as generic) either
bull $0 copay or bull $120 copay or bull $295 copay
For all other drugs either bull $0 copay or bull $360 copay or bull $740 copay
You may get your drugs at network retail pharmacies and mail order pharmacies
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 an in-network pharmacy
Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Additional Plan Benefits
24-hour Nurse Line $0 copay for 24-hour Nurse Line
Caring registered nurses are available by phone 24 hours a day 7 days a week to answer your health questions in a confidential and convenient service
Fitness $0 copay for membership in Health ClubFitness Classes
Please see your EOC for plan coverage details
Home Safety $1500 allowance once per lifetime for the purchase and installation of approved safety devices in bathrooms Please see your EOC for plan coverage details
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H4513 PLAN 010
This section demonstrates the Medicaid Medicare Part A and B cost sharing when benefit package for full benefit dual-eligible the state is responsible for paying these recipients in the state of Texas The amounts For more information about your services offered in your Medicaid benefit Medicaid benefits and copayments please package are based on your Medicaid contact the State Medicaid Office eligibility level (Categorically Needy or
The benefits described below are covered Medically Needy) Medicare coverage must
by Medicaid The benefits described in the be used first and the Medicaid Program may
Covered Medical and Hospital Benefits cover payment of Medicare Part A and B
section of the Summary of Benefits are deductible and coinsurance for all Medicare
covered by Medicare For each benefit listed covered services The services listed below
below you can see what Texas Medicaid are available only to those SNP members
covers and what our plan covers What you eligible under Medicaid for medical services
pay for covered services may depend on If you are eligible for both Medicare and
your level of Medicaid eligibility Medicaid you will not be held liable for
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Important Information
Premium and other important information
Medicaid assistance with premium payment may vary based on your level of Medicaid eligibility
Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for Original Medicare services
$2800 monthly plan premium in addition to your monthly Medicare Part B premium
In-Network
In this plan you will have no cost-sharing responsibility for Medicare-covered services
Doctor and hospital choice (For more information see Emergency Care and Urgently Needed Care)
For those who meet QMB requirements Medicaid pays coinsurance copayments and deductibles for Medicare-covered services Members should follow Medicare guidelines related to hospital and doctor choice
$0 copay for Medicaid-covered services
In-Network
You must go to network doctors specialists and hospitals
Referral required for network hospitals and specialists (for certain benefits)
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Inpatient Care
Inpatient Hospital Care (Includes substance abuse and rehabilitation services)
Admissions for the single diagnosis of chemical dependency or abuse without an accompanying medical complication are not a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Our plan covers an unlimited number of days for an inpatient hospital stay
bull You pay nothing per day for days 1 through 90
bull You pay nothing per day for days 91 and beyond
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Inpatient Mental Health Care
Inpatient admissions to acute care hospitals for adults and children for psychiatric conditions are a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
You get up to 190 days of inpatient psychiatric hospital care in a lifetime Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met This limitation does not apply to inpatient psychiatric services furnished in a general hospital
bull You pay nothing per day for days 1 through 90
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Skilled Nursing Facility (SNF) (in a Medicare-certified skilled nursing facility)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Our plan covers up to 100 days in a SNF
bull You pay nothing per day for days 1 through 100
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Home Health Care (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
$0 copay for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered home health visits
Hospice 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 for Medicaid-covered services
You must get care from a Medicare-certified hospice
Your plan will pay for a consultative visit before you select hospice
Outpatient Care
Doctor Office Visits 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for each Medicare-covered primary care doctor visit
$0 copay for each Medicare-covered specialist visit
Chiropractic 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 for Medicaid-covered services
In-Network
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered chiropractic visits
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part)
Podiatry 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered podiatry visits Medicare-covered podiatry visits are for medically-necessary foot care
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient Mental For Dual-eligible Members Medicaid In-Network Health Care pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare $0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
therapy visit
bull each Medicare-covered group therapy visit
$0 copay for Medicare-covered partial hospitalization program services
Outpatient For Dual-eligible Members Medicaid In-Network Substance pays for this service if it is not covered Authorization rules may apply Abuse Care by Medicare or when the Medicare
$0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
substance abuse outpatient treatment visit
bull each Medicare-covered group substance abuse outpatient treatment visit
Outpatient For Dual-eligible Members Medicaid In-Network ServicesSurgery pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) is required
$0 copay for Medicaid-covered services $0 copay for each Medicare-covered ambulatory surgical center visit
$0 copay for each Medicare-covered outpatient hospital facility visit
Ambulance Services For Dual-eligible Members Medicaid In-Network (medically necessary pays for this service if it is not covered Authorization rules may apply ambulance services) by Medicare or when the Medicare
$0 copay per ground trip benefit is exhausted 0 coinsurance per air trip $0 copay for Medicaid-covered services
Emergency Care For Dual-eligible Members Medicaid $0 copay for Medicare-covered (you may go to any pays for this service if it is not covered emergency room visits emergency room if you by Medicare or when the Medicare $50000 plan coverage limit for reasonably believe you benefit is exhausted supplemental emergency services need emergency care) $0 copay for Medicaid-covered services outside the US and its territories every
year
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Urgently Needed Care (this is not emergency care and in most cases is out of the service area)
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 for Medicaid-covered services
$0 copay for Medicare-covered urgently-needed-care Visits
If you are admitted to the hospital within 24 hours for the same condition you pay $0 for the urgently-needed-care visit
Outpatient Rehabilitation Services (occupational therapy physical therapy speech and language therapy)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Medically necessary physical therapy occupational therapy and speech and language pathology services are covered
$0 copay for Medicare-covered Occupational Therapy visits
$0 copay for Medicare-covered Physical Therapy and or Speech and Language Pathology visits
Outpatient Medical Services and Supplies
Durable Medical Equipment (includes wheelchairs oxygen etc)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered durable medical equipment
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Prosthetic Devices For Dual-eligible Members under age 21 In-Network (includes braces (CCP) Medicaid pays for this service if it Authorization rules may apply artificial limbs is not covered by Medicare or when the
$0 copay for Medicare-covered and eyes etc) Medicare benefit is exhausted bull prosthetic devices For all Dual-eligible Members Medicaid
pays for breast prostheses if not covered bull medical supplies related to prosthetics by Medicare or when the Medicare splints and other devices benefit is exhausted Quantity limitations apply and vary with each device Prior authorization will NOT be required within limitations except for miscellaneous codes
$0 copay for Medicaid-covered services
Diabetes Programs For Dual-eligible Members Medicaid In-Network and Supplies pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered Diabetes self-management training
$0 copay for Medicare-covered
bull Diabetes monitoring supplies
bull Therapeutic shoes or inserts
Diabetic Supplies and Services are limited to specific manufacturers products andor brands Contact the plan for a list of covered supplies
Diagnostic Tests For Dual-eligible Members Medicaid In-Network X-rays Lab Services pays for this service if it is not covered Authorization rules may apply and Radiology by Medicare or when the Medicare
Referral from your Primary Care Services benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered
bull lab services
bull diagnostic procedures and tests
bull X-rays
bull diagnostic radiology services (not including X-rays)
bull therapeutic radiology services
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Cardiac and Pulmonary Rehabilitation Services
Outpatient cardiac rehabilitation is covered for members meeting specific diagnostic criteria for a limited number of sessions
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing $0 copay for Medicare-covered Pulmonary Rehabilitation Services
Preventive Services
Preventive Services bull Bone Mass Measurement Texas Medicaid covers only the Single Photon Absorptiometry Test
$0 copay for Medicaid-covered services
bull Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam for women with Medicare) 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 for Medicaid-covered services
bull Colorectal Cancer Screening (for people with Medicare age 50 and older) 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 for Medicaid-covered services
bull Immunization (Flu vaccine Hepatitis B Vaccine for people with Medicare who are at risk Pneumonia vaccine) 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 for Medicaid-covered services
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for all preventive services covered under Original Medicare at zero cost sharing
Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare
Plan covers a physical exam annually
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services bull Health Wellness Education (Written (continued) health education materials including
Newsletters Nutritional Training Additional Smoking Cessation other wellness benefits) This is not a Texas Medicaid benefit but is available in some of the pilot programs like the Diabetes and Asthma projects For Dual-eligible Members participating in the Diabetes and Asthma pilot program Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
bull Mammograms (Annual Screening ndash for women with Medicare age 40 and older) 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 for Medicaid-covered services
bull Physical Exams 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 for Medicaid-covered services
bull Prostate Cancer Screening Exams (for men with Medicare age 50 and older) 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 for Medicaid-covered services
bull Telemedicine 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 for Medicaid-covered services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services Assistive Communication Devices This (continued) is a benefit for clients in an ICF-MR For
Dual-eligible Members who meet the above criteria Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
Kidney Disease 0 or 20 coinsurance for renal dialysis In-Network and Conditions 0 or 20 coinsurance for kidney Authorization rules may apply
disease education services Referral by your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient For Dual-eligible Members Medicaid Drugs covered under Medicare Part B Prescription Drugs pays for this service if it is not covered $0 yearly deductible for Medicare Part B
by Medicare or when Medicare benefit is drugs exhausted
$0 copay for Medicare Part B drugs $0 copayment for Medicaid-covered
Drugs covered under Medicare Part D prescription drugs not covered by Medicare Part D In-Network
Deductible $0 to $74 per year for Part D prescription drugs
Initial Coverage
Depending on your income and institutional status you pay the following
For generic drugs (including brand drugs treated as generic) either bull A $0 copay or bull A $120 copay or bull A $295 copay
For all other drugs either bull A $0 copay or bull A $360 copay or bull A $740 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Dental Services This is a benefit only for Texas Health In-Network Steps eligible clients and for clients in an Authorization rules may apply ICF-MR who are 21 years of age and
Referral from your Primary Care older For Dual-eligible Members who Physician (PCP) may be required meet the above criteria Medicaid pays
for this service if it is not covered by $0 copay for Medicare-covered dental Medicare or when the Medicare benefit benefits is exhausted $0 copay for the following preventive $0 copay for Medicaid-covered services dental benefits
bull up to 1 oral exam(s) every six months bull up to 1 cleaning(s) every six months bull up to 1 dental X-ray every year
$0 copay for the following comprehensive services bull Restorative ndash Fillings Crowns bull Periodontics bull Extractions bull Prosthodontics bull Oral Surgery
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Hearing Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered Referral by your Primary Care Physician by Medicare or when the Medicare (PCP) may be required benefit is exhausted
Exam to diagnose and treat hearing and $0 copay for Medicaid-covered services balance issues $0 copay
Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids
Please see your EOC for plan coverage details
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at
risk
$0 copay for up to 1 supplemental routine eye exam every year
$0 copay for
bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
bull up to 1 pair of eyeglasses (lenses and frames) every year
bull contact lenses
bull up to 1 pair of eyeglass lenses every year
bull up to 1 eyeglass frame(s) every year
$250 plan coverage limit for eyewear every year
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs
bull 24 Hour Nurse Line
bull Gym membership
Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items
Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Covered Medical and Hospital Benefits Note Services with a 1 may require prior authorization
Services with a 2 may require a referral from your doctor
Outpatient Care and Services
Acupuncture Not covered
Ambulance1 You pay nothing
Chiropractic Care2 Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position) You pay nothing
Dental Services1 Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth) $0 copay
Preventive dental services bull Cleaning (for up to 1 every six months) $0 copay bull Dental x-ray(s) (for up to 1 every year) $0 copay bull Oral exam (for up to 1 every six months) $0 copay Comprehensive services bull Restorative ndash Fillings Crowns $0 copay bull Periodontics $0 copay bull Extractions $0 copay bull Prosthodontics $0 copay bull Oral Surgery $0 copay
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Diabetes Supplies and Services2
Diabetes monitoring supplies You pay nothing Diabetes self-management training You pay nothing Therapeutic shoes or inserts You pay nothing
Diagnostic Tests Lab and Radiology Services and X-Rays (Costs for these services may vary based on place of service)12
Diagnostic radiology services (such as MRIs CT scans) You pay nothing Diagnostic tests and procedures You pay nothing Lab services You pay nothing Outpatient x-rays You pay nothing Therapeutic radiology services (such as radiation treatment for cancer) You pay nothing
Doctorrsquos Office Visits12 Primary care physician visit You pay nothing Specialist visit You pay nothing
Durable Medical Equipment (wheelchairs oxygen etc)1
You pay nothing
Emergency Care You pay nothing
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Foot Care Foot exams and treatment if you have diabetes-related nerve damage andor (podiatry services)2 meet certain conditions You pay nothing
Hearing Services2 Exam to diagnose and treat hearing and balance issues $0 copay Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids Please see your EOC for plan coverage details
Home Health Care1 You pay nothing
Mental Health Care1 Inpatient visit
Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital
Our plan covers 90 days for an inpatient hospital stay
Our plan also covers 60 ldquolifetime reserve daysrdquo These are ldquoextrardquo days that we cover If your hospital stay is longer than 90 days you can use these extra days But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days bull You pay nothing per day for days 1 through 90
Outpatient group therapy visit You pay nothing
Outpatient individual therapy visit You pay nothing
Outpatient Rehabilitation12 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing Occupational therapy visit You pay nothing Physical therapy and speech and language therapy visit You pay nothing
Outpatient Group therapy visit You pay nothing Substance Abuse1 Individual therapy visit You pay nothing
Outpatient Surgery12 Ambulatory surgical center You pay nothing Outpatient hospital You pay nothing
Over-the-Counter Items Please visit our website to see our list of covered over-the-counter items Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Prosthetic Devices Prosthetic devices You pay nothing (braces artificial limbs etc)1 Related medical supplies You pay nothing
Renal Dialysis12 You pay nothing
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Transportation1 You pay nothing $0 copayment for unlimited one‑way trips to plan‑approved location ever year Please see your EOC for plan coverage details
Urgently Needed Services You pay nothing If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for urgently needed services See the ldquoInpatient Hospital Carerdquo section of this booklet for other costs
Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) $0 copay
Routine eye exam (for up to 1 every year) $0 copay
Contact lenses $0 copay
Eyeglasses (frames and lenses) (for up to 1 every year) $0 copay
Eyeglass frames (for up to 1 every year) $0 copay
Eyeglass lenses (for up to 1 every year) $0 copay
Eyeglasses or contact lenses after cataract surgery $0 copay
Our plan pays up to $250 every year for eyewear
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Preventive Care You pay nothing
Our plan covers many preventive services including
bull Abdominal aortic aneurysm screening
bull Alcohol misuse counseling
bull Bone mass measurement
bull Breast cancer screening (mammogram)
bull Cardiovascular disease (behavioral therapy)
bull Cardiovascular screenings
bull Cervical and vaginal cancer screening
bull Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
bull Depression screening
bull Diabetes screenings
bull HIV screening
bull Medical nutrition therapy services
bull Obesity screening and counseling
bull Prostate cancer screenings (PSA)
bull Sexually transmitted infections screening and counseling
bull Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
bull Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
bull ldquoWelcome to Medicarerdquo preventive visit (one-time)
bull Yearly ldquoWellnessrdquo visit
Any additional preventive services approved by Medicare during the contract year will be covered
Annual physical exam You pay nothing
Hospice You pay nothing for hospice care from a Medicare-certified hospice You may have to pay part of the cost for drugs and respite care Hospice is covered outside of our plan Please contact us for more details
Inpatient Care
Inpatient Hospital Care12 Our plan covers an unlimited number of days for an inpatient hospital stay
bull You pay nothing per day for days 1 through 90
bull You pay nothing per day for days 91 and beyond
Inpatient Mental Health Care For inpatient mental health care see the ldquoMental Health Carerdquo section of this booklet
Skilled Nursing Facility (SNF)1
Our plan covers up to 100 days in a SNF
bull You pay nothing per day for days 1 through 100
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Prescription Drug Benefits
How much do I pay For Part B drugs such as chemotherapy drugs1 You pay nothing Other Part B drugs1 You pay nothing
Initial Coverage Depending on your income and institutional status you pay the following For generic drugs (including brand drugs treated as generic) either
bull $0 copay or bull $120 copay or bull $295 copay
For all other drugs either bull $0 copay or bull $360 copay or bull $740 copay
You may get your drugs at network retail pharmacies and mail order pharmacies
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 an in-network pharmacy
Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Additional Plan Benefits
24-hour Nurse Line $0 copay for 24-hour Nurse Line
Caring registered nurses are available by phone 24 hours a day 7 days a week to answer your health questions in a confidential and convenient service
Fitness $0 copay for membership in Health ClubFitness Classes
Please see your EOC for plan coverage details
Home Safety $1500 allowance once per lifetime for the purchase and installation of approved safety devices in bathrooms Please see your EOC for plan coverage details
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H4513 PLAN 010
This section demonstrates the Medicaid Medicare Part A and B cost sharing when benefit package for full benefit dual-eligible the state is responsible for paying these recipients in the state of Texas The amounts For more information about your services offered in your Medicaid benefit Medicaid benefits and copayments please package are based on your Medicaid contact the State Medicaid Office eligibility level (Categorically Needy or
The benefits described below are covered Medically Needy) Medicare coverage must
by Medicaid The benefits described in the be used first and the Medicaid Program may
Covered Medical and Hospital Benefits cover payment of Medicare Part A and B
section of the Summary of Benefits are deductible and coinsurance for all Medicare
covered by Medicare For each benefit listed covered services The services listed below
below you can see what Texas Medicaid are available only to those SNP members
covers and what our plan covers What you eligible under Medicaid for medical services
pay for covered services may depend on If you are eligible for both Medicare and
your level of Medicaid eligibility Medicaid you will not be held liable for
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Important Information
Premium and other important information
Medicaid assistance with premium payment may vary based on your level of Medicaid eligibility
Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for Original Medicare services
$2800 monthly plan premium in addition to your monthly Medicare Part B premium
In-Network
In this plan you will have no cost-sharing responsibility for Medicare-covered services
Doctor and hospital choice (For more information see Emergency Care and Urgently Needed Care)
For those who meet QMB requirements Medicaid pays coinsurance copayments and deductibles for Medicare-covered services Members should follow Medicare guidelines related to hospital and doctor choice
$0 copay for Medicaid-covered services
In-Network
You must go to network doctors specialists and hospitals
Referral required for network hospitals and specialists (for certain benefits)
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Inpatient Care
Inpatient Hospital Care (Includes substance abuse and rehabilitation services)
Admissions for the single diagnosis of chemical dependency or abuse without an accompanying medical complication are not a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Our plan covers an unlimited number of days for an inpatient hospital stay
bull You pay nothing per day for days 1 through 90
bull You pay nothing per day for days 91 and beyond
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Inpatient Mental Health Care
Inpatient admissions to acute care hospitals for adults and children for psychiatric conditions are a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
You get up to 190 days of inpatient psychiatric hospital care in a lifetime Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met This limitation does not apply to inpatient psychiatric services furnished in a general hospital
bull You pay nothing per day for days 1 through 90
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Skilled Nursing Facility (SNF) (in a Medicare-certified skilled nursing facility)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Our plan covers up to 100 days in a SNF
bull You pay nothing per day for days 1 through 100
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Home Health Care (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
$0 copay for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered home health visits
Hospice 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 for Medicaid-covered services
You must get care from a Medicare-certified hospice
Your plan will pay for a consultative visit before you select hospice
Outpatient Care
Doctor Office Visits 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for each Medicare-covered primary care doctor visit
$0 copay for each Medicare-covered specialist visit
Chiropractic 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 for Medicaid-covered services
In-Network
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered chiropractic visits
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part)
Podiatry 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered podiatry visits Medicare-covered podiatry visits are for medically-necessary foot care
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient Mental For Dual-eligible Members Medicaid In-Network Health Care pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare $0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
therapy visit
bull each Medicare-covered group therapy visit
$0 copay for Medicare-covered partial hospitalization program services
Outpatient For Dual-eligible Members Medicaid In-Network Substance pays for this service if it is not covered Authorization rules may apply Abuse Care by Medicare or when the Medicare
$0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
substance abuse outpatient treatment visit
bull each Medicare-covered group substance abuse outpatient treatment visit
Outpatient For Dual-eligible Members Medicaid In-Network ServicesSurgery pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) is required
$0 copay for Medicaid-covered services $0 copay for each Medicare-covered ambulatory surgical center visit
$0 copay for each Medicare-covered outpatient hospital facility visit
Ambulance Services For Dual-eligible Members Medicaid In-Network (medically necessary pays for this service if it is not covered Authorization rules may apply ambulance services) by Medicare or when the Medicare
$0 copay per ground trip benefit is exhausted 0 coinsurance per air trip $0 copay for Medicaid-covered services
Emergency Care For Dual-eligible Members Medicaid $0 copay for Medicare-covered (you may go to any pays for this service if it is not covered emergency room visits emergency room if you by Medicare or when the Medicare $50000 plan coverage limit for reasonably believe you benefit is exhausted supplemental emergency services need emergency care) $0 copay for Medicaid-covered services outside the US and its territories every
year
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Urgently Needed Care (this is not emergency care and in most cases is out of the service area)
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 for Medicaid-covered services
$0 copay for Medicare-covered urgently-needed-care Visits
If you are admitted to the hospital within 24 hours for the same condition you pay $0 for the urgently-needed-care visit
Outpatient Rehabilitation Services (occupational therapy physical therapy speech and language therapy)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Medically necessary physical therapy occupational therapy and speech and language pathology services are covered
$0 copay for Medicare-covered Occupational Therapy visits
$0 copay for Medicare-covered Physical Therapy and or Speech and Language Pathology visits
Outpatient Medical Services and Supplies
Durable Medical Equipment (includes wheelchairs oxygen etc)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered durable medical equipment
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Prosthetic Devices For Dual-eligible Members under age 21 In-Network (includes braces (CCP) Medicaid pays for this service if it Authorization rules may apply artificial limbs is not covered by Medicare or when the
$0 copay for Medicare-covered and eyes etc) Medicare benefit is exhausted bull prosthetic devices For all Dual-eligible Members Medicaid
pays for breast prostheses if not covered bull medical supplies related to prosthetics by Medicare or when the Medicare splints and other devices benefit is exhausted Quantity limitations apply and vary with each device Prior authorization will NOT be required within limitations except for miscellaneous codes
$0 copay for Medicaid-covered services
Diabetes Programs For Dual-eligible Members Medicaid In-Network and Supplies pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered Diabetes self-management training
$0 copay for Medicare-covered
bull Diabetes monitoring supplies
bull Therapeutic shoes or inserts
Diabetic Supplies and Services are limited to specific manufacturers products andor brands Contact the plan for a list of covered supplies
Diagnostic Tests For Dual-eligible Members Medicaid In-Network X-rays Lab Services pays for this service if it is not covered Authorization rules may apply and Radiology by Medicare or when the Medicare
Referral from your Primary Care Services benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered
bull lab services
bull diagnostic procedures and tests
bull X-rays
bull diagnostic radiology services (not including X-rays)
bull therapeutic radiology services
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Cardiac and Pulmonary Rehabilitation Services
Outpatient cardiac rehabilitation is covered for members meeting specific diagnostic criteria for a limited number of sessions
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing $0 copay for Medicare-covered Pulmonary Rehabilitation Services
Preventive Services
Preventive Services bull Bone Mass Measurement Texas Medicaid covers only the Single Photon Absorptiometry Test
$0 copay for Medicaid-covered services
bull Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam for women with Medicare) 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 for Medicaid-covered services
bull Colorectal Cancer Screening (for people with Medicare age 50 and older) 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 for Medicaid-covered services
bull Immunization (Flu vaccine Hepatitis B Vaccine for people with Medicare who are at risk Pneumonia vaccine) 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 for Medicaid-covered services
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for all preventive services covered under Original Medicare at zero cost sharing
Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare
Plan covers a physical exam annually
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services bull Health Wellness Education (Written (continued) health education materials including
Newsletters Nutritional Training Additional Smoking Cessation other wellness benefits) This is not a Texas Medicaid benefit but is available in some of the pilot programs like the Diabetes and Asthma projects For Dual-eligible Members participating in the Diabetes and Asthma pilot program Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
bull Mammograms (Annual Screening ndash for women with Medicare age 40 and older) 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 for Medicaid-covered services
bull Physical Exams 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 for Medicaid-covered services
bull Prostate Cancer Screening Exams (for men with Medicare age 50 and older) 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 for Medicaid-covered services
bull Telemedicine 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 for Medicaid-covered services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services Assistive Communication Devices This (continued) is a benefit for clients in an ICF-MR For
Dual-eligible Members who meet the above criteria Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
Kidney Disease 0 or 20 coinsurance for renal dialysis In-Network and Conditions 0 or 20 coinsurance for kidney Authorization rules may apply
disease education services Referral by your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient For Dual-eligible Members Medicaid Drugs covered under Medicare Part B Prescription Drugs pays for this service if it is not covered $0 yearly deductible for Medicare Part B
by Medicare or when Medicare benefit is drugs exhausted
$0 copay for Medicare Part B drugs $0 copayment for Medicaid-covered
Drugs covered under Medicare Part D prescription drugs not covered by Medicare Part D In-Network
Deductible $0 to $74 per year for Part D prescription drugs
Initial Coverage
Depending on your income and institutional status you pay the following
For generic drugs (including brand drugs treated as generic) either bull A $0 copay or bull A $120 copay or bull A $295 copay
For all other drugs either bull A $0 copay or bull A $360 copay or bull A $740 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Dental Services This is a benefit only for Texas Health In-Network Steps eligible clients and for clients in an Authorization rules may apply ICF-MR who are 21 years of age and
Referral from your Primary Care older For Dual-eligible Members who Physician (PCP) may be required meet the above criteria Medicaid pays
for this service if it is not covered by $0 copay for Medicare-covered dental Medicare or when the Medicare benefit benefits is exhausted $0 copay for the following preventive $0 copay for Medicaid-covered services dental benefits
bull up to 1 oral exam(s) every six months bull up to 1 cleaning(s) every six months bull up to 1 dental X-ray every year
$0 copay for the following comprehensive services bull Restorative ndash Fillings Crowns bull Periodontics bull Extractions bull Prosthodontics bull Oral Surgery
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Hearing Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered Referral by your Primary Care Physician by Medicare or when the Medicare (PCP) may be required benefit is exhausted
Exam to diagnose and treat hearing and $0 copay for Medicaid-covered services balance issues $0 copay
Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids
Please see your EOC for plan coverage details
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at
risk
$0 copay for up to 1 supplemental routine eye exam every year
$0 copay for
bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
bull up to 1 pair of eyeglasses (lenses and frames) every year
bull contact lenses
bull up to 1 pair of eyeglass lenses every year
bull up to 1 eyeglass frame(s) every year
$250 plan coverage limit for eyewear every year
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs
bull 24 Hour Nurse Line
bull Gym membership
Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items
Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Foot Care Foot exams and treatment if you have diabetes-related nerve damage andor (podiatry services)2 meet certain conditions You pay nothing
Hearing Services2 Exam to diagnose and treat hearing and balance issues $0 copay Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids Please see your EOC for plan coverage details
Home Health Care1 You pay nothing
Mental Health Care1 Inpatient visit
Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital
Our plan covers 90 days for an inpatient hospital stay
Our plan also covers 60 ldquolifetime reserve daysrdquo These are ldquoextrardquo days that we cover If your hospital stay is longer than 90 days you can use these extra days But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days bull You pay nothing per day for days 1 through 90
Outpatient group therapy visit You pay nothing
Outpatient individual therapy visit You pay nothing
Outpatient Rehabilitation12 Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing Occupational therapy visit You pay nothing Physical therapy and speech and language therapy visit You pay nothing
Outpatient Group therapy visit You pay nothing Substance Abuse1 Individual therapy visit You pay nothing
Outpatient Surgery12 Ambulatory surgical center You pay nothing Outpatient hospital You pay nothing
Over-the-Counter Items Please visit our website to see our list of covered over-the-counter items Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Prosthetic Devices Prosthetic devices You pay nothing (braces artificial limbs etc)1 Related medical supplies You pay nothing
Renal Dialysis12 You pay nothing
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Transportation1 You pay nothing $0 copayment for unlimited one‑way trips to plan‑approved location ever year Please see your EOC for plan coverage details
Urgently Needed Services You pay nothing If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for urgently needed services See the ldquoInpatient Hospital Carerdquo section of this booklet for other costs
Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) $0 copay
Routine eye exam (for up to 1 every year) $0 copay
Contact lenses $0 copay
Eyeglasses (frames and lenses) (for up to 1 every year) $0 copay
Eyeglass frames (for up to 1 every year) $0 copay
Eyeglass lenses (for up to 1 every year) $0 copay
Eyeglasses or contact lenses after cataract surgery $0 copay
Our plan pays up to $250 every year for eyewear
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Preventive Care You pay nothing
Our plan covers many preventive services including
bull Abdominal aortic aneurysm screening
bull Alcohol misuse counseling
bull Bone mass measurement
bull Breast cancer screening (mammogram)
bull Cardiovascular disease (behavioral therapy)
bull Cardiovascular screenings
bull Cervical and vaginal cancer screening
bull Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
bull Depression screening
bull Diabetes screenings
bull HIV screening
bull Medical nutrition therapy services
bull Obesity screening and counseling
bull Prostate cancer screenings (PSA)
bull Sexually transmitted infections screening and counseling
bull Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
bull Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
bull ldquoWelcome to Medicarerdquo preventive visit (one-time)
bull Yearly ldquoWellnessrdquo visit
Any additional preventive services approved by Medicare during the contract year will be covered
Annual physical exam You pay nothing
Hospice You pay nothing for hospice care from a Medicare-certified hospice You may have to pay part of the cost for drugs and respite care Hospice is covered outside of our plan Please contact us for more details
Inpatient Care
Inpatient Hospital Care12 Our plan covers an unlimited number of days for an inpatient hospital stay
bull You pay nothing per day for days 1 through 90
bull You pay nothing per day for days 91 and beyond
Inpatient Mental Health Care For inpatient mental health care see the ldquoMental Health Carerdquo section of this booklet
Skilled Nursing Facility (SNF)1
Our plan covers up to 100 days in a SNF
bull You pay nothing per day for days 1 through 100
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Prescription Drug Benefits
How much do I pay For Part B drugs such as chemotherapy drugs1 You pay nothing Other Part B drugs1 You pay nothing
Initial Coverage Depending on your income and institutional status you pay the following For generic drugs (including brand drugs treated as generic) either
bull $0 copay or bull $120 copay or bull $295 copay
For all other drugs either bull $0 copay or bull $360 copay or bull $740 copay
You may get your drugs at network retail pharmacies and mail order pharmacies
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 an in-network pharmacy
Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Additional Plan Benefits
24-hour Nurse Line $0 copay for 24-hour Nurse Line
Caring registered nurses are available by phone 24 hours a day 7 days a week to answer your health questions in a confidential and convenient service
Fitness $0 copay for membership in Health ClubFitness Classes
Please see your EOC for plan coverage details
Home Safety $1500 allowance once per lifetime for the purchase and installation of approved safety devices in bathrooms Please see your EOC for plan coverage details
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H4513 PLAN 010
This section demonstrates the Medicaid Medicare Part A and B cost sharing when benefit package for full benefit dual-eligible the state is responsible for paying these recipients in the state of Texas The amounts For more information about your services offered in your Medicaid benefit Medicaid benefits and copayments please package are based on your Medicaid contact the State Medicaid Office eligibility level (Categorically Needy or
The benefits described below are covered Medically Needy) Medicare coverage must
by Medicaid The benefits described in the be used first and the Medicaid Program may
Covered Medical and Hospital Benefits cover payment of Medicare Part A and B
section of the Summary of Benefits are deductible and coinsurance for all Medicare
covered by Medicare For each benefit listed covered services The services listed below
below you can see what Texas Medicaid are available only to those SNP members
covers and what our plan covers What you eligible under Medicaid for medical services
pay for covered services may depend on If you are eligible for both Medicare and
your level of Medicaid eligibility Medicaid you will not be held liable for
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Important Information
Premium and other important information
Medicaid assistance with premium payment may vary based on your level of Medicaid eligibility
Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for Original Medicare services
$2800 monthly plan premium in addition to your monthly Medicare Part B premium
In-Network
In this plan you will have no cost-sharing responsibility for Medicare-covered services
Doctor and hospital choice (For more information see Emergency Care and Urgently Needed Care)
For those who meet QMB requirements Medicaid pays coinsurance copayments and deductibles for Medicare-covered services Members should follow Medicare guidelines related to hospital and doctor choice
$0 copay for Medicaid-covered services
In-Network
You must go to network doctors specialists and hospitals
Referral required for network hospitals and specialists (for certain benefits)
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Inpatient Care
Inpatient Hospital Care (Includes substance abuse and rehabilitation services)
Admissions for the single diagnosis of chemical dependency or abuse without an accompanying medical complication are not a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Our plan covers an unlimited number of days for an inpatient hospital stay
bull You pay nothing per day for days 1 through 90
bull You pay nothing per day for days 91 and beyond
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Inpatient Mental Health Care
Inpatient admissions to acute care hospitals for adults and children for psychiatric conditions are a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
You get up to 190 days of inpatient psychiatric hospital care in a lifetime Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met This limitation does not apply to inpatient psychiatric services furnished in a general hospital
bull You pay nothing per day for days 1 through 90
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Skilled Nursing Facility (SNF) (in a Medicare-certified skilled nursing facility)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Our plan covers up to 100 days in a SNF
bull You pay nothing per day for days 1 through 100
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Home Health Care (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
$0 copay for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered home health visits
Hospice 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 for Medicaid-covered services
You must get care from a Medicare-certified hospice
Your plan will pay for a consultative visit before you select hospice
Outpatient Care
Doctor Office Visits 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for each Medicare-covered primary care doctor visit
$0 copay for each Medicare-covered specialist visit
Chiropractic 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 for Medicaid-covered services
In-Network
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered chiropractic visits
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part)
Podiatry 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered podiatry visits Medicare-covered podiatry visits are for medically-necessary foot care
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient Mental For Dual-eligible Members Medicaid In-Network Health Care pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare $0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
therapy visit
bull each Medicare-covered group therapy visit
$0 copay for Medicare-covered partial hospitalization program services
Outpatient For Dual-eligible Members Medicaid In-Network Substance pays for this service if it is not covered Authorization rules may apply Abuse Care by Medicare or when the Medicare
$0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
substance abuse outpatient treatment visit
bull each Medicare-covered group substance abuse outpatient treatment visit
Outpatient For Dual-eligible Members Medicaid In-Network ServicesSurgery pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) is required
$0 copay for Medicaid-covered services $0 copay for each Medicare-covered ambulatory surgical center visit
$0 copay for each Medicare-covered outpatient hospital facility visit
Ambulance Services For Dual-eligible Members Medicaid In-Network (medically necessary pays for this service if it is not covered Authorization rules may apply ambulance services) by Medicare or when the Medicare
$0 copay per ground trip benefit is exhausted 0 coinsurance per air trip $0 copay for Medicaid-covered services
Emergency Care For Dual-eligible Members Medicaid $0 copay for Medicare-covered (you may go to any pays for this service if it is not covered emergency room visits emergency room if you by Medicare or when the Medicare $50000 plan coverage limit for reasonably believe you benefit is exhausted supplemental emergency services need emergency care) $0 copay for Medicaid-covered services outside the US and its territories every
year
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Urgently Needed Care (this is not emergency care and in most cases is out of the service area)
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 for Medicaid-covered services
$0 copay for Medicare-covered urgently-needed-care Visits
If you are admitted to the hospital within 24 hours for the same condition you pay $0 for the urgently-needed-care visit
Outpatient Rehabilitation Services (occupational therapy physical therapy speech and language therapy)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Medically necessary physical therapy occupational therapy and speech and language pathology services are covered
$0 copay for Medicare-covered Occupational Therapy visits
$0 copay for Medicare-covered Physical Therapy and or Speech and Language Pathology visits
Outpatient Medical Services and Supplies
Durable Medical Equipment (includes wheelchairs oxygen etc)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered durable medical equipment
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Prosthetic Devices For Dual-eligible Members under age 21 In-Network (includes braces (CCP) Medicaid pays for this service if it Authorization rules may apply artificial limbs is not covered by Medicare or when the
$0 copay for Medicare-covered and eyes etc) Medicare benefit is exhausted bull prosthetic devices For all Dual-eligible Members Medicaid
pays for breast prostheses if not covered bull medical supplies related to prosthetics by Medicare or when the Medicare splints and other devices benefit is exhausted Quantity limitations apply and vary with each device Prior authorization will NOT be required within limitations except for miscellaneous codes
$0 copay for Medicaid-covered services
Diabetes Programs For Dual-eligible Members Medicaid In-Network and Supplies pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered Diabetes self-management training
$0 copay for Medicare-covered
bull Diabetes monitoring supplies
bull Therapeutic shoes or inserts
Diabetic Supplies and Services are limited to specific manufacturers products andor brands Contact the plan for a list of covered supplies
Diagnostic Tests For Dual-eligible Members Medicaid In-Network X-rays Lab Services pays for this service if it is not covered Authorization rules may apply and Radiology by Medicare or when the Medicare
Referral from your Primary Care Services benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered
bull lab services
bull diagnostic procedures and tests
bull X-rays
bull diagnostic radiology services (not including X-rays)
bull therapeutic radiology services
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Cardiac and Pulmonary Rehabilitation Services
Outpatient cardiac rehabilitation is covered for members meeting specific diagnostic criteria for a limited number of sessions
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing $0 copay for Medicare-covered Pulmonary Rehabilitation Services
Preventive Services
Preventive Services bull Bone Mass Measurement Texas Medicaid covers only the Single Photon Absorptiometry Test
$0 copay for Medicaid-covered services
bull Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam for women with Medicare) 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 for Medicaid-covered services
bull Colorectal Cancer Screening (for people with Medicare age 50 and older) 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 for Medicaid-covered services
bull Immunization (Flu vaccine Hepatitis B Vaccine for people with Medicare who are at risk Pneumonia vaccine) 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 for Medicaid-covered services
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for all preventive services covered under Original Medicare at zero cost sharing
Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare
Plan covers a physical exam annually
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services bull Health Wellness Education (Written (continued) health education materials including
Newsletters Nutritional Training Additional Smoking Cessation other wellness benefits) This is not a Texas Medicaid benefit but is available in some of the pilot programs like the Diabetes and Asthma projects For Dual-eligible Members participating in the Diabetes and Asthma pilot program Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
bull Mammograms (Annual Screening ndash for women with Medicare age 40 and older) 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 for Medicaid-covered services
bull Physical Exams 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 for Medicaid-covered services
bull Prostate Cancer Screening Exams (for men with Medicare age 50 and older) 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 for Medicaid-covered services
bull Telemedicine 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 for Medicaid-covered services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services Assistive Communication Devices This (continued) is a benefit for clients in an ICF-MR For
Dual-eligible Members who meet the above criteria Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
Kidney Disease 0 or 20 coinsurance for renal dialysis In-Network and Conditions 0 or 20 coinsurance for kidney Authorization rules may apply
disease education services Referral by your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient For Dual-eligible Members Medicaid Drugs covered under Medicare Part B Prescription Drugs pays for this service if it is not covered $0 yearly deductible for Medicare Part B
by Medicare or when Medicare benefit is drugs exhausted
$0 copay for Medicare Part B drugs $0 copayment for Medicaid-covered
Drugs covered under Medicare Part D prescription drugs not covered by Medicare Part D In-Network
Deductible $0 to $74 per year for Part D prescription drugs
Initial Coverage
Depending on your income and institutional status you pay the following
For generic drugs (including brand drugs treated as generic) either bull A $0 copay or bull A $120 copay or bull A $295 copay
For all other drugs either bull A $0 copay or bull A $360 copay or bull A $740 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Dental Services This is a benefit only for Texas Health In-Network Steps eligible clients and for clients in an Authorization rules may apply ICF-MR who are 21 years of age and
Referral from your Primary Care older For Dual-eligible Members who Physician (PCP) may be required meet the above criteria Medicaid pays
for this service if it is not covered by $0 copay for Medicare-covered dental Medicare or when the Medicare benefit benefits is exhausted $0 copay for the following preventive $0 copay for Medicaid-covered services dental benefits
bull up to 1 oral exam(s) every six months bull up to 1 cleaning(s) every six months bull up to 1 dental X-ray every year
$0 copay for the following comprehensive services bull Restorative ndash Fillings Crowns bull Periodontics bull Extractions bull Prosthodontics bull Oral Surgery
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Hearing Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered Referral by your Primary Care Physician by Medicare or when the Medicare (PCP) may be required benefit is exhausted
Exam to diagnose and treat hearing and $0 copay for Medicaid-covered services balance issues $0 copay
Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids
Please see your EOC for plan coverage details
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at
risk
$0 copay for up to 1 supplemental routine eye exam every year
$0 copay for
bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
bull up to 1 pair of eyeglasses (lenses and frames) every year
bull contact lenses
bull up to 1 pair of eyeglass lenses every year
bull up to 1 eyeglass frame(s) every year
$250 plan coverage limit for eyewear every year
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs
bull 24 Hour Nurse Line
bull Gym membership
Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items
Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Transportation1 You pay nothing $0 copayment for unlimited one‑way trips to plan‑approved location ever year Please see your EOC for plan coverage details
Urgently Needed Services You pay nothing If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for urgently needed services See the ldquoInpatient Hospital Carerdquo section of this booklet for other costs
Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening) $0 copay
Routine eye exam (for up to 1 every year) $0 copay
Contact lenses $0 copay
Eyeglasses (frames and lenses) (for up to 1 every year) $0 copay
Eyeglass frames (for up to 1 every year) $0 copay
Eyeglass lenses (for up to 1 every year) $0 copay
Eyeglasses or contact lenses after cataract surgery $0 copay
Our plan pays up to $250 every year for eyewear
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Preventive Care You pay nothing
Our plan covers many preventive services including
bull Abdominal aortic aneurysm screening
bull Alcohol misuse counseling
bull Bone mass measurement
bull Breast cancer screening (mammogram)
bull Cardiovascular disease (behavioral therapy)
bull Cardiovascular screenings
bull Cervical and vaginal cancer screening
bull Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
bull Depression screening
bull Diabetes screenings
bull HIV screening
bull Medical nutrition therapy services
bull Obesity screening and counseling
bull Prostate cancer screenings (PSA)
bull Sexually transmitted infections screening and counseling
bull Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
bull Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
bull ldquoWelcome to Medicarerdquo preventive visit (one-time)
bull Yearly ldquoWellnessrdquo visit
Any additional preventive services approved by Medicare during the contract year will be covered
Annual physical exam You pay nothing
Hospice You pay nothing for hospice care from a Medicare-certified hospice You may have to pay part of the cost for drugs and respite care Hospice is covered outside of our plan Please contact us for more details
Inpatient Care
Inpatient Hospital Care12 Our plan covers an unlimited number of days for an inpatient hospital stay
bull You pay nothing per day for days 1 through 90
bull You pay nothing per day for days 91 and beyond
Inpatient Mental Health Care For inpatient mental health care see the ldquoMental Health Carerdquo section of this booklet
Skilled Nursing Facility (SNF)1
Our plan covers up to 100 days in a SNF
bull You pay nothing per day for days 1 through 100
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Prescription Drug Benefits
How much do I pay For Part B drugs such as chemotherapy drugs1 You pay nothing Other Part B drugs1 You pay nothing
Initial Coverage Depending on your income and institutional status you pay the following For generic drugs (including brand drugs treated as generic) either
bull $0 copay or bull $120 copay or bull $295 copay
For all other drugs either bull $0 copay or bull $360 copay or bull $740 copay
You may get your drugs at network retail pharmacies and mail order pharmacies
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 an in-network pharmacy
Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Additional Plan Benefits
24-hour Nurse Line $0 copay for 24-hour Nurse Line
Caring registered nurses are available by phone 24 hours a day 7 days a week to answer your health questions in a confidential and convenient service
Fitness $0 copay for membership in Health ClubFitness Classes
Please see your EOC for plan coverage details
Home Safety $1500 allowance once per lifetime for the purchase and installation of approved safety devices in bathrooms Please see your EOC for plan coverage details
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H4513 PLAN 010
This section demonstrates the Medicaid Medicare Part A and B cost sharing when benefit package for full benefit dual-eligible the state is responsible for paying these recipients in the state of Texas The amounts For more information about your services offered in your Medicaid benefit Medicaid benefits and copayments please package are based on your Medicaid contact the State Medicaid Office eligibility level (Categorically Needy or
The benefits described below are covered Medically Needy) Medicare coverage must
by Medicaid The benefits described in the be used first and the Medicaid Program may
Covered Medical and Hospital Benefits cover payment of Medicare Part A and B
section of the Summary of Benefits are deductible and coinsurance for all Medicare
covered by Medicare For each benefit listed covered services The services listed below
below you can see what Texas Medicaid are available only to those SNP members
covers and what our plan covers What you eligible under Medicaid for medical services
pay for covered services may depend on If you are eligible for both Medicare and
your level of Medicaid eligibility Medicaid you will not be held liable for
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Important Information
Premium and other important information
Medicaid assistance with premium payment may vary based on your level of Medicaid eligibility
Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for Original Medicare services
$2800 monthly plan premium in addition to your monthly Medicare Part B premium
In-Network
In this plan you will have no cost-sharing responsibility for Medicare-covered services
Doctor and hospital choice (For more information see Emergency Care and Urgently Needed Care)
For those who meet QMB requirements Medicaid pays coinsurance copayments and deductibles for Medicare-covered services Members should follow Medicare guidelines related to hospital and doctor choice
$0 copay for Medicaid-covered services
In-Network
You must go to network doctors specialists and hospitals
Referral required for network hospitals and specialists (for certain benefits)
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Inpatient Care
Inpatient Hospital Care (Includes substance abuse and rehabilitation services)
Admissions for the single diagnosis of chemical dependency or abuse without an accompanying medical complication are not a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Our plan covers an unlimited number of days for an inpatient hospital stay
bull You pay nothing per day for days 1 through 90
bull You pay nothing per day for days 91 and beyond
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Inpatient Mental Health Care
Inpatient admissions to acute care hospitals for adults and children for psychiatric conditions are a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
You get up to 190 days of inpatient psychiatric hospital care in a lifetime Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met This limitation does not apply to inpatient psychiatric services furnished in a general hospital
bull You pay nothing per day for days 1 through 90
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Skilled Nursing Facility (SNF) (in a Medicare-certified skilled nursing facility)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Our plan covers up to 100 days in a SNF
bull You pay nothing per day for days 1 through 100
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Home Health Care (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
$0 copay for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered home health visits
Hospice 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 for Medicaid-covered services
You must get care from a Medicare-certified hospice
Your plan will pay for a consultative visit before you select hospice
Outpatient Care
Doctor Office Visits 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for each Medicare-covered primary care doctor visit
$0 copay for each Medicare-covered specialist visit
Chiropractic 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 for Medicaid-covered services
In-Network
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered chiropractic visits
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part)
Podiatry 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered podiatry visits Medicare-covered podiatry visits are for medically-necessary foot care
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient Mental For Dual-eligible Members Medicaid In-Network Health Care pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare $0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
therapy visit
bull each Medicare-covered group therapy visit
$0 copay for Medicare-covered partial hospitalization program services
Outpatient For Dual-eligible Members Medicaid In-Network Substance pays for this service if it is not covered Authorization rules may apply Abuse Care by Medicare or when the Medicare
$0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
substance abuse outpatient treatment visit
bull each Medicare-covered group substance abuse outpatient treatment visit
Outpatient For Dual-eligible Members Medicaid In-Network ServicesSurgery pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) is required
$0 copay for Medicaid-covered services $0 copay for each Medicare-covered ambulatory surgical center visit
$0 copay for each Medicare-covered outpatient hospital facility visit
Ambulance Services For Dual-eligible Members Medicaid In-Network (medically necessary pays for this service if it is not covered Authorization rules may apply ambulance services) by Medicare or when the Medicare
$0 copay per ground trip benefit is exhausted 0 coinsurance per air trip $0 copay for Medicaid-covered services
Emergency Care For Dual-eligible Members Medicaid $0 copay for Medicare-covered (you may go to any pays for this service if it is not covered emergency room visits emergency room if you by Medicare or when the Medicare $50000 plan coverage limit for reasonably believe you benefit is exhausted supplemental emergency services need emergency care) $0 copay for Medicaid-covered services outside the US and its territories every
year
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Urgently Needed Care (this is not emergency care and in most cases is out of the service area)
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 for Medicaid-covered services
$0 copay for Medicare-covered urgently-needed-care Visits
If you are admitted to the hospital within 24 hours for the same condition you pay $0 for the urgently-needed-care visit
Outpatient Rehabilitation Services (occupational therapy physical therapy speech and language therapy)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Medically necessary physical therapy occupational therapy and speech and language pathology services are covered
$0 copay for Medicare-covered Occupational Therapy visits
$0 copay for Medicare-covered Physical Therapy and or Speech and Language Pathology visits
Outpatient Medical Services and Supplies
Durable Medical Equipment (includes wheelchairs oxygen etc)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered durable medical equipment
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Prosthetic Devices For Dual-eligible Members under age 21 In-Network (includes braces (CCP) Medicaid pays for this service if it Authorization rules may apply artificial limbs is not covered by Medicare or when the
$0 copay for Medicare-covered and eyes etc) Medicare benefit is exhausted bull prosthetic devices For all Dual-eligible Members Medicaid
pays for breast prostheses if not covered bull medical supplies related to prosthetics by Medicare or when the Medicare splints and other devices benefit is exhausted Quantity limitations apply and vary with each device Prior authorization will NOT be required within limitations except for miscellaneous codes
$0 copay for Medicaid-covered services
Diabetes Programs For Dual-eligible Members Medicaid In-Network and Supplies pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered Diabetes self-management training
$0 copay for Medicare-covered
bull Diabetes monitoring supplies
bull Therapeutic shoes or inserts
Diabetic Supplies and Services are limited to specific manufacturers products andor brands Contact the plan for a list of covered supplies
Diagnostic Tests For Dual-eligible Members Medicaid In-Network X-rays Lab Services pays for this service if it is not covered Authorization rules may apply and Radiology by Medicare or when the Medicare
Referral from your Primary Care Services benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered
bull lab services
bull diagnostic procedures and tests
bull X-rays
bull diagnostic radiology services (not including X-rays)
bull therapeutic radiology services
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Cardiac and Pulmonary Rehabilitation Services
Outpatient cardiac rehabilitation is covered for members meeting specific diagnostic criteria for a limited number of sessions
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing $0 copay for Medicare-covered Pulmonary Rehabilitation Services
Preventive Services
Preventive Services bull Bone Mass Measurement Texas Medicaid covers only the Single Photon Absorptiometry Test
$0 copay for Medicaid-covered services
bull Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam for women with Medicare) 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 for Medicaid-covered services
bull Colorectal Cancer Screening (for people with Medicare age 50 and older) 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 for Medicaid-covered services
bull Immunization (Flu vaccine Hepatitis B Vaccine for people with Medicare who are at risk Pneumonia vaccine) 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 for Medicaid-covered services
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for all preventive services covered under Original Medicare at zero cost sharing
Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare
Plan covers a physical exam annually
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services bull Health Wellness Education (Written (continued) health education materials including
Newsletters Nutritional Training Additional Smoking Cessation other wellness benefits) This is not a Texas Medicaid benefit but is available in some of the pilot programs like the Diabetes and Asthma projects For Dual-eligible Members participating in the Diabetes and Asthma pilot program Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
bull Mammograms (Annual Screening ndash for women with Medicare age 40 and older) 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 for Medicaid-covered services
bull Physical Exams 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 for Medicaid-covered services
bull Prostate Cancer Screening Exams (for men with Medicare age 50 and older) 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 for Medicaid-covered services
bull Telemedicine 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 for Medicaid-covered services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services Assistive Communication Devices This (continued) is a benefit for clients in an ICF-MR For
Dual-eligible Members who meet the above criteria Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
Kidney Disease 0 or 20 coinsurance for renal dialysis In-Network and Conditions 0 or 20 coinsurance for kidney Authorization rules may apply
disease education services Referral by your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient For Dual-eligible Members Medicaid Drugs covered under Medicare Part B Prescription Drugs pays for this service if it is not covered $0 yearly deductible for Medicare Part B
by Medicare or when Medicare benefit is drugs exhausted
$0 copay for Medicare Part B drugs $0 copayment for Medicaid-covered
Drugs covered under Medicare Part D prescription drugs not covered by Medicare Part D In-Network
Deductible $0 to $74 per year for Part D prescription drugs
Initial Coverage
Depending on your income and institutional status you pay the following
For generic drugs (including brand drugs treated as generic) either bull A $0 copay or bull A $120 copay or bull A $295 copay
For all other drugs either bull A $0 copay or bull A $360 copay or bull A $740 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Dental Services This is a benefit only for Texas Health In-Network Steps eligible clients and for clients in an Authorization rules may apply ICF-MR who are 21 years of age and
Referral from your Primary Care older For Dual-eligible Members who Physician (PCP) may be required meet the above criteria Medicaid pays
for this service if it is not covered by $0 copay for Medicare-covered dental Medicare or when the Medicare benefit benefits is exhausted $0 copay for the following preventive $0 copay for Medicaid-covered services dental benefits
bull up to 1 oral exam(s) every six months bull up to 1 cleaning(s) every six months bull up to 1 dental X-ray every year
$0 copay for the following comprehensive services bull Restorative ndash Fillings Crowns bull Periodontics bull Extractions bull Prosthodontics bull Oral Surgery
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Hearing Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered Referral by your Primary Care Physician by Medicare or when the Medicare (PCP) may be required benefit is exhausted
Exam to diagnose and treat hearing and $0 copay for Medicaid-covered services balance issues $0 copay
Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids
Please see your EOC for plan coverage details
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at
risk
$0 copay for up to 1 supplemental routine eye exam every year
$0 copay for
bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
bull up to 1 pair of eyeglasses (lenses and frames) every year
bull contact lenses
bull up to 1 pair of eyeglass lenses every year
bull up to 1 eyeglass frame(s) every year
$250 plan coverage limit for eyewear every year
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs
bull 24 Hour Nurse Line
bull Gym membership
Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items
Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Preventive Care You pay nothing
Our plan covers many preventive services including
bull Abdominal aortic aneurysm screening
bull Alcohol misuse counseling
bull Bone mass measurement
bull Breast cancer screening (mammogram)
bull Cardiovascular disease (behavioral therapy)
bull Cardiovascular screenings
bull Cervical and vaginal cancer screening
bull Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
bull Depression screening
bull Diabetes screenings
bull HIV screening
bull Medical nutrition therapy services
bull Obesity screening and counseling
bull Prostate cancer screenings (PSA)
bull Sexually transmitted infections screening and counseling
bull Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
bull Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
bull ldquoWelcome to Medicarerdquo preventive visit (one-time)
bull Yearly ldquoWellnessrdquo visit
Any additional preventive services approved by Medicare during the contract year will be covered
Annual physical exam You pay nothing
Hospice You pay nothing for hospice care from a Medicare-certified hospice You may have to pay part of the cost for drugs and respite care Hospice is covered outside of our plan Please contact us for more details
Inpatient Care
Inpatient Hospital Care12 Our plan covers an unlimited number of days for an inpatient hospital stay
bull You pay nothing per day for days 1 through 90
bull You pay nothing per day for days 91 and beyond
Inpatient Mental Health Care For inpatient mental health care see the ldquoMental Health Carerdquo section of this booklet
Skilled Nursing Facility (SNF)1
Our plan covers up to 100 days in a SNF
bull You pay nothing per day for days 1 through 100
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Prescription Drug Benefits
How much do I pay For Part B drugs such as chemotherapy drugs1 You pay nothing Other Part B drugs1 You pay nothing
Initial Coverage Depending on your income and institutional status you pay the following For generic drugs (including brand drugs treated as generic) either
bull $0 copay or bull $120 copay or bull $295 copay
For all other drugs either bull $0 copay or bull $360 copay or bull $740 copay
You may get your drugs at network retail pharmacies and mail order pharmacies
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 an in-network pharmacy
Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Additional Plan Benefits
24-hour Nurse Line $0 copay for 24-hour Nurse Line
Caring registered nurses are available by phone 24 hours a day 7 days a week to answer your health questions in a confidential and convenient service
Fitness $0 copay for membership in Health ClubFitness Classes
Please see your EOC for plan coverage details
Home Safety $1500 allowance once per lifetime for the purchase and installation of approved safety devices in bathrooms Please see your EOC for plan coverage details
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H4513 PLAN 010
This section demonstrates the Medicaid Medicare Part A and B cost sharing when benefit package for full benefit dual-eligible the state is responsible for paying these recipients in the state of Texas The amounts For more information about your services offered in your Medicaid benefit Medicaid benefits and copayments please package are based on your Medicaid contact the State Medicaid Office eligibility level (Categorically Needy or
The benefits described below are covered Medically Needy) Medicare coverage must
by Medicaid The benefits described in the be used first and the Medicaid Program may
Covered Medical and Hospital Benefits cover payment of Medicare Part A and B
section of the Summary of Benefits are deductible and coinsurance for all Medicare
covered by Medicare For each benefit listed covered services The services listed below
below you can see what Texas Medicaid are available only to those SNP members
covers and what our plan covers What you eligible under Medicaid for medical services
pay for covered services may depend on If you are eligible for both Medicare and
your level of Medicaid eligibility Medicaid you will not be held liable for
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Important Information
Premium and other important information
Medicaid assistance with premium payment may vary based on your level of Medicaid eligibility
Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for Original Medicare services
$2800 monthly plan premium in addition to your monthly Medicare Part B premium
In-Network
In this plan you will have no cost-sharing responsibility for Medicare-covered services
Doctor and hospital choice (For more information see Emergency Care and Urgently Needed Care)
For those who meet QMB requirements Medicaid pays coinsurance copayments and deductibles for Medicare-covered services Members should follow Medicare guidelines related to hospital and doctor choice
$0 copay for Medicaid-covered services
In-Network
You must go to network doctors specialists and hospitals
Referral required for network hospitals and specialists (for certain benefits)
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Inpatient Care
Inpatient Hospital Care (Includes substance abuse and rehabilitation services)
Admissions for the single diagnosis of chemical dependency or abuse without an accompanying medical complication are not a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Our plan covers an unlimited number of days for an inpatient hospital stay
bull You pay nothing per day for days 1 through 90
bull You pay nothing per day for days 91 and beyond
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Inpatient Mental Health Care
Inpatient admissions to acute care hospitals for adults and children for psychiatric conditions are a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
You get up to 190 days of inpatient psychiatric hospital care in a lifetime Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met This limitation does not apply to inpatient psychiatric services furnished in a general hospital
bull You pay nothing per day for days 1 through 90
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Skilled Nursing Facility (SNF) (in a Medicare-certified skilled nursing facility)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Our plan covers up to 100 days in a SNF
bull You pay nothing per day for days 1 through 100
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Home Health Care (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
$0 copay for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered home health visits
Hospice 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 for Medicaid-covered services
You must get care from a Medicare-certified hospice
Your plan will pay for a consultative visit before you select hospice
Outpatient Care
Doctor Office Visits 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for each Medicare-covered primary care doctor visit
$0 copay for each Medicare-covered specialist visit
Chiropractic 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 for Medicaid-covered services
In-Network
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered chiropractic visits
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part)
Podiatry 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered podiatry visits Medicare-covered podiatry visits are for medically-necessary foot care
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient Mental For Dual-eligible Members Medicaid In-Network Health Care pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare $0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
therapy visit
bull each Medicare-covered group therapy visit
$0 copay for Medicare-covered partial hospitalization program services
Outpatient For Dual-eligible Members Medicaid In-Network Substance pays for this service if it is not covered Authorization rules may apply Abuse Care by Medicare or when the Medicare
$0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
substance abuse outpatient treatment visit
bull each Medicare-covered group substance abuse outpatient treatment visit
Outpatient For Dual-eligible Members Medicaid In-Network ServicesSurgery pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) is required
$0 copay for Medicaid-covered services $0 copay for each Medicare-covered ambulatory surgical center visit
$0 copay for each Medicare-covered outpatient hospital facility visit
Ambulance Services For Dual-eligible Members Medicaid In-Network (medically necessary pays for this service if it is not covered Authorization rules may apply ambulance services) by Medicare or when the Medicare
$0 copay per ground trip benefit is exhausted 0 coinsurance per air trip $0 copay for Medicaid-covered services
Emergency Care For Dual-eligible Members Medicaid $0 copay for Medicare-covered (you may go to any pays for this service if it is not covered emergency room visits emergency room if you by Medicare or when the Medicare $50000 plan coverage limit for reasonably believe you benefit is exhausted supplemental emergency services need emergency care) $0 copay for Medicaid-covered services outside the US and its territories every
year
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Urgently Needed Care (this is not emergency care and in most cases is out of the service area)
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 for Medicaid-covered services
$0 copay for Medicare-covered urgently-needed-care Visits
If you are admitted to the hospital within 24 hours for the same condition you pay $0 for the urgently-needed-care visit
Outpatient Rehabilitation Services (occupational therapy physical therapy speech and language therapy)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Medically necessary physical therapy occupational therapy and speech and language pathology services are covered
$0 copay for Medicare-covered Occupational Therapy visits
$0 copay for Medicare-covered Physical Therapy and or Speech and Language Pathology visits
Outpatient Medical Services and Supplies
Durable Medical Equipment (includes wheelchairs oxygen etc)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered durable medical equipment
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Prosthetic Devices For Dual-eligible Members under age 21 In-Network (includes braces (CCP) Medicaid pays for this service if it Authorization rules may apply artificial limbs is not covered by Medicare or when the
$0 copay for Medicare-covered and eyes etc) Medicare benefit is exhausted bull prosthetic devices For all Dual-eligible Members Medicaid
pays for breast prostheses if not covered bull medical supplies related to prosthetics by Medicare or when the Medicare splints and other devices benefit is exhausted Quantity limitations apply and vary with each device Prior authorization will NOT be required within limitations except for miscellaneous codes
$0 copay for Medicaid-covered services
Diabetes Programs For Dual-eligible Members Medicaid In-Network and Supplies pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered Diabetes self-management training
$0 copay for Medicare-covered
bull Diabetes monitoring supplies
bull Therapeutic shoes or inserts
Diabetic Supplies and Services are limited to specific manufacturers products andor brands Contact the plan for a list of covered supplies
Diagnostic Tests For Dual-eligible Members Medicaid In-Network X-rays Lab Services pays for this service if it is not covered Authorization rules may apply and Radiology by Medicare or when the Medicare
Referral from your Primary Care Services benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered
bull lab services
bull diagnostic procedures and tests
bull X-rays
bull diagnostic radiology services (not including X-rays)
bull therapeutic radiology services
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Cardiac and Pulmonary Rehabilitation Services
Outpatient cardiac rehabilitation is covered for members meeting specific diagnostic criteria for a limited number of sessions
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing $0 copay for Medicare-covered Pulmonary Rehabilitation Services
Preventive Services
Preventive Services bull Bone Mass Measurement Texas Medicaid covers only the Single Photon Absorptiometry Test
$0 copay for Medicaid-covered services
bull Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam for women with Medicare) 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 for Medicaid-covered services
bull Colorectal Cancer Screening (for people with Medicare age 50 and older) 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 for Medicaid-covered services
bull Immunization (Flu vaccine Hepatitis B Vaccine for people with Medicare who are at risk Pneumonia vaccine) 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 for Medicaid-covered services
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for all preventive services covered under Original Medicare at zero cost sharing
Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare
Plan covers a physical exam annually
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services bull Health Wellness Education (Written (continued) health education materials including
Newsletters Nutritional Training Additional Smoking Cessation other wellness benefits) This is not a Texas Medicaid benefit but is available in some of the pilot programs like the Diabetes and Asthma projects For Dual-eligible Members participating in the Diabetes and Asthma pilot program Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
bull Mammograms (Annual Screening ndash for women with Medicare age 40 and older) 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 for Medicaid-covered services
bull Physical Exams 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 for Medicaid-covered services
bull Prostate Cancer Screening Exams (for men with Medicare age 50 and older) 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 for Medicaid-covered services
bull Telemedicine 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 for Medicaid-covered services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services Assistive Communication Devices This (continued) is a benefit for clients in an ICF-MR For
Dual-eligible Members who meet the above criteria Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
Kidney Disease 0 or 20 coinsurance for renal dialysis In-Network and Conditions 0 or 20 coinsurance for kidney Authorization rules may apply
disease education services Referral by your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient For Dual-eligible Members Medicaid Drugs covered under Medicare Part B Prescription Drugs pays for this service if it is not covered $0 yearly deductible for Medicare Part B
by Medicare or when Medicare benefit is drugs exhausted
$0 copay for Medicare Part B drugs $0 copayment for Medicaid-covered
Drugs covered under Medicare Part D prescription drugs not covered by Medicare Part D In-Network
Deductible $0 to $74 per year for Part D prescription drugs
Initial Coverage
Depending on your income and institutional status you pay the following
For generic drugs (including brand drugs treated as generic) either bull A $0 copay or bull A $120 copay or bull A $295 copay
For all other drugs either bull A $0 copay or bull A $360 copay or bull A $740 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Dental Services This is a benefit only for Texas Health In-Network Steps eligible clients and for clients in an Authorization rules may apply ICF-MR who are 21 years of age and
Referral from your Primary Care older For Dual-eligible Members who Physician (PCP) may be required meet the above criteria Medicaid pays
for this service if it is not covered by $0 copay for Medicare-covered dental Medicare or when the Medicare benefit benefits is exhausted $0 copay for the following preventive $0 copay for Medicaid-covered services dental benefits
bull up to 1 oral exam(s) every six months bull up to 1 cleaning(s) every six months bull up to 1 dental X-ray every year
$0 copay for the following comprehensive services bull Restorative ndash Fillings Crowns bull Periodontics bull Extractions bull Prosthodontics bull Oral Surgery
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Hearing Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered Referral by your Primary Care Physician by Medicare or when the Medicare (PCP) may be required benefit is exhausted
Exam to diagnose and treat hearing and $0 copay for Medicaid-covered services balance issues $0 copay
Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids
Please see your EOC for plan coverage details
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at
risk
$0 copay for up to 1 supplemental routine eye exam every year
$0 copay for
bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
bull up to 1 pair of eyeglasses (lenses and frames) every year
bull contact lenses
bull up to 1 pair of eyeglass lenses every year
bull up to 1 eyeglass frame(s) every year
$250 plan coverage limit for eyewear every year
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs
bull 24 Hour Nurse Line
bull Gym membership
Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items
Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
Benefit Cigna-HealthSpring TotalCare (HMO SNP)
Prescription Drug Benefits
How much do I pay For Part B drugs such as chemotherapy drugs1 You pay nothing Other Part B drugs1 You pay nothing
Initial Coverage Depending on your income and institutional status you pay the following For generic drugs (including brand drugs treated as generic) either
bull $0 copay or bull $120 copay or bull $295 copay
For all other drugs either bull $0 copay or bull $360 copay or bull $740 copay
You may get your drugs at network retail pharmacies and mail order pharmacies
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 an in-network pharmacy
Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Additional Plan Benefits
24-hour Nurse Line $0 copay for 24-hour Nurse Line
Caring registered nurses are available by phone 24 hours a day 7 days a week to answer your health questions in a confidential and convenient service
Fitness $0 copay for membership in Health ClubFitness Classes
Please see your EOC for plan coverage details
Home Safety $1500 allowance once per lifetime for the purchase and installation of approved safety devices in bathrooms Please see your EOC for plan coverage details
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H4513 PLAN 010
This section demonstrates the Medicaid Medicare Part A and B cost sharing when benefit package for full benefit dual-eligible the state is responsible for paying these recipients in the state of Texas The amounts For more information about your services offered in your Medicaid benefit Medicaid benefits and copayments please package are based on your Medicaid contact the State Medicaid Office eligibility level (Categorically Needy or
The benefits described below are covered Medically Needy) Medicare coverage must
by Medicaid The benefits described in the be used first and the Medicaid Program may
Covered Medical and Hospital Benefits cover payment of Medicare Part A and B
section of the Summary of Benefits are deductible and coinsurance for all Medicare
covered by Medicare For each benefit listed covered services The services listed below
below you can see what Texas Medicaid are available only to those SNP members
covers and what our plan covers What you eligible under Medicaid for medical services
pay for covered services may depend on If you are eligible for both Medicare and
your level of Medicaid eligibility Medicaid you will not be held liable for
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Important Information
Premium and other important information
Medicaid assistance with premium payment may vary based on your level of Medicaid eligibility
Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for Original Medicare services
$2800 monthly plan premium in addition to your monthly Medicare Part B premium
In-Network
In this plan you will have no cost-sharing responsibility for Medicare-covered services
Doctor and hospital choice (For more information see Emergency Care and Urgently Needed Care)
For those who meet QMB requirements Medicaid pays coinsurance copayments and deductibles for Medicare-covered services Members should follow Medicare guidelines related to hospital and doctor choice
$0 copay for Medicaid-covered services
In-Network
You must go to network doctors specialists and hospitals
Referral required for network hospitals and specialists (for certain benefits)
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Inpatient Care
Inpatient Hospital Care (Includes substance abuse and rehabilitation services)
Admissions for the single diagnosis of chemical dependency or abuse without an accompanying medical complication are not a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Our plan covers an unlimited number of days for an inpatient hospital stay
bull You pay nothing per day for days 1 through 90
bull You pay nothing per day for days 91 and beyond
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Inpatient Mental Health Care
Inpatient admissions to acute care hospitals for adults and children for psychiatric conditions are a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
You get up to 190 days of inpatient psychiatric hospital care in a lifetime Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met This limitation does not apply to inpatient psychiatric services furnished in a general hospital
bull You pay nothing per day for days 1 through 90
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Skilled Nursing Facility (SNF) (in a Medicare-certified skilled nursing facility)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Our plan covers up to 100 days in a SNF
bull You pay nothing per day for days 1 through 100
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Home Health Care (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
$0 copay for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered home health visits
Hospice 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 for Medicaid-covered services
You must get care from a Medicare-certified hospice
Your plan will pay for a consultative visit before you select hospice
Outpatient Care
Doctor Office Visits 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for each Medicare-covered primary care doctor visit
$0 copay for each Medicare-covered specialist visit
Chiropractic 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 for Medicaid-covered services
In-Network
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered chiropractic visits
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part)
Podiatry 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered podiatry visits Medicare-covered podiatry visits are for medically-necessary foot care
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient Mental For Dual-eligible Members Medicaid In-Network Health Care pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare $0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
therapy visit
bull each Medicare-covered group therapy visit
$0 copay for Medicare-covered partial hospitalization program services
Outpatient For Dual-eligible Members Medicaid In-Network Substance pays for this service if it is not covered Authorization rules may apply Abuse Care by Medicare or when the Medicare
$0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
substance abuse outpatient treatment visit
bull each Medicare-covered group substance abuse outpatient treatment visit
Outpatient For Dual-eligible Members Medicaid In-Network ServicesSurgery pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) is required
$0 copay for Medicaid-covered services $0 copay for each Medicare-covered ambulatory surgical center visit
$0 copay for each Medicare-covered outpatient hospital facility visit
Ambulance Services For Dual-eligible Members Medicaid In-Network (medically necessary pays for this service if it is not covered Authorization rules may apply ambulance services) by Medicare or when the Medicare
$0 copay per ground trip benefit is exhausted 0 coinsurance per air trip $0 copay for Medicaid-covered services
Emergency Care For Dual-eligible Members Medicaid $0 copay for Medicare-covered (you may go to any pays for this service if it is not covered emergency room visits emergency room if you by Medicare or when the Medicare $50000 plan coverage limit for reasonably believe you benefit is exhausted supplemental emergency services need emergency care) $0 copay for Medicaid-covered services outside the US and its territories every
year
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Urgently Needed Care (this is not emergency care and in most cases is out of the service area)
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 for Medicaid-covered services
$0 copay for Medicare-covered urgently-needed-care Visits
If you are admitted to the hospital within 24 hours for the same condition you pay $0 for the urgently-needed-care visit
Outpatient Rehabilitation Services (occupational therapy physical therapy speech and language therapy)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Medically necessary physical therapy occupational therapy and speech and language pathology services are covered
$0 copay for Medicare-covered Occupational Therapy visits
$0 copay for Medicare-covered Physical Therapy and or Speech and Language Pathology visits
Outpatient Medical Services and Supplies
Durable Medical Equipment (includes wheelchairs oxygen etc)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered durable medical equipment
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Prosthetic Devices For Dual-eligible Members under age 21 In-Network (includes braces (CCP) Medicaid pays for this service if it Authorization rules may apply artificial limbs is not covered by Medicare or when the
$0 copay for Medicare-covered and eyes etc) Medicare benefit is exhausted bull prosthetic devices For all Dual-eligible Members Medicaid
pays for breast prostheses if not covered bull medical supplies related to prosthetics by Medicare or when the Medicare splints and other devices benefit is exhausted Quantity limitations apply and vary with each device Prior authorization will NOT be required within limitations except for miscellaneous codes
$0 copay for Medicaid-covered services
Diabetes Programs For Dual-eligible Members Medicaid In-Network and Supplies pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered Diabetes self-management training
$0 copay for Medicare-covered
bull Diabetes monitoring supplies
bull Therapeutic shoes or inserts
Diabetic Supplies and Services are limited to specific manufacturers products andor brands Contact the plan for a list of covered supplies
Diagnostic Tests For Dual-eligible Members Medicaid In-Network X-rays Lab Services pays for this service if it is not covered Authorization rules may apply and Radiology by Medicare or when the Medicare
Referral from your Primary Care Services benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered
bull lab services
bull diagnostic procedures and tests
bull X-rays
bull diagnostic radiology services (not including X-rays)
bull therapeutic radiology services
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Cardiac and Pulmonary Rehabilitation Services
Outpatient cardiac rehabilitation is covered for members meeting specific diagnostic criteria for a limited number of sessions
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing $0 copay for Medicare-covered Pulmonary Rehabilitation Services
Preventive Services
Preventive Services bull Bone Mass Measurement Texas Medicaid covers only the Single Photon Absorptiometry Test
$0 copay for Medicaid-covered services
bull Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam for women with Medicare) 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 for Medicaid-covered services
bull Colorectal Cancer Screening (for people with Medicare age 50 and older) 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 for Medicaid-covered services
bull Immunization (Flu vaccine Hepatitis B Vaccine for people with Medicare who are at risk Pneumonia vaccine) 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 for Medicaid-covered services
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for all preventive services covered under Original Medicare at zero cost sharing
Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare
Plan covers a physical exam annually
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services bull Health Wellness Education (Written (continued) health education materials including
Newsletters Nutritional Training Additional Smoking Cessation other wellness benefits) This is not a Texas Medicaid benefit but is available in some of the pilot programs like the Diabetes and Asthma projects For Dual-eligible Members participating in the Diabetes and Asthma pilot program Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
bull Mammograms (Annual Screening ndash for women with Medicare age 40 and older) 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 for Medicaid-covered services
bull Physical Exams 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 for Medicaid-covered services
bull Prostate Cancer Screening Exams (for men with Medicare age 50 and older) 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 for Medicaid-covered services
bull Telemedicine 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 for Medicaid-covered services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services Assistive Communication Devices This (continued) is a benefit for clients in an ICF-MR For
Dual-eligible Members who meet the above criteria Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
Kidney Disease 0 or 20 coinsurance for renal dialysis In-Network and Conditions 0 or 20 coinsurance for kidney Authorization rules may apply
disease education services Referral by your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient For Dual-eligible Members Medicaid Drugs covered under Medicare Part B Prescription Drugs pays for this service if it is not covered $0 yearly deductible for Medicare Part B
by Medicare or when Medicare benefit is drugs exhausted
$0 copay for Medicare Part B drugs $0 copayment for Medicaid-covered
Drugs covered under Medicare Part D prescription drugs not covered by Medicare Part D In-Network
Deductible $0 to $74 per year for Part D prescription drugs
Initial Coverage
Depending on your income and institutional status you pay the following
For generic drugs (including brand drugs treated as generic) either bull A $0 copay or bull A $120 copay or bull A $295 copay
For all other drugs either bull A $0 copay or bull A $360 copay or bull A $740 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Dental Services This is a benefit only for Texas Health In-Network Steps eligible clients and for clients in an Authorization rules may apply ICF-MR who are 21 years of age and
Referral from your Primary Care older For Dual-eligible Members who Physician (PCP) may be required meet the above criteria Medicaid pays
for this service if it is not covered by $0 copay for Medicare-covered dental Medicare or when the Medicare benefit benefits is exhausted $0 copay for the following preventive $0 copay for Medicaid-covered services dental benefits
bull up to 1 oral exam(s) every six months bull up to 1 cleaning(s) every six months bull up to 1 dental X-ray every year
$0 copay for the following comprehensive services bull Restorative ndash Fillings Crowns bull Periodontics bull Extractions bull Prosthodontics bull Oral Surgery
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Hearing Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered Referral by your Primary Care Physician by Medicare or when the Medicare (PCP) may be required benefit is exhausted
Exam to diagnose and treat hearing and $0 copay for Medicaid-covered services balance issues $0 copay
Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids
Please see your EOC for plan coverage details
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at
risk
$0 copay for up to 1 supplemental routine eye exam every year
$0 copay for
bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
bull up to 1 pair of eyeglasses (lenses and frames) every year
bull contact lenses
bull up to 1 pair of eyeglass lenses every year
bull up to 1 eyeglass frame(s) every year
$250 plan coverage limit for eyewear every year
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs
bull 24 Hour Nurse Line
bull Gym membership
Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items
Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H4513 PLAN 010
This section demonstrates the Medicaid Medicare Part A and B cost sharing when benefit package for full benefit dual-eligible the state is responsible for paying these recipients in the state of Texas The amounts For more information about your services offered in your Medicaid benefit Medicaid benefits and copayments please package are based on your Medicaid contact the State Medicaid Office eligibility level (Categorically Needy or
The benefits described below are covered Medically Needy) Medicare coverage must
by Medicaid The benefits described in the be used first and the Medicaid Program may
Covered Medical and Hospital Benefits cover payment of Medicare Part A and B
section of the Summary of Benefits are deductible and coinsurance for all Medicare
covered by Medicare For each benefit listed covered services The services listed below
below you can see what Texas Medicaid are available only to those SNP members
covers and what our plan covers What you eligible under Medicaid for medical services
pay for covered services may depend on If you are eligible for both Medicare and
your level of Medicaid eligibility Medicaid you will not be held liable for
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Important Information
Premium and other important information
Medicaid assistance with premium payment may vary based on your level of Medicaid eligibility
Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for Original Medicare services
$2800 monthly plan premium in addition to your monthly Medicare Part B premium
In-Network
In this plan you will have no cost-sharing responsibility for Medicare-covered services
Doctor and hospital choice (For more information see Emergency Care and Urgently Needed Care)
For those who meet QMB requirements Medicaid pays coinsurance copayments and deductibles for Medicare-covered services Members should follow Medicare guidelines related to hospital and doctor choice
$0 copay for Medicaid-covered services
In-Network
You must go to network doctors specialists and hospitals
Referral required for network hospitals and specialists (for certain benefits)
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Inpatient Care
Inpatient Hospital Care (Includes substance abuse and rehabilitation services)
Admissions for the single diagnosis of chemical dependency or abuse without an accompanying medical complication are not a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Our plan covers an unlimited number of days for an inpatient hospital stay
bull You pay nothing per day for days 1 through 90
bull You pay nothing per day for days 91 and beyond
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Inpatient Mental Health Care
Inpatient admissions to acute care hospitals for adults and children for psychiatric conditions are a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
You get up to 190 days of inpatient psychiatric hospital care in a lifetime Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met This limitation does not apply to inpatient psychiatric services furnished in a general hospital
bull You pay nothing per day for days 1 through 90
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Skilled Nursing Facility (SNF) (in a Medicare-certified skilled nursing facility)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Our plan covers up to 100 days in a SNF
bull You pay nothing per day for days 1 through 100
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Home Health Care (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
$0 copay for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered home health visits
Hospice 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 for Medicaid-covered services
You must get care from a Medicare-certified hospice
Your plan will pay for a consultative visit before you select hospice
Outpatient Care
Doctor Office Visits 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for each Medicare-covered primary care doctor visit
$0 copay for each Medicare-covered specialist visit
Chiropractic 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 for Medicaid-covered services
In-Network
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered chiropractic visits
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part)
Podiatry 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered podiatry visits Medicare-covered podiatry visits are for medically-necessary foot care
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient Mental For Dual-eligible Members Medicaid In-Network Health Care pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare $0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
therapy visit
bull each Medicare-covered group therapy visit
$0 copay for Medicare-covered partial hospitalization program services
Outpatient For Dual-eligible Members Medicaid In-Network Substance pays for this service if it is not covered Authorization rules may apply Abuse Care by Medicare or when the Medicare
$0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
substance abuse outpatient treatment visit
bull each Medicare-covered group substance abuse outpatient treatment visit
Outpatient For Dual-eligible Members Medicaid In-Network ServicesSurgery pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) is required
$0 copay for Medicaid-covered services $0 copay for each Medicare-covered ambulatory surgical center visit
$0 copay for each Medicare-covered outpatient hospital facility visit
Ambulance Services For Dual-eligible Members Medicaid In-Network (medically necessary pays for this service if it is not covered Authorization rules may apply ambulance services) by Medicare or when the Medicare
$0 copay per ground trip benefit is exhausted 0 coinsurance per air trip $0 copay for Medicaid-covered services
Emergency Care For Dual-eligible Members Medicaid $0 copay for Medicare-covered (you may go to any pays for this service if it is not covered emergency room visits emergency room if you by Medicare or when the Medicare $50000 plan coverage limit for reasonably believe you benefit is exhausted supplemental emergency services need emergency care) $0 copay for Medicaid-covered services outside the US and its territories every
year
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Urgently Needed Care (this is not emergency care and in most cases is out of the service area)
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 for Medicaid-covered services
$0 copay for Medicare-covered urgently-needed-care Visits
If you are admitted to the hospital within 24 hours for the same condition you pay $0 for the urgently-needed-care visit
Outpatient Rehabilitation Services (occupational therapy physical therapy speech and language therapy)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Medically necessary physical therapy occupational therapy and speech and language pathology services are covered
$0 copay for Medicare-covered Occupational Therapy visits
$0 copay for Medicare-covered Physical Therapy and or Speech and Language Pathology visits
Outpatient Medical Services and Supplies
Durable Medical Equipment (includes wheelchairs oxygen etc)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered durable medical equipment
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Prosthetic Devices For Dual-eligible Members under age 21 In-Network (includes braces (CCP) Medicaid pays for this service if it Authorization rules may apply artificial limbs is not covered by Medicare or when the
$0 copay for Medicare-covered and eyes etc) Medicare benefit is exhausted bull prosthetic devices For all Dual-eligible Members Medicaid
pays for breast prostheses if not covered bull medical supplies related to prosthetics by Medicare or when the Medicare splints and other devices benefit is exhausted Quantity limitations apply and vary with each device Prior authorization will NOT be required within limitations except for miscellaneous codes
$0 copay for Medicaid-covered services
Diabetes Programs For Dual-eligible Members Medicaid In-Network and Supplies pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered Diabetes self-management training
$0 copay for Medicare-covered
bull Diabetes monitoring supplies
bull Therapeutic shoes or inserts
Diabetic Supplies and Services are limited to specific manufacturers products andor brands Contact the plan for a list of covered supplies
Diagnostic Tests For Dual-eligible Members Medicaid In-Network X-rays Lab Services pays for this service if it is not covered Authorization rules may apply and Radiology by Medicare or when the Medicare
Referral from your Primary Care Services benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered
bull lab services
bull diagnostic procedures and tests
bull X-rays
bull diagnostic radiology services (not including X-rays)
bull therapeutic radiology services
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Cardiac and Pulmonary Rehabilitation Services
Outpatient cardiac rehabilitation is covered for members meeting specific diagnostic criteria for a limited number of sessions
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing $0 copay for Medicare-covered Pulmonary Rehabilitation Services
Preventive Services
Preventive Services bull Bone Mass Measurement Texas Medicaid covers only the Single Photon Absorptiometry Test
$0 copay for Medicaid-covered services
bull Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam for women with Medicare) 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 for Medicaid-covered services
bull Colorectal Cancer Screening (for people with Medicare age 50 and older) 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 for Medicaid-covered services
bull Immunization (Flu vaccine Hepatitis B Vaccine for people with Medicare who are at risk Pneumonia vaccine) 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 for Medicaid-covered services
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for all preventive services covered under Original Medicare at zero cost sharing
Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare
Plan covers a physical exam annually
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services bull Health Wellness Education (Written (continued) health education materials including
Newsletters Nutritional Training Additional Smoking Cessation other wellness benefits) This is not a Texas Medicaid benefit but is available in some of the pilot programs like the Diabetes and Asthma projects For Dual-eligible Members participating in the Diabetes and Asthma pilot program Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
bull Mammograms (Annual Screening ndash for women with Medicare age 40 and older) 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 for Medicaid-covered services
bull Physical Exams 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 for Medicaid-covered services
bull Prostate Cancer Screening Exams (for men with Medicare age 50 and older) 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 for Medicaid-covered services
bull Telemedicine 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 for Medicaid-covered services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services Assistive Communication Devices This (continued) is a benefit for clients in an ICF-MR For
Dual-eligible Members who meet the above criteria Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
Kidney Disease 0 or 20 coinsurance for renal dialysis In-Network and Conditions 0 or 20 coinsurance for kidney Authorization rules may apply
disease education services Referral by your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient For Dual-eligible Members Medicaid Drugs covered under Medicare Part B Prescription Drugs pays for this service if it is not covered $0 yearly deductible for Medicare Part B
by Medicare or when Medicare benefit is drugs exhausted
$0 copay for Medicare Part B drugs $0 copayment for Medicaid-covered
Drugs covered under Medicare Part D prescription drugs not covered by Medicare Part D In-Network
Deductible $0 to $74 per year for Part D prescription drugs
Initial Coverage
Depending on your income and institutional status you pay the following
For generic drugs (including brand drugs treated as generic) either bull A $0 copay or bull A $120 copay or bull A $295 copay
For all other drugs either bull A $0 copay or bull A $360 copay or bull A $740 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Dental Services This is a benefit only for Texas Health In-Network Steps eligible clients and for clients in an Authorization rules may apply ICF-MR who are 21 years of age and
Referral from your Primary Care older For Dual-eligible Members who Physician (PCP) may be required meet the above criteria Medicaid pays
for this service if it is not covered by $0 copay for Medicare-covered dental Medicare or when the Medicare benefit benefits is exhausted $0 copay for the following preventive $0 copay for Medicaid-covered services dental benefits
bull up to 1 oral exam(s) every six months bull up to 1 cleaning(s) every six months bull up to 1 dental X-ray every year
$0 copay for the following comprehensive services bull Restorative ndash Fillings Crowns bull Periodontics bull Extractions bull Prosthodontics bull Oral Surgery
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Hearing Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered Referral by your Primary Care Physician by Medicare or when the Medicare (PCP) may be required benefit is exhausted
Exam to diagnose and treat hearing and $0 copay for Medicaid-covered services balance issues $0 copay
Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids
Please see your EOC for plan coverage details
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at
risk
$0 copay for up to 1 supplemental routine eye exam every year
$0 copay for
bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
bull up to 1 pair of eyeglasses (lenses and frames) every year
bull contact lenses
bull up to 1 pair of eyeglass lenses every year
bull up to 1 eyeglass frame(s) every year
$250 plan coverage limit for eyewear every year
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs
bull 24 Hour Nurse Line
bull Gym membership
Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items
Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Inpatient Care
Inpatient Hospital Care (Includes substance abuse and rehabilitation services)
Admissions for the single diagnosis of chemical dependency or abuse without an accompanying medical complication are not a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Our plan covers an unlimited number of days for an inpatient hospital stay
bull You pay nothing per day for days 1 through 90
bull You pay nothing per day for days 91 and beyond
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Inpatient Mental Health Care
Inpatient admissions to acute care hospitals for adults and children for psychiatric conditions are a benefit of Texas Medicaid
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 for Medicaid-covered services
In-Network
Authorization rules may apply
You get up to 190 days of inpatient psychiatric hospital care in a lifetime Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met This limitation does not apply to inpatient psychiatric services furnished in a general hospital
bull You pay nothing per day for days 1 through 90
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital
Skilled Nursing Facility (SNF) (in a Medicare-certified skilled nursing facility)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Our plan covers up to 100 days in a SNF
bull You pay nothing per day for days 1 through 100
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Home Health Care (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
$0 copay for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered home health visits
Hospice 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 for Medicaid-covered services
You must get care from a Medicare-certified hospice
Your plan will pay for a consultative visit before you select hospice
Outpatient Care
Doctor Office Visits 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for each Medicare-covered primary care doctor visit
$0 copay for each Medicare-covered specialist visit
Chiropractic 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 for Medicaid-covered services
In-Network
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered chiropractic visits
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part)
Podiatry 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered podiatry visits Medicare-covered podiatry visits are for medically-necessary foot care
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient Mental For Dual-eligible Members Medicaid In-Network Health Care pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare $0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
therapy visit
bull each Medicare-covered group therapy visit
$0 copay for Medicare-covered partial hospitalization program services
Outpatient For Dual-eligible Members Medicaid In-Network Substance pays for this service if it is not covered Authorization rules may apply Abuse Care by Medicare or when the Medicare
$0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
substance abuse outpatient treatment visit
bull each Medicare-covered group substance abuse outpatient treatment visit
Outpatient For Dual-eligible Members Medicaid In-Network ServicesSurgery pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) is required
$0 copay for Medicaid-covered services $0 copay for each Medicare-covered ambulatory surgical center visit
$0 copay for each Medicare-covered outpatient hospital facility visit
Ambulance Services For Dual-eligible Members Medicaid In-Network (medically necessary pays for this service if it is not covered Authorization rules may apply ambulance services) by Medicare or when the Medicare
$0 copay per ground trip benefit is exhausted 0 coinsurance per air trip $0 copay for Medicaid-covered services
Emergency Care For Dual-eligible Members Medicaid $0 copay for Medicare-covered (you may go to any pays for this service if it is not covered emergency room visits emergency room if you by Medicare or when the Medicare $50000 plan coverage limit for reasonably believe you benefit is exhausted supplemental emergency services need emergency care) $0 copay for Medicaid-covered services outside the US and its territories every
year
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Urgently Needed Care (this is not emergency care and in most cases is out of the service area)
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 for Medicaid-covered services
$0 copay for Medicare-covered urgently-needed-care Visits
If you are admitted to the hospital within 24 hours for the same condition you pay $0 for the urgently-needed-care visit
Outpatient Rehabilitation Services (occupational therapy physical therapy speech and language therapy)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Medically necessary physical therapy occupational therapy and speech and language pathology services are covered
$0 copay for Medicare-covered Occupational Therapy visits
$0 copay for Medicare-covered Physical Therapy and or Speech and Language Pathology visits
Outpatient Medical Services and Supplies
Durable Medical Equipment (includes wheelchairs oxygen etc)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered durable medical equipment
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Prosthetic Devices For Dual-eligible Members under age 21 In-Network (includes braces (CCP) Medicaid pays for this service if it Authorization rules may apply artificial limbs is not covered by Medicare or when the
$0 copay for Medicare-covered and eyes etc) Medicare benefit is exhausted bull prosthetic devices For all Dual-eligible Members Medicaid
pays for breast prostheses if not covered bull medical supplies related to prosthetics by Medicare or when the Medicare splints and other devices benefit is exhausted Quantity limitations apply and vary with each device Prior authorization will NOT be required within limitations except for miscellaneous codes
$0 copay for Medicaid-covered services
Diabetes Programs For Dual-eligible Members Medicaid In-Network and Supplies pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered Diabetes self-management training
$0 copay for Medicare-covered
bull Diabetes monitoring supplies
bull Therapeutic shoes or inserts
Diabetic Supplies and Services are limited to specific manufacturers products andor brands Contact the plan for a list of covered supplies
Diagnostic Tests For Dual-eligible Members Medicaid In-Network X-rays Lab Services pays for this service if it is not covered Authorization rules may apply and Radiology by Medicare or when the Medicare
Referral from your Primary Care Services benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered
bull lab services
bull diagnostic procedures and tests
bull X-rays
bull diagnostic radiology services (not including X-rays)
bull therapeutic radiology services
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Cardiac and Pulmonary Rehabilitation Services
Outpatient cardiac rehabilitation is covered for members meeting specific diagnostic criteria for a limited number of sessions
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing $0 copay for Medicare-covered Pulmonary Rehabilitation Services
Preventive Services
Preventive Services bull Bone Mass Measurement Texas Medicaid covers only the Single Photon Absorptiometry Test
$0 copay for Medicaid-covered services
bull Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam for women with Medicare) 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 for Medicaid-covered services
bull Colorectal Cancer Screening (for people with Medicare age 50 and older) 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 for Medicaid-covered services
bull Immunization (Flu vaccine Hepatitis B Vaccine for people with Medicare who are at risk Pneumonia vaccine) 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 for Medicaid-covered services
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for all preventive services covered under Original Medicare at zero cost sharing
Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare
Plan covers a physical exam annually
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services bull Health Wellness Education (Written (continued) health education materials including
Newsletters Nutritional Training Additional Smoking Cessation other wellness benefits) This is not a Texas Medicaid benefit but is available in some of the pilot programs like the Diabetes and Asthma projects For Dual-eligible Members participating in the Diabetes and Asthma pilot program Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
bull Mammograms (Annual Screening ndash for women with Medicare age 40 and older) 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 for Medicaid-covered services
bull Physical Exams 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 for Medicaid-covered services
bull Prostate Cancer Screening Exams (for men with Medicare age 50 and older) 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 for Medicaid-covered services
bull Telemedicine 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 for Medicaid-covered services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services Assistive Communication Devices This (continued) is a benefit for clients in an ICF-MR For
Dual-eligible Members who meet the above criteria Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
Kidney Disease 0 or 20 coinsurance for renal dialysis In-Network and Conditions 0 or 20 coinsurance for kidney Authorization rules may apply
disease education services Referral by your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient For Dual-eligible Members Medicaid Drugs covered under Medicare Part B Prescription Drugs pays for this service if it is not covered $0 yearly deductible for Medicare Part B
by Medicare or when Medicare benefit is drugs exhausted
$0 copay for Medicare Part B drugs $0 copayment for Medicaid-covered
Drugs covered under Medicare Part D prescription drugs not covered by Medicare Part D In-Network
Deductible $0 to $74 per year for Part D prescription drugs
Initial Coverage
Depending on your income and institutional status you pay the following
For generic drugs (including brand drugs treated as generic) either bull A $0 copay or bull A $120 copay or bull A $295 copay
For all other drugs either bull A $0 copay or bull A $360 copay or bull A $740 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Dental Services This is a benefit only for Texas Health In-Network Steps eligible clients and for clients in an Authorization rules may apply ICF-MR who are 21 years of age and
Referral from your Primary Care older For Dual-eligible Members who Physician (PCP) may be required meet the above criteria Medicaid pays
for this service if it is not covered by $0 copay for Medicare-covered dental Medicare or when the Medicare benefit benefits is exhausted $0 copay for the following preventive $0 copay for Medicaid-covered services dental benefits
bull up to 1 oral exam(s) every six months bull up to 1 cleaning(s) every six months bull up to 1 dental X-ray every year
$0 copay for the following comprehensive services bull Restorative ndash Fillings Crowns bull Periodontics bull Extractions bull Prosthodontics bull Oral Surgery
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Hearing Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered Referral by your Primary Care Physician by Medicare or when the Medicare (PCP) may be required benefit is exhausted
Exam to diagnose and treat hearing and $0 copay for Medicaid-covered services balance issues $0 copay
Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids
Please see your EOC for plan coverage details
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at
risk
$0 copay for up to 1 supplemental routine eye exam every year
$0 copay for
bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
bull up to 1 pair of eyeglasses (lenses and frames) every year
bull contact lenses
bull up to 1 pair of eyeglass lenses every year
bull up to 1 eyeglass frame(s) every year
$250 plan coverage limit for eyewear every year
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs
bull 24 Hour Nurse Line
bull Gym membership
Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items
Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Home Health Care (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
$0 copay for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered home health visits
Hospice 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 for Medicaid-covered services
You must get care from a Medicare-certified hospice
Your plan will pay for a consultative visit before you select hospice
Outpatient Care
Doctor Office Visits 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for each Medicare-covered primary care doctor visit
$0 copay for each Medicare-covered specialist visit
Chiropractic 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 for Medicaid-covered services
In-Network
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered chiropractic visits
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part)
Podiatry 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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered podiatry visits Medicare-covered podiatry visits are for medically-necessary foot care
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient Mental For Dual-eligible Members Medicaid In-Network Health Care pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare $0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
therapy visit
bull each Medicare-covered group therapy visit
$0 copay for Medicare-covered partial hospitalization program services
Outpatient For Dual-eligible Members Medicaid In-Network Substance pays for this service if it is not covered Authorization rules may apply Abuse Care by Medicare or when the Medicare
$0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
substance abuse outpatient treatment visit
bull each Medicare-covered group substance abuse outpatient treatment visit
Outpatient For Dual-eligible Members Medicaid In-Network ServicesSurgery pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) is required
$0 copay for Medicaid-covered services $0 copay for each Medicare-covered ambulatory surgical center visit
$0 copay for each Medicare-covered outpatient hospital facility visit
Ambulance Services For Dual-eligible Members Medicaid In-Network (medically necessary pays for this service if it is not covered Authorization rules may apply ambulance services) by Medicare or when the Medicare
$0 copay per ground trip benefit is exhausted 0 coinsurance per air trip $0 copay for Medicaid-covered services
Emergency Care For Dual-eligible Members Medicaid $0 copay for Medicare-covered (you may go to any pays for this service if it is not covered emergency room visits emergency room if you by Medicare or when the Medicare $50000 plan coverage limit for reasonably believe you benefit is exhausted supplemental emergency services need emergency care) $0 copay for Medicaid-covered services outside the US and its territories every
year
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Urgently Needed Care (this is not emergency care and in most cases is out of the service area)
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 for Medicaid-covered services
$0 copay for Medicare-covered urgently-needed-care Visits
If you are admitted to the hospital within 24 hours for the same condition you pay $0 for the urgently-needed-care visit
Outpatient Rehabilitation Services (occupational therapy physical therapy speech and language therapy)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Medically necessary physical therapy occupational therapy and speech and language pathology services are covered
$0 copay for Medicare-covered Occupational Therapy visits
$0 copay for Medicare-covered Physical Therapy and or Speech and Language Pathology visits
Outpatient Medical Services and Supplies
Durable Medical Equipment (includes wheelchairs oxygen etc)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered durable medical equipment
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Prosthetic Devices For Dual-eligible Members under age 21 In-Network (includes braces (CCP) Medicaid pays for this service if it Authorization rules may apply artificial limbs is not covered by Medicare or when the
$0 copay for Medicare-covered and eyes etc) Medicare benefit is exhausted bull prosthetic devices For all Dual-eligible Members Medicaid
pays for breast prostheses if not covered bull medical supplies related to prosthetics by Medicare or when the Medicare splints and other devices benefit is exhausted Quantity limitations apply and vary with each device Prior authorization will NOT be required within limitations except for miscellaneous codes
$0 copay for Medicaid-covered services
Diabetes Programs For Dual-eligible Members Medicaid In-Network and Supplies pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered Diabetes self-management training
$0 copay for Medicare-covered
bull Diabetes monitoring supplies
bull Therapeutic shoes or inserts
Diabetic Supplies and Services are limited to specific manufacturers products andor brands Contact the plan for a list of covered supplies
Diagnostic Tests For Dual-eligible Members Medicaid In-Network X-rays Lab Services pays for this service if it is not covered Authorization rules may apply and Radiology by Medicare or when the Medicare
Referral from your Primary Care Services benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered
bull lab services
bull diagnostic procedures and tests
bull X-rays
bull diagnostic radiology services (not including X-rays)
bull therapeutic radiology services
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Cardiac and Pulmonary Rehabilitation Services
Outpatient cardiac rehabilitation is covered for members meeting specific diagnostic criteria for a limited number of sessions
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing $0 copay for Medicare-covered Pulmonary Rehabilitation Services
Preventive Services
Preventive Services bull Bone Mass Measurement Texas Medicaid covers only the Single Photon Absorptiometry Test
$0 copay for Medicaid-covered services
bull Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam for women with Medicare) 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 for Medicaid-covered services
bull Colorectal Cancer Screening (for people with Medicare age 50 and older) 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 for Medicaid-covered services
bull Immunization (Flu vaccine Hepatitis B Vaccine for people with Medicare who are at risk Pneumonia vaccine) 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 for Medicaid-covered services
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for all preventive services covered under Original Medicare at zero cost sharing
Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare
Plan covers a physical exam annually
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services bull Health Wellness Education (Written (continued) health education materials including
Newsletters Nutritional Training Additional Smoking Cessation other wellness benefits) This is not a Texas Medicaid benefit but is available in some of the pilot programs like the Diabetes and Asthma projects For Dual-eligible Members participating in the Diabetes and Asthma pilot program Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
bull Mammograms (Annual Screening ndash for women with Medicare age 40 and older) 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 for Medicaid-covered services
bull Physical Exams 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 for Medicaid-covered services
bull Prostate Cancer Screening Exams (for men with Medicare age 50 and older) 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 for Medicaid-covered services
bull Telemedicine 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 for Medicaid-covered services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services Assistive Communication Devices This (continued) is a benefit for clients in an ICF-MR For
Dual-eligible Members who meet the above criteria Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
Kidney Disease 0 or 20 coinsurance for renal dialysis In-Network and Conditions 0 or 20 coinsurance for kidney Authorization rules may apply
disease education services Referral by your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient For Dual-eligible Members Medicaid Drugs covered under Medicare Part B Prescription Drugs pays for this service if it is not covered $0 yearly deductible for Medicare Part B
by Medicare or when Medicare benefit is drugs exhausted
$0 copay for Medicare Part B drugs $0 copayment for Medicaid-covered
Drugs covered under Medicare Part D prescription drugs not covered by Medicare Part D In-Network
Deductible $0 to $74 per year for Part D prescription drugs
Initial Coverage
Depending on your income and institutional status you pay the following
For generic drugs (including brand drugs treated as generic) either bull A $0 copay or bull A $120 copay or bull A $295 copay
For all other drugs either bull A $0 copay or bull A $360 copay or bull A $740 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Dental Services This is a benefit only for Texas Health In-Network Steps eligible clients and for clients in an Authorization rules may apply ICF-MR who are 21 years of age and
Referral from your Primary Care older For Dual-eligible Members who Physician (PCP) may be required meet the above criteria Medicaid pays
for this service if it is not covered by $0 copay for Medicare-covered dental Medicare or when the Medicare benefit benefits is exhausted $0 copay for the following preventive $0 copay for Medicaid-covered services dental benefits
bull up to 1 oral exam(s) every six months bull up to 1 cleaning(s) every six months bull up to 1 dental X-ray every year
$0 copay for the following comprehensive services bull Restorative ndash Fillings Crowns bull Periodontics bull Extractions bull Prosthodontics bull Oral Surgery
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Hearing Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered Referral by your Primary Care Physician by Medicare or when the Medicare (PCP) may be required benefit is exhausted
Exam to diagnose and treat hearing and $0 copay for Medicaid-covered services balance issues $0 copay
Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids
Please see your EOC for plan coverage details
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at
risk
$0 copay for up to 1 supplemental routine eye exam every year
$0 copay for
bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
bull up to 1 pair of eyeglasses (lenses and frames) every year
bull contact lenses
bull up to 1 pair of eyeglass lenses every year
bull up to 1 eyeglass frame(s) every year
$250 plan coverage limit for eyewear every year
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs
bull 24 Hour Nurse Line
bull Gym membership
Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items
Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient Mental For Dual-eligible Members Medicaid In-Network Health Care pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare $0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
therapy visit
bull each Medicare-covered group therapy visit
$0 copay for Medicare-covered partial hospitalization program services
Outpatient For Dual-eligible Members Medicaid In-Network Substance pays for this service if it is not covered Authorization rules may apply Abuse Care by Medicare or when the Medicare
$0 copay for benefit is exhausted bull each Medicare-covered individual $0 copay for Medicaid-covered services
substance abuse outpatient treatment visit
bull each Medicare-covered group substance abuse outpatient treatment visit
Outpatient For Dual-eligible Members Medicaid In-Network ServicesSurgery pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) is required
$0 copay for Medicaid-covered services $0 copay for each Medicare-covered ambulatory surgical center visit
$0 copay for each Medicare-covered outpatient hospital facility visit
Ambulance Services For Dual-eligible Members Medicaid In-Network (medically necessary pays for this service if it is not covered Authorization rules may apply ambulance services) by Medicare or when the Medicare
$0 copay per ground trip benefit is exhausted 0 coinsurance per air trip $0 copay for Medicaid-covered services
Emergency Care For Dual-eligible Members Medicaid $0 copay for Medicare-covered (you may go to any pays for this service if it is not covered emergency room visits emergency room if you by Medicare or when the Medicare $50000 plan coverage limit for reasonably believe you benefit is exhausted supplemental emergency services need emergency care) $0 copay for Medicaid-covered services outside the US and its territories every
year
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Urgently Needed Care (this is not emergency care and in most cases is out of the service area)
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 for Medicaid-covered services
$0 copay for Medicare-covered urgently-needed-care Visits
If you are admitted to the hospital within 24 hours for the same condition you pay $0 for the urgently-needed-care visit
Outpatient Rehabilitation Services (occupational therapy physical therapy speech and language therapy)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Medically necessary physical therapy occupational therapy and speech and language pathology services are covered
$0 copay for Medicare-covered Occupational Therapy visits
$0 copay for Medicare-covered Physical Therapy and or Speech and Language Pathology visits
Outpatient Medical Services and Supplies
Durable Medical Equipment (includes wheelchairs oxygen etc)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered durable medical equipment
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Prosthetic Devices For Dual-eligible Members under age 21 In-Network (includes braces (CCP) Medicaid pays for this service if it Authorization rules may apply artificial limbs is not covered by Medicare or when the
$0 copay for Medicare-covered and eyes etc) Medicare benefit is exhausted bull prosthetic devices For all Dual-eligible Members Medicaid
pays for breast prostheses if not covered bull medical supplies related to prosthetics by Medicare or when the Medicare splints and other devices benefit is exhausted Quantity limitations apply and vary with each device Prior authorization will NOT be required within limitations except for miscellaneous codes
$0 copay for Medicaid-covered services
Diabetes Programs For Dual-eligible Members Medicaid In-Network and Supplies pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered Diabetes self-management training
$0 copay for Medicare-covered
bull Diabetes monitoring supplies
bull Therapeutic shoes or inserts
Diabetic Supplies and Services are limited to specific manufacturers products andor brands Contact the plan for a list of covered supplies
Diagnostic Tests For Dual-eligible Members Medicaid In-Network X-rays Lab Services pays for this service if it is not covered Authorization rules may apply and Radiology by Medicare or when the Medicare
Referral from your Primary Care Services benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered
bull lab services
bull diagnostic procedures and tests
bull X-rays
bull diagnostic radiology services (not including X-rays)
bull therapeutic radiology services
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Cardiac and Pulmonary Rehabilitation Services
Outpatient cardiac rehabilitation is covered for members meeting specific diagnostic criteria for a limited number of sessions
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing $0 copay for Medicare-covered Pulmonary Rehabilitation Services
Preventive Services
Preventive Services bull Bone Mass Measurement Texas Medicaid covers only the Single Photon Absorptiometry Test
$0 copay for Medicaid-covered services
bull Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam for women with Medicare) 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 for Medicaid-covered services
bull Colorectal Cancer Screening (for people with Medicare age 50 and older) 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 for Medicaid-covered services
bull Immunization (Flu vaccine Hepatitis B Vaccine for people with Medicare who are at risk Pneumonia vaccine) 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 for Medicaid-covered services
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for all preventive services covered under Original Medicare at zero cost sharing
Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare
Plan covers a physical exam annually
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services bull Health Wellness Education (Written (continued) health education materials including
Newsletters Nutritional Training Additional Smoking Cessation other wellness benefits) This is not a Texas Medicaid benefit but is available in some of the pilot programs like the Diabetes and Asthma projects For Dual-eligible Members participating in the Diabetes and Asthma pilot program Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
bull Mammograms (Annual Screening ndash for women with Medicare age 40 and older) 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 for Medicaid-covered services
bull Physical Exams 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 for Medicaid-covered services
bull Prostate Cancer Screening Exams (for men with Medicare age 50 and older) 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 for Medicaid-covered services
bull Telemedicine 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 for Medicaid-covered services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services Assistive Communication Devices This (continued) is a benefit for clients in an ICF-MR For
Dual-eligible Members who meet the above criteria Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
Kidney Disease 0 or 20 coinsurance for renal dialysis In-Network and Conditions 0 or 20 coinsurance for kidney Authorization rules may apply
disease education services Referral by your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient For Dual-eligible Members Medicaid Drugs covered under Medicare Part B Prescription Drugs pays for this service if it is not covered $0 yearly deductible for Medicare Part B
by Medicare or when Medicare benefit is drugs exhausted
$0 copay for Medicare Part B drugs $0 copayment for Medicaid-covered
Drugs covered under Medicare Part D prescription drugs not covered by Medicare Part D In-Network
Deductible $0 to $74 per year for Part D prescription drugs
Initial Coverage
Depending on your income and institutional status you pay the following
For generic drugs (including brand drugs treated as generic) either bull A $0 copay or bull A $120 copay or bull A $295 copay
For all other drugs either bull A $0 copay or bull A $360 copay or bull A $740 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Dental Services This is a benefit only for Texas Health In-Network Steps eligible clients and for clients in an Authorization rules may apply ICF-MR who are 21 years of age and
Referral from your Primary Care older For Dual-eligible Members who Physician (PCP) may be required meet the above criteria Medicaid pays
for this service if it is not covered by $0 copay for Medicare-covered dental Medicare or when the Medicare benefit benefits is exhausted $0 copay for the following preventive $0 copay for Medicaid-covered services dental benefits
bull up to 1 oral exam(s) every six months bull up to 1 cleaning(s) every six months bull up to 1 dental X-ray every year
$0 copay for the following comprehensive services bull Restorative ndash Fillings Crowns bull Periodontics bull Extractions bull Prosthodontics bull Oral Surgery
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Hearing Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered Referral by your Primary Care Physician by Medicare or when the Medicare (PCP) may be required benefit is exhausted
Exam to diagnose and treat hearing and $0 copay for Medicaid-covered services balance issues $0 copay
Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids
Please see your EOC for plan coverage details
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at
risk
$0 copay for up to 1 supplemental routine eye exam every year
$0 copay for
bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
bull up to 1 pair of eyeglasses (lenses and frames) every year
bull contact lenses
bull up to 1 pair of eyeglass lenses every year
bull up to 1 eyeglass frame(s) every year
$250 plan coverage limit for eyewear every year
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs
bull 24 Hour Nurse Line
bull Gym membership
Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items
Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Urgently Needed Care (this is not emergency care and in most cases is out of the service area)
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 for Medicaid-covered services
$0 copay for Medicare-covered urgently-needed-care Visits
If you are admitted to the hospital within 24 hours for the same condition you pay $0 for the urgently-needed-care visit
Outpatient Rehabilitation Services (occupational therapy physical therapy speech and language therapy)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Medically necessary physical therapy occupational therapy and speech and language pathology services are covered
$0 copay for Medicare-covered Occupational Therapy visits
$0 copay for Medicare-covered Physical Therapy and or Speech and Language Pathology visits
Outpatient Medical Services and Supplies
Durable Medical Equipment (includes wheelchairs oxygen etc)
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 for Medicaid-covered services
In-Network
Authorization rules may apply
$0 copay for Medicare-covered durable medical equipment
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Prosthetic Devices For Dual-eligible Members under age 21 In-Network (includes braces (CCP) Medicaid pays for this service if it Authorization rules may apply artificial limbs is not covered by Medicare or when the
$0 copay for Medicare-covered and eyes etc) Medicare benefit is exhausted bull prosthetic devices For all Dual-eligible Members Medicaid
pays for breast prostheses if not covered bull medical supplies related to prosthetics by Medicare or when the Medicare splints and other devices benefit is exhausted Quantity limitations apply and vary with each device Prior authorization will NOT be required within limitations except for miscellaneous codes
$0 copay for Medicaid-covered services
Diabetes Programs For Dual-eligible Members Medicaid In-Network and Supplies pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered Diabetes self-management training
$0 copay for Medicare-covered
bull Diabetes monitoring supplies
bull Therapeutic shoes or inserts
Diabetic Supplies and Services are limited to specific manufacturers products andor brands Contact the plan for a list of covered supplies
Diagnostic Tests For Dual-eligible Members Medicaid In-Network X-rays Lab Services pays for this service if it is not covered Authorization rules may apply and Radiology by Medicare or when the Medicare
Referral from your Primary Care Services benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered
bull lab services
bull diagnostic procedures and tests
bull X-rays
bull diagnostic radiology services (not including X-rays)
bull therapeutic radiology services
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Cardiac and Pulmonary Rehabilitation Services
Outpatient cardiac rehabilitation is covered for members meeting specific diagnostic criteria for a limited number of sessions
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing $0 copay for Medicare-covered Pulmonary Rehabilitation Services
Preventive Services
Preventive Services bull Bone Mass Measurement Texas Medicaid covers only the Single Photon Absorptiometry Test
$0 copay for Medicaid-covered services
bull Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam for women with Medicare) 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 for Medicaid-covered services
bull Colorectal Cancer Screening (for people with Medicare age 50 and older) 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 for Medicaid-covered services
bull Immunization (Flu vaccine Hepatitis B Vaccine for people with Medicare who are at risk Pneumonia vaccine) 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 for Medicaid-covered services
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for all preventive services covered under Original Medicare at zero cost sharing
Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare
Plan covers a physical exam annually
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services bull Health Wellness Education (Written (continued) health education materials including
Newsletters Nutritional Training Additional Smoking Cessation other wellness benefits) This is not a Texas Medicaid benefit but is available in some of the pilot programs like the Diabetes and Asthma projects For Dual-eligible Members participating in the Diabetes and Asthma pilot program Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
bull Mammograms (Annual Screening ndash for women with Medicare age 40 and older) 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 for Medicaid-covered services
bull Physical Exams 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 for Medicaid-covered services
bull Prostate Cancer Screening Exams (for men with Medicare age 50 and older) 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 for Medicaid-covered services
bull Telemedicine 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 for Medicaid-covered services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services Assistive Communication Devices This (continued) is a benefit for clients in an ICF-MR For
Dual-eligible Members who meet the above criteria Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
Kidney Disease 0 or 20 coinsurance for renal dialysis In-Network and Conditions 0 or 20 coinsurance for kidney Authorization rules may apply
disease education services Referral by your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient For Dual-eligible Members Medicaid Drugs covered under Medicare Part B Prescription Drugs pays for this service if it is not covered $0 yearly deductible for Medicare Part B
by Medicare or when Medicare benefit is drugs exhausted
$0 copay for Medicare Part B drugs $0 copayment for Medicaid-covered
Drugs covered under Medicare Part D prescription drugs not covered by Medicare Part D In-Network
Deductible $0 to $74 per year for Part D prescription drugs
Initial Coverage
Depending on your income and institutional status you pay the following
For generic drugs (including brand drugs treated as generic) either bull A $0 copay or bull A $120 copay or bull A $295 copay
For all other drugs either bull A $0 copay or bull A $360 copay or bull A $740 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Dental Services This is a benefit only for Texas Health In-Network Steps eligible clients and for clients in an Authorization rules may apply ICF-MR who are 21 years of age and
Referral from your Primary Care older For Dual-eligible Members who Physician (PCP) may be required meet the above criteria Medicaid pays
for this service if it is not covered by $0 copay for Medicare-covered dental Medicare or when the Medicare benefit benefits is exhausted $0 copay for the following preventive $0 copay for Medicaid-covered services dental benefits
bull up to 1 oral exam(s) every six months bull up to 1 cleaning(s) every six months bull up to 1 dental X-ray every year
$0 copay for the following comprehensive services bull Restorative ndash Fillings Crowns bull Periodontics bull Extractions bull Prosthodontics bull Oral Surgery
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Hearing Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered Referral by your Primary Care Physician by Medicare or when the Medicare (PCP) may be required benefit is exhausted
Exam to diagnose and treat hearing and $0 copay for Medicaid-covered services balance issues $0 copay
Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids
Please see your EOC for plan coverage details
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at
risk
$0 copay for up to 1 supplemental routine eye exam every year
$0 copay for
bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
bull up to 1 pair of eyeglasses (lenses and frames) every year
bull contact lenses
bull up to 1 pair of eyeglass lenses every year
bull up to 1 eyeglass frame(s) every year
$250 plan coverage limit for eyewear every year
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs
bull 24 Hour Nurse Line
bull Gym membership
Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items
Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Prosthetic Devices For Dual-eligible Members under age 21 In-Network (includes braces (CCP) Medicaid pays for this service if it Authorization rules may apply artificial limbs is not covered by Medicare or when the
$0 copay for Medicare-covered and eyes etc) Medicare benefit is exhausted bull prosthetic devices For all Dual-eligible Members Medicaid
pays for breast prostheses if not covered bull medical supplies related to prosthetics by Medicare or when the Medicare splints and other devices benefit is exhausted Quantity limitations apply and vary with each device Prior authorization will NOT be required within limitations except for miscellaneous codes
$0 copay for Medicaid-covered services
Diabetes Programs For Dual-eligible Members Medicaid In-Network and Supplies pays for this service if it is not covered Authorization rules may apply
by Medicare or when the Medicare Referral from your Primary Care benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered Diabetes self-management training
$0 copay for Medicare-covered
bull Diabetes monitoring supplies
bull Therapeutic shoes or inserts
Diabetic Supplies and Services are limited to specific manufacturers products andor brands Contact the plan for a list of covered supplies
Diagnostic Tests For Dual-eligible Members Medicaid In-Network X-rays Lab Services pays for this service if it is not covered Authorization rules may apply and Radiology by Medicare or when the Medicare
Referral from your Primary Care Services benefit is exhausted Physician (PCP) may be required
$0 copay for Medicaid-covered services $0 copay for Medicare-covered
bull lab services
bull diagnostic procedures and tests
bull X-rays
bull diagnostic radiology services (not including X-rays)
bull therapeutic radiology services
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Cardiac and Pulmonary Rehabilitation Services
Outpatient cardiac rehabilitation is covered for members meeting specific diagnostic criteria for a limited number of sessions
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing $0 copay for Medicare-covered Pulmonary Rehabilitation Services
Preventive Services
Preventive Services bull Bone Mass Measurement Texas Medicaid covers only the Single Photon Absorptiometry Test
$0 copay for Medicaid-covered services
bull Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam for women with Medicare) 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 for Medicaid-covered services
bull Colorectal Cancer Screening (for people with Medicare age 50 and older) 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 for Medicaid-covered services
bull Immunization (Flu vaccine Hepatitis B Vaccine for people with Medicare who are at risk Pneumonia vaccine) 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 for Medicaid-covered services
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for all preventive services covered under Original Medicare at zero cost sharing
Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare
Plan covers a physical exam annually
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services bull Health Wellness Education (Written (continued) health education materials including
Newsletters Nutritional Training Additional Smoking Cessation other wellness benefits) This is not a Texas Medicaid benefit but is available in some of the pilot programs like the Diabetes and Asthma projects For Dual-eligible Members participating in the Diabetes and Asthma pilot program Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
bull Mammograms (Annual Screening ndash for women with Medicare age 40 and older) 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 for Medicaid-covered services
bull Physical Exams 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 for Medicaid-covered services
bull Prostate Cancer Screening Exams (for men with Medicare age 50 and older) 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 for Medicaid-covered services
bull Telemedicine 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 for Medicaid-covered services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services Assistive Communication Devices This (continued) is a benefit for clients in an ICF-MR For
Dual-eligible Members who meet the above criteria Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
Kidney Disease 0 or 20 coinsurance for renal dialysis In-Network and Conditions 0 or 20 coinsurance for kidney Authorization rules may apply
disease education services Referral by your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient For Dual-eligible Members Medicaid Drugs covered under Medicare Part B Prescription Drugs pays for this service if it is not covered $0 yearly deductible for Medicare Part B
by Medicare or when Medicare benefit is drugs exhausted
$0 copay for Medicare Part B drugs $0 copayment for Medicaid-covered
Drugs covered under Medicare Part D prescription drugs not covered by Medicare Part D In-Network
Deductible $0 to $74 per year for Part D prescription drugs
Initial Coverage
Depending on your income and institutional status you pay the following
For generic drugs (including brand drugs treated as generic) either bull A $0 copay or bull A $120 copay or bull A $295 copay
For all other drugs either bull A $0 copay or bull A $360 copay or bull A $740 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Dental Services This is a benefit only for Texas Health In-Network Steps eligible clients and for clients in an Authorization rules may apply ICF-MR who are 21 years of age and
Referral from your Primary Care older For Dual-eligible Members who Physician (PCP) may be required meet the above criteria Medicaid pays
for this service if it is not covered by $0 copay for Medicare-covered dental Medicare or when the Medicare benefit benefits is exhausted $0 copay for the following preventive $0 copay for Medicaid-covered services dental benefits
bull up to 1 oral exam(s) every six months bull up to 1 cleaning(s) every six months bull up to 1 dental X-ray every year
$0 copay for the following comprehensive services bull Restorative ndash Fillings Crowns bull Periodontics bull Extractions bull Prosthodontics bull Oral Surgery
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Hearing Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered Referral by your Primary Care Physician by Medicare or when the Medicare (PCP) may be required benefit is exhausted
Exam to diagnose and treat hearing and $0 copay for Medicaid-covered services balance issues $0 copay
Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids
Please see your EOC for plan coverage details
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at
risk
$0 copay for up to 1 supplemental routine eye exam every year
$0 copay for
bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
bull up to 1 pair of eyeglasses (lenses and frames) every year
bull contact lenses
bull up to 1 pair of eyeglass lenses every year
bull up to 1 eyeglass frame(s) every year
$250 plan coverage limit for eyewear every year
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs
bull 24 Hour Nurse Line
bull Gym membership
Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items
Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
Benefit Category (Excludes Medicare-covered services)
Texas Medicaid-covered services
Cigna-HealthSpring TotalCare (HMO SNP)
Cardiac and Pulmonary Rehabilitation Services
Outpatient cardiac rehabilitation is covered for members meeting specific diagnostic criteria for a limited number of sessions
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 for Medicaid-covered services
In-Network
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks) You pay nothing $0 copay for Medicare-covered Pulmonary Rehabilitation Services
Preventive Services
Preventive Services bull Bone Mass Measurement Texas Medicaid covers only the Single Photon Absorptiometry Test
$0 copay for Medicaid-covered services
bull Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam for women with Medicare) 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 for Medicaid-covered services
bull Colorectal Cancer Screening (for people with Medicare age 50 and older) 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 for Medicaid-covered services
bull Immunization (Flu vaccine Hepatitis B Vaccine for people with Medicare who are at risk Pneumonia vaccine) 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 for Medicaid-covered services
Authorization rules may apply
Referral from your Primary Care Physician (PCP) may be required
$0 copay for all preventive services covered under Original Medicare at zero cost sharing
Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare
Plan covers a physical exam annually
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services bull Health Wellness Education (Written (continued) health education materials including
Newsletters Nutritional Training Additional Smoking Cessation other wellness benefits) This is not a Texas Medicaid benefit but is available in some of the pilot programs like the Diabetes and Asthma projects For Dual-eligible Members participating in the Diabetes and Asthma pilot program Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
bull Mammograms (Annual Screening ndash for women with Medicare age 40 and older) 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 for Medicaid-covered services
bull Physical Exams 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 for Medicaid-covered services
bull Prostate Cancer Screening Exams (for men with Medicare age 50 and older) 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 for Medicaid-covered services
bull Telemedicine 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 for Medicaid-covered services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services Assistive Communication Devices This (continued) is a benefit for clients in an ICF-MR For
Dual-eligible Members who meet the above criteria Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
Kidney Disease 0 or 20 coinsurance for renal dialysis In-Network and Conditions 0 or 20 coinsurance for kidney Authorization rules may apply
disease education services Referral by your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient For Dual-eligible Members Medicaid Drugs covered under Medicare Part B Prescription Drugs pays for this service if it is not covered $0 yearly deductible for Medicare Part B
by Medicare or when Medicare benefit is drugs exhausted
$0 copay for Medicare Part B drugs $0 copayment for Medicaid-covered
Drugs covered under Medicare Part D prescription drugs not covered by Medicare Part D In-Network
Deductible $0 to $74 per year for Part D prescription drugs
Initial Coverage
Depending on your income and institutional status you pay the following
For generic drugs (including brand drugs treated as generic) either bull A $0 copay or bull A $120 copay or bull A $295 copay
For all other drugs either bull A $0 copay or bull A $360 copay or bull A $740 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Dental Services This is a benefit only for Texas Health In-Network Steps eligible clients and for clients in an Authorization rules may apply ICF-MR who are 21 years of age and
Referral from your Primary Care older For Dual-eligible Members who Physician (PCP) may be required meet the above criteria Medicaid pays
for this service if it is not covered by $0 copay for Medicare-covered dental Medicare or when the Medicare benefit benefits is exhausted $0 copay for the following preventive $0 copay for Medicaid-covered services dental benefits
bull up to 1 oral exam(s) every six months bull up to 1 cleaning(s) every six months bull up to 1 dental X-ray every year
$0 copay for the following comprehensive services bull Restorative ndash Fillings Crowns bull Periodontics bull Extractions bull Prosthodontics bull Oral Surgery
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Hearing Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered Referral by your Primary Care Physician by Medicare or when the Medicare (PCP) may be required benefit is exhausted
Exam to diagnose and treat hearing and $0 copay for Medicaid-covered services balance issues $0 copay
Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids
Please see your EOC for plan coverage details
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at
risk
$0 copay for up to 1 supplemental routine eye exam every year
$0 copay for
bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
bull up to 1 pair of eyeglasses (lenses and frames) every year
bull contact lenses
bull up to 1 pair of eyeglass lenses every year
bull up to 1 eyeglass frame(s) every year
$250 plan coverage limit for eyewear every year
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs
bull 24 Hour Nurse Line
bull Gym membership
Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items
Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services bull Health Wellness Education (Written (continued) health education materials including
Newsletters Nutritional Training Additional Smoking Cessation other wellness benefits) This is not a Texas Medicaid benefit but is available in some of the pilot programs like the Diabetes and Asthma projects For Dual-eligible Members participating in the Diabetes and Asthma pilot program Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
bull Mammograms (Annual Screening ndash for women with Medicare age 40 and older) 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 for Medicaid-covered services
bull Physical Exams 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 for Medicaid-covered services
bull Prostate Cancer Screening Exams (for men with Medicare age 50 and older) 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 for Medicaid-covered services
bull Telemedicine 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 for Medicaid-covered services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services Assistive Communication Devices This (continued) is a benefit for clients in an ICF-MR For
Dual-eligible Members who meet the above criteria Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
Kidney Disease 0 or 20 coinsurance for renal dialysis In-Network and Conditions 0 or 20 coinsurance for kidney Authorization rules may apply
disease education services Referral by your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient For Dual-eligible Members Medicaid Drugs covered under Medicare Part B Prescription Drugs pays for this service if it is not covered $0 yearly deductible for Medicare Part B
by Medicare or when Medicare benefit is drugs exhausted
$0 copay for Medicare Part B drugs $0 copayment for Medicaid-covered
Drugs covered under Medicare Part D prescription drugs not covered by Medicare Part D In-Network
Deductible $0 to $74 per year for Part D prescription drugs
Initial Coverage
Depending on your income and institutional status you pay the following
For generic drugs (including brand drugs treated as generic) either bull A $0 copay or bull A $120 copay or bull A $295 copay
For all other drugs either bull A $0 copay or bull A $360 copay or bull A $740 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Dental Services This is a benefit only for Texas Health In-Network Steps eligible clients and for clients in an Authorization rules may apply ICF-MR who are 21 years of age and
Referral from your Primary Care older For Dual-eligible Members who Physician (PCP) may be required meet the above criteria Medicaid pays
for this service if it is not covered by $0 copay for Medicare-covered dental Medicare or when the Medicare benefit benefits is exhausted $0 copay for the following preventive $0 copay for Medicaid-covered services dental benefits
bull up to 1 oral exam(s) every six months bull up to 1 cleaning(s) every six months bull up to 1 dental X-ray every year
$0 copay for the following comprehensive services bull Restorative ndash Fillings Crowns bull Periodontics bull Extractions bull Prosthodontics bull Oral Surgery
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Hearing Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered Referral by your Primary Care Physician by Medicare or when the Medicare (PCP) may be required benefit is exhausted
Exam to diagnose and treat hearing and $0 copay for Medicaid-covered services balance issues $0 copay
Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids
Please see your EOC for plan coverage details
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at
risk
$0 copay for up to 1 supplemental routine eye exam every year
$0 copay for
bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
bull up to 1 pair of eyeglasses (lenses and frames) every year
bull contact lenses
bull up to 1 pair of eyeglass lenses every year
bull up to 1 eyeglass frame(s) every year
$250 plan coverage limit for eyewear every year
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs
bull 24 Hour Nurse Line
bull Gym membership
Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items
Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Preventive Services Assistive Communication Devices This (continued) is a benefit for clients in an ICF-MR For
Dual-eligible Members who meet the above criteria Medicaid pays for this service if it is not covered by Medicare or when the Medicare benefit is exhausted
$0 copay for Medicaid-covered services
Kidney Disease 0 or 20 coinsurance for renal dialysis In-Network and Conditions 0 or 20 coinsurance for kidney Authorization rules may apply
disease education services Referral by your Primary Care Physician (PCP) may be required
$0 copay for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient For Dual-eligible Members Medicaid Drugs covered under Medicare Part B Prescription Drugs pays for this service if it is not covered $0 yearly deductible for Medicare Part B
by Medicare or when Medicare benefit is drugs exhausted
$0 copay for Medicare Part B drugs $0 copayment for Medicaid-covered
Drugs covered under Medicare Part D prescription drugs not covered by Medicare Part D In-Network
Deductible $0 to $74 per year for Part D prescription drugs
Initial Coverage
Depending on your income and institutional status you pay the following
For generic drugs (including brand drugs treated as generic) either bull A $0 copay or bull A $120 copay or bull A $295 copay
For all other drugs either bull A $0 copay or bull A $360 copay or bull A $740 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Dental Services This is a benefit only for Texas Health In-Network Steps eligible clients and for clients in an Authorization rules may apply ICF-MR who are 21 years of age and
Referral from your Primary Care older For Dual-eligible Members who Physician (PCP) may be required meet the above criteria Medicaid pays
for this service if it is not covered by $0 copay for Medicare-covered dental Medicare or when the Medicare benefit benefits is exhausted $0 copay for the following preventive $0 copay for Medicaid-covered services dental benefits
bull up to 1 oral exam(s) every six months bull up to 1 cleaning(s) every six months bull up to 1 dental X-ray every year
$0 copay for the following comprehensive services bull Restorative ndash Fillings Crowns bull Periodontics bull Extractions bull Prosthodontics bull Oral Surgery
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Hearing Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered Referral by your Primary Care Physician by Medicare or when the Medicare (PCP) may be required benefit is exhausted
Exam to diagnose and treat hearing and $0 copay for Medicaid-covered services balance issues $0 copay
Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids
Please see your EOC for plan coverage details
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at
risk
$0 copay for up to 1 supplemental routine eye exam every year
$0 copay for
bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
bull up to 1 pair of eyeglasses (lenses and frames) every year
bull contact lenses
bull up to 1 pair of eyeglass lenses every year
bull up to 1 eyeglass frame(s) every year
$250 plan coverage limit for eyewear every year
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs
bull 24 Hour Nurse Line
bull Gym membership
Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items
Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Outpatient For Dual-eligible Members Medicaid Drugs covered under Medicare Part B Prescription Drugs pays for this service if it is not covered $0 yearly deductible for Medicare Part B
by Medicare or when Medicare benefit is drugs exhausted
$0 copay for Medicare Part B drugs $0 copayment for Medicaid-covered
Drugs covered under Medicare Part D prescription drugs not covered by Medicare Part D In-Network
Deductible $0 to $74 per year for Part D prescription drugs
Initial Coverage
Depending on your income and institutional status you pay the following
For generic drugs (including brand drugs treated as generic) either bull A $0 copay or bull A $120 copay or bull A $295 copay
For all other drugs either bull A $0 copay or bull A $360 copay or bull A $740 copay
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4850 you pay nothing for all drugs
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Dental Services This is a benefit only for Texas Health In-Network Steps eligible clients and for clients in an Authorization rules may apply ICF-MR who are 21 years of age and
Referral from your Primary Care older For Dual-eligible Members who Physician (PCP) may be required meet the above criteria Medicaid pays
for this service if it is not covered by $0 copay for Medicare-covered dental Medicare or when the Medicare benefit benefits is exhausted $0 copay for the following preventive $0 copay for Medicaid-covered services dental benefits
bull up to 1 oral exam(s) every six months bull up to 1 cleaning(s) every six months bull up to 1 dental X-ray every year
$0 copay for the following comprehensive services bull Restorative ndash Fillings Crowns bull Periodontics bull Extractions bull Prosthodontics bull Oral Surgery
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Hearing Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered Referral by your Primary Care Physician by Medicare or when the Medicare (PCP) may be required benefit is exhausted
Exam to diagnose and treat hearing and $0 copay for Medicaid-covered services balance issues $0 copay
Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids
Please see your EOC for plan coverage details
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at
risk
$0 copay for up to 1 supplemental routine eye exam every year
$0 copay for
bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
bull up to 1 pair of eyeglasses (lenses and frames) every year
bull contact lenses
bull up to 1 pair of eyeglass lenses every year
bull up to 1 eyeglass frame(s) every year
$250 plan coverage limit for eyewear every year
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs
bull 24 Hour Nurse Line
bull Gym membership
Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items
Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Dental Services This is a benefit only for Texas Health In-Network Steps eligible clients and for clients in an Authorization rules may apply ICF-MR who are 21 years of age and
Referral from your Primary Care older For Dual-eligible Members who Physician (PCP) may be required meet the above criteria Medicaid pays
for this service if it is not covered by $0 copay for Medicare-covered dental Medicare or when the Medicare benefit benefits is exhausted $0 copay for the following preventive $0 copay for Medicaid-covered services dental benefits
bull up to 1 oral exam(s) every six months bull up to 1 cleaning(s) every six months bull up to 1 dental X-ray every year
$0 copay for the following comprehensive services bull Restorative ndash Fillings Crowns bull Periodontics bull Extractions bull Prosthodontics bull Oral Surgery
Endodontics is not covered
Please see your EOC for plan coverage details
$1000 plan coverage limit for comprehensive dental benefits every year
Hearing Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered Referral by your Primary Care Physician by Medicare or when the Medicare (PCP) may be required benefit is exhausted
Exam to diagnose and treat hearing and $0 copay for Medicaid-covered services balance issues $0 copay
Routine hearing exam (for up to 1 every year) $0 copay Hearing aid fittingevaluation (for up to 1 every three years) $0 copay Hearing aid $0 copay Our plan pays up to $500 every three years for hearing aids
Please see your EOC for plan coverage details
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at
risk
$0 copay for up to 1 supplemental routine eye exam every year
$0 copay for
bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
bull up to 1 pair of eyeglasses (lenses and frames) every year
bull contact lenses
bull up to 1 pair of eyeglass lenses every year
bull up to 1 eyeglass frame(s) every year
$250 plan coverage limit for eyewear every year
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs
bull 24 Hour Nurse Line
bull Gym membership
Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items
Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Vision Services For Dual-eligible Members Medicaid In-Network pays for this service if it is not covered $0 copay for Medicare-covered by Medicare or when the Medicare diagnosis and treatment for diseases benefit is exhausted and conditions of the eye including an $0 copay for Medicaid-covered services annual glaucoma screening for people at
risk
$0 copay for up to 1 supplemental routine eye exam every year
$0 copay for
bull one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery
bull up to 1 pair of eyeglasses (lenses and frames) every year
bull contact lenses
bull up to 1 pair of eyeglass lenses every year
bull up to 1 eyeglass frame(s) every year
$250 plan coverage limit for eyewear every year
$0 copays for supplemental eyewear (except after cataract surgery) apply up to the plan allowance Please see your EOC for plan coverage details
WellnessEducation 24 hour Nurse Advice Hotline Texas In-Network and other Medicaid Wellness Program The plan covers the following Supplemental supplemental educationwellness Benefits and Services programs
bull 24 Hour Nurse Line
bull Gym membership
Over-the- Not covered Please visit our website to see our list of Counter Items covered over-the-counter items
Limited to $70 per month for specific over‑the‑counter drugs and other health‑related pharmacy products as listed in the OTC catalog
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Transportation For Dual-eligible Members the Medicaid In-Network (routine) Medical Transportation provides this Authorization rules may apply
service if it is not covered by Medicare $0 copay for unlimited trip(s) to plan-or when the Medicare benefit is approved locations every year exhausted
$0 copay for Medicaid-covered services
Home and Community Based Waiver Services
Those who meet QMB requirements and also meet the financial criteria for full Medicaid coverage may be eligible to receive all Medicaid services not covered by Medicare including waiver services Waiver services are limited to individuals who meet additional waiver eligibility criteria
Community Based For information on waiver services and Not covered Alternatives eligibility for this waiver contact the (CBA) Waiver Department of Aging and Disability
Services (DADS)
Community Living For information on waiver services and Not covered Assistance and eligibility for this waiver contact the Support Services Department of Aging and Disability (CLASS) Waiver Services (DADS)
Consolidated Waiver For information on waiver services and Not covered Program (CWP) - eligibility for this waiver contact the Bexar CountySan Department of Aging and Disability Antonio Only Services (DADS)
Deaf Blind With For information on waiver services and Not covered Multiple Disabilities eligibility for this waiver contact the Waiver (DB-MD) Department of Aging and Disability
Services (DADS)
Home and For information on waiver services and Not covered Community Services eligibility for this waiver contact the (HCS) Waiver Department of Aging and Disability
Services (DADS)
Medically For information on waiver services and Not covered Dependent Children eligibility for this waiver contact the Program (MDCP) Department of Aging and Disability
Services (DADS)
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc
Benefit Category Texas Medicaid- Cigna-HealthSpring TotalCare
(Excludes Medicare-covered services (HMO SNP)
covered services)
Star+Plus Waiver For information on waiver services and Not covered eligibility for this waiver contact the Department of Aging and Disability Services (DADS)
Texas Home Living For information on waiver services and Not covered Waiver (TXHML) eligibility for this waiver contact the
Department of Aging and Disability Services (DADS)
This plan is available to anyone who has both Medical Assistance from the State and Medicare For full dual-eligible members the state will continue to pay your Medicare Part B premium Premiums copays co-insurance and deductibles may vary based on the level of Extra Help you receive Please contact the plan for further details
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation including Cigna Health and Life Insurance Company Cigna HealthCare of South Carolina Inc Cigna HealthCare of North Carolina Inc Cigna HealthCare of Georgia Inc Cigna HealthCare of Arizona Inc Cigna HealthCare of St Louis Inc HealthSpring Life amp Health Insurance Company Inc HealthSpring of Tennessee Inc HealthSpring of Alabama Inc HealthSpring of Florida Inc Bravo Health Mid-Atlantic Inc and Bravo Health Pennsylvania Inc The Cigna name logos and other Cigna marks are owned by Cigna Intellectual Property Inc