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Chapter 4. - Medical Benefits Chart (what is covered and what you pay)


Chapter 4. - Medical Benefits Chart (what is covered and what you pay)



This chapter focuses on your covered services and what you pay for your medical benefits. It includes a Medical Benefits Chart that lists your covered services and shows how much you will pay for each covered service as a member of KelseyCare Advantage Rx+Choice. Later in this chapter, you can find information about medical services that are not covered. It also explains limits on certain services.


Section 1.1 - Types of out-of-pocket costs you may pay for your covered services

To understand the payment information we give you in this chapter, you need to know about the types of out-of-pocket costs you may pay for your covered services.

  • A "copayment" is the fixed amount you pay each time you receive certain medical services. You pay a copayment at the time you get the medical service. (The Medical Benefits Chart in Section 2 tells you more about your copayments.)
  • "Coinsurance" is the percentage you pay of the total cost of certain medical services. You pay a coinsurance at the time you get the medical service. (The Medical Benefits Chart in Section 2 tells you more about your coinsurance.)

Most people who qualify for Medicaid or for the Qualified Medicare Beneficiary (QMB) program should never pay deductibles, copayments or coinsurance. Be sure to show your proof of Medicaid or QMB eligibility to your provider, if applicable. If you think that you are being asked to pay improperly, contact Member Services.


Section 1.2 - What is the most you will pay for Medicare Part A and Part B covered medical services?

Because you are enrolled in a Medicare Advantage Plan, there is a limit to how much you have to pay out-of-pocket each year for in-network medical services that are covered under Medicare Part A and Part B (see the Medical Benefits Chart in Section 2, below). This limit is called the maximum out-of-pocket amount for medical services.

As a member of KelseyCare Advantage Rx+Choice, the most you will have to pay out-of-pocket for in-network covered Medicare Part A and Part B services in 2019 is $3,400. The amounts you pay for copayments and coinsurance for in-network covered services count toward this maximum out-of-pocket amount. (The amounts you pay for your plan premiums and for your Part D prescription drugs do not count toward your maximum out-of-pocket amount.) In addition, amounts you pay for some services do not count toward your maximum out-of-pocket amount. These services are marked with an asterisk in the Medical Benefits Chart. If you reach the maximum out-of-pocket amount of $3,400, you will not have to pay any out-of-pocket costs for the rest of the year for in-network covered Part A and Part B services. However, you must continue to pay your plan premium and the Medicare Part B premium (unless your Part B premium is paid for you by Medicaid or another third party).

The most you will have to pay out-of-pocket for Point-of-Service (POS) out-of-network covered Part A and Part B services in 2019 is $10,000. The amounts you pay for copayments and coinsurance for out-of-network covered services count toward this maximum out-of-pocket amount. The amounts you pay for your plan premium and Part D prescription drugs do not count toward your maximum out-of-pocket amount. In addition, amounts you pay for some services do not count toward your maximum out-of-pocket amount. These services are marked with an asterisk in the Medical Benefits Chart. If you reach the maximum out-of-pocket amount of $10,000 for covered POS out-of-network services, you will not have to pay any out-of-pocket costs for the rest of the year for out-of-network covered Part A and Part B services. However, you must continue to pay your plan premium and the Medicare Part B premium (unless your Part B premium is paid for you by Medicaid or another third party).


Section 1.3 - Our plan does not allow providers to "balance bill" you

As a member of KelseyCare Advantage Rx+Choice, an important protection for you is that you only have to pay your cost-sharing amount when you get services covered by our plan. We do not allow providers to add additional separate charges, called "balance billing." This protection (that you never pay more than your cost-sharing amount) applies even if we pay the provider less than the provider charges for a service and even if there is a dispute and we don’t pay certain provider charges.

Here is how this protection works.

  • If your cost-sharing is a copayment (a set amount of dollars, for example, $15.00), then you pay only that amount for any covered services from a network provider.
  • If your cost-sharing is a coinsurance (a percentage of the total charges), then you never pay more than that percentage. However, your cost depends on which type of provider you see:

    • If you receive the covered services from a network provider, you pay the coinsurance percentage multiplied by the plan’s reimbursement rate (as determined in the contract between the provider and the plan).

    • If you receive the covered services from an out-of-network provider who participates with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for participating providers. (Remember, the plan covers services from out-of-network providers only in certain situations, such as when you get a referral.)

    • If you receive the covered services from an out-of-network provider who does not participate with Medicare, you pay the coinsurance percentage multiplied by the Medicare payment rate for non-participating providers. (Remember, the plan covers services from out-of-network providers only in certain situations, such as when you get a referral.)
  • If you believe a provider has "balance billed" you, call Member Services (phone numbers are printed on the back cover of this booklet).

Section 2.1 - Your medical benefits and costs as a member of the plan

The Medical Benefits Chart on the following pages lists the services KelseyCare Advantage Rx+Choice covers and what you pay out-of-pocket for each service. The services listed in the Medical Benefits Chart are covered only when the following coverage requirements are met:

  • Your Medicare covered services must be provided according to the coverage guidelines established by Medicare.
  • Your services (including medical care, services, supplies, and equipment) must be medically necessary. "Medically necessary" means that the services, supplies, or drugs are needed for the prevention, diagnosis, or treatment of your medical condition and meet accepted standards of medical practice.
  • You receive your care from a network provider. In most cases, care you receive from an out-of-network provider will not be covered. Chapter 3 provides more information about requirements for using network providers and the situations when we will cover services from an out-of-network provider.
  • You have a primary care provider (a PCP) who is providing and overseeing your care. In most situations, your PCP must give you approval in advance before you can see other non-Kelsey-Seybold providers outside Kelsey-Seybold Medical Group. This is called giving you a "referral." Chapter 3 provides more information about getting a referral and the situations when you do not need a referral.
  • Some of the services listed in the Medical Benefits Chart are covered only if your doctor or other network provider gets approval in advance (sometimes called "prior authorization") from us. Covered services that need approval in advance are marked in the Medical Benefits Chart by a footnote.
  • We may also charge you "administrative fees" for missed appointments or for not paying your required cost-sharing at the time of service. Call Member Services if you have questions regarding these administrative fees. (Phone numbers for Member Services are printed on the back cover of this booklet.)

Other important things to know about our coverage:

  • Like all Medicare health plans, we cover everything that Original Medicare covers. For some of these benefits, you pay more in our plan than you would in Original Medicare. For others, you pay less. (If you want to know more about the coverage and costs of Original Medicare, look in your Medicare & You 2019 Handbook. View it online at https://www.medicare.gov or ask for 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.)
  • For all preventive services that are covered at no cost under Original Medicare, we also cover the service at no cost to you. However, if you also are treated or monitored for an existing medical condition during the visit when you receive the preventive service, a copayment will apply for the care received for the existing medical condition.
  • Sometimes, Medicare adds coverage under Original Medicare for new services during the year. If Medicare adds coverage for any services during 2019, either Medicare or our plan will cover those services.

You will see this apple next to the preventive services in the benefits chart.

Medical Benefits Chart

Services that are covered for you What you must pay when you get these services
Abdominal aortic aneurysm screening

A one-time screening ultrasound for people at risk. The plan only covers this screening if you have certain risk factors and if you get a referral for it from your physician, physician assistant, nurse practitioner, or clinical nurse specialist.


In-network:
There is no coinsurance, copayment, or deductible for members eligible for this preventive screening.

Out-of-network:
There is 50% coinsurance for members eligible for this preventive screening.
Ambulance services

  • Covered ambulance services include fixed wing, rotary wing, and ground ambulance services, to the nearest appropriate facility that can provide care only if they are furnished to a member whose medical condition is such that other means of transportation could endanger the person’s health or if authorized by the plan.
  • Non-emergency transportation by ambulance is appropriate if it is documented that the member’s condition is such that other means of transportation could endanger the person’s health and that transportation by ambulance is medically required.


In-network:
$100 copayment for each Medicare-covered ambulance trip Copayment is for each one-way trip.

Out-of-network:
50% coinsurance for non-emergency trips Emergency care is covered worldwide.

Non-emergency ambulance services are not covered for transportation back to the service area if you are traveling in or outside the United States.
Prior authorization required for non-emergency ambulance services.
Annual wellness visit

If you’ve had Part B for longer than 12 months, you can get an annual wellness visit to develop or update a personalized prevention plan based on your current health and risk factors. This is covered once every 12 months.

Note: Your first annual wellness visit can’t take place within 12 months of your "Welcome to Medicare" preventive visit. However, you don’t need to have had a "Welcome to Medicare" visit to be covered for annual wellness visits after you’ve had Part B for 12 months.


In-network:
There is no coinsurance, copayment, or deductible for the annual wellness visit.

Out-of-network:
There is a 50% coinsurance for the annual wellness visit.
Bone mass measurement

For qualified individuals (generally, this means people at risk of losing bone mass or at risk of osteoporosis), the following services are covered every 24 months or more frequently if medically necessary: procedures to identify bone mass, detect bone loss, or determine bone quality, including a physician’s interpretation of the results.


In-network:
There is no coinsurance, copayment, or deductible for Medicare-covered bone mass measurement.

Out-of-network:
There is 50% coinsurance for Medicare-covered bone mass measurement.
Breast cancer screening (mammograms)

Covered services include:
  • One baseline mammogram between the ages of 35 and 39
  • One screening mammogram every 12 months for women age 40 and older
  • Clinical breast exams once every 24 months


In-network:
There is no coinsurance, copayment, or deductible for covered screening mammograms.

Out-of-network:
There is 50% coinsurance for covered screening mammograms.
Cardiac rehabilitation services

Comprehensive programs of cardiac rehabilitation services that include exercise, education, and counseling are covered for members who meet certain conditions with a doctor’s referral. The plan also covers intensive cardiac rehabilitation programs that are typically more rigorous or more intense than cardiac rehabilitation programs.


In-network:
$35 copayment for cardiac rehabilitation therapy up to Medicare-approved visit limits.

Out-of-network:
50% coinsurance for cardiac rehabilitation therapy up to Medicare-approved visit limits
Prior authorization required.
Cardiovascular disease risk reduction visit (therapy for cardiovascular disease)

We cover one visit per year with your primary care doctor to help lower your risk for cardiovascular disease. During this visit, your doctor may discuss aspirin use (if appropriate), check your blood pressure, and give you tips to make sure you’re eating healthy.


In-network:
There is no coinsurance, copayment, or deductible for the intensive behavioral therapy cardiovascular disease preventive benefit.

Out-of-network:
There is 50% coinsurance for the intensive behavioral therapy cardiovascular disease preventive benefit.
Cardiovascular disease testing

Blood tests for the detection of cardiovascular disease (or abnormalities associated with an elevated risk of cardiovascular disease) once every 5 years (60 months).


In-network:
There is no coinsurance, copayment, or deductible for cardiovascular disease testing that is covered once every 5 years.

Out-of-network:
There is 50% coinsurance for cardiovascular disease testing that is covered once every 5 years.
Cervical and vaginal cancer screening

Covered services include:
  • For all women: Pap tests and pelvic exams are covered once every 24 months
  • If you are at high risk of cervical or vaginal cancer or you are of childbearing age and have had an abnormal Pap test within the past 3 years: one Pap test every 12 months


In-network:
There is no coinsurance, copayment, or deductible for Medicare-covered preventive Pap and pelvic exams.

Out-of-network:
There is 50% coinsurance for Medicare-covered preventive Pap and pelvic exams.
Chiropractic services

Covered services include:
  • We cover only manual manipulation of the spine to correct subluxation


In-network:
$20 copayment per visit

Out-of-network:
20% coinsurance per visit
Some services require prior authorization.
Limited to Medicare-covered chiropractic services
Colorectal cancer screening

For people 50 and older, the following are covered:
  • Flexible sigmoidoscopy (or screening barium enema as an alternative) every 48 months
One of the following every 12 months:
  • Guaiac-based fecal occult blood test (gFOBT)
  • Fecal immunochemical test (FIT)
DNA based colorectal screening every 3 years For people at high risk of colorectal cancer, we cover:
  • Screening colonoscopy (or screening barium enema as an alternative) every 24 months
For people not at high risk of colorectal cancer, we cover:
  • Screening colonoscopy every 10 years (120 months), but not within 48 months of a screening sigmoidoscopy


In-network:
There is no coinsurance, copayment or deductible for a Medicare-covered colorectal cancer screening exam.

You will not pay a copayment for a colonoscopy, even if certain procedures (such as a biopsy or polyp removal) are done during your screening colonoscopy.

You will pay the outpatient hospital ($300) copayment or ambulatory surgery ($225) copayment if the colonoscopy is combined with another non-colonoscopy outpatient procedure.

Out-of-network:
There is 50% coinsurance for a Medicare-covered colorectal cancer screening exam

You will pay 20% coinsurance for all Medicare-covered outpatient surgery including services provided at hospital outpatient facilities and ambulatory surgical centers.

Prior Authorization required.
Dental services

In general, preventive dental services (such as cleaning, routine dental exams, and dental x-rays) are not covered by Original Medicare. We cover Medicare-covered services.

Routine dental care is not covered, examples include treatment of infected teeth, dental implants or preparation of jaw bone for dental implants.


In-network:
$35 copayment for Medicare-covered dental services.

Out-of-network:
50% coinsurance for Medicare-covered dental services.
Routine dental care is not covered.
Prior authorization required.
Depression screening

We cover one screening for depression per year. The screening must be done in a primary care setting that can provide follow-up treatment and/or referrals.


In-network:
There is no coinsurance, copayment, or deductible for an annual depression screening visit.

Out-of-network:
There is 50% coinsurance for an annual depression screening visit.
Diabetes screening

We cover this screening (includes fasting glucose tests) if you have any of the following risk factors: high blood pressure (hypertension), history of abnormal cholesterol and triglyceride levels (dyslipidemia), obesity, or a history of high blood sugar (glucose). Tests may also be covered if you meet other requirements, like being overweight and having a family history of diabetes.

Based on the results of these tests, you may be eligible for up to two diabetes screenings every 12 months.


In-network:
There is no coinsurance, copayment, or deductible for the Medicare covered diabetes screening tests.

Out-of-network:
There is 50% coinsurance for the Medicare-covered diabetes screening tests.
Diabetes self-management training, diabetic services and supplies

For all people who have diabetes (insulin and non-insulin users). Covered services include:
  • Supplies to monitor your blood glucose: Blood glucose monitor, blood glucose test strips, lancet devices and lancets, and glucose-control solutions for checking the accuracy of test strips and monitors
  • For people with diabetes who have severe diabetic foot disease: One pair per calendar year of therapeutic custom-molded shoes (including inserts provided with such shoes) and two additional pairs of inserts, or one pair of depth shoes and three pairs of inserts (not including the non-customized removable inserts provided with such shoes). Coverage includes fitting.
  • Diabetes self-management training is covered under certain conditions


In-network:
0% coinsurance if you use a preferred brand of diabetic testing supplies (includes meters and test strips)

Preferred brands are: LifeScan (i.e. OneTouch®) and Roche (i.e. ACCU-CHEK® Aviva, ACCU-CHEK® Nano)

Non-preferred brands of diabetic supplies (includes meters and test strips) are not covered unless determined medically necessary by a physician

0% coinsurance for lancets, lancet devices and control solutions

20% coinsurance for diabetic shoes and inserts

$0 copayment for diabetic self-management training

20% coinsurance for insulin pump and supplies

Out-of-network:
There is 50% coinsurance for members eligible for diabetes self-management training, diabetic services and diabetic supplies.

Some services require prior authorization.
Durable medical equipment (DME) and related supplies

(For a definition of "durable medical equipment," see Chapter 12 of this booklet.)

Covered items include, but are not limited to: wheelchairs, crutches, powered mattress systems, diabetic supplies, hospital beds ordered by a provider for use in the home, IV infusion pumps, speech generating devices, oxygen equipment, nebulizers, and walkers.

We cover all medically necessary DME covered by Original Medicare. If our supplier in your area does not carry a particular brand or manufacturer, you may ask them if they can special order it for you. The most recent list of suppliers is available on our website at www.kelseycareadvantage.com.


In-network:
20% coinsurance

Out-of-network:
50% coinsurance
Prior authorization required.
Emergency care

Emergency care refers to services that are:
  • Furnished by a provider qualified to furnish emergency services, and
  • Needed to evaluate or stabilize an emergency medical condition
A medical emergency is when you, or any other prudent layperson with an average knowledge of health and medicine, believe that you have medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse. Cost sharing for necessary emergency services furnished out-of-network is the same as for such services furnished in-network.

Emergency care is covered worldwide. Your out-of-pocket costs may be higher if you are receiving care outside the United States.

The Point-of-Service benefit is not used for emergency room visits, emergency hospital admissions, urgent care or out of area dialysis and you will not pay extra for that care. It is covered under your network benefits. If you have an emergency admission to a network hospital and you want your inpatient care managed by a non-network physician, we will cover the physician cost under your POS benefits.


In-network:
$75 copayment for emergency room visit
Cost-sharing is waived if member is admitted to the hospital within three (3) days.
If you receive emergency care at an out-of-network hospital and need inpatient care after your emergency condition is stabilized, you must have your inpatient care at the out-of-network hospital authorized by the plan and your cost is the cost-sharing you would pay at a network hospital.
Out-of-pocket costs for receiving emergency care outside of the United States do not count toward your out-of-pocket maximum apart from the emergency copayment.
Health and wellness education programs

These are programs focused on health conditions such as high blood pressure, cholesterol, asthma, and special diets. The plan covers the following supplemental education/wellness programs:
– Health Education Materials
– Newsletters
– Nutritional Benefit
– Nursing Hotline

These services are focused on clinical health conditions such as high blood pressure, high cholesterol, asthma or COPD, diabetes and special diets in association with Medical Management programs.

Members have access to SilverSneakers®. SilverSneakers® can help you live a healthier, more active life. You have access to trained instructors who lead specially designed group exercise classes. At participating locations nationwide you can take classes plus use exercise equipment and other amenities.* In addition to SilverSneakers classes offered in fitness classrooms, SilverSneakers FLEX® offers options in settings outside traditional participating locations. SilverSneakers BOOM™ classes, MIND, MUSCLE and MOVE, offer more intense workouts inside participating locations.

*Classes and amenities vary by location.


In-network:
$0 copayment

*Not covered under your POS benefit
Hearing services

Diagnostic hearing and balance evaluations performed by your provider to determine if you need medical treatment are covered as outpatient care when furnished by a physician, audiologist, or other qualified provider.

Routine hearing exams are covered when administered at a Kelsey-Seybold Clinic or by your PCP.


In-network:
$35 copayment for Medicare-covered diagnostic hearing exams
* $35 copayment for one (1) routine hearing exam each year
*$35 copayment for one (1) hearing aid fitting exam every year

Out-of-network:
20% coinsurance for Medicare-covered diagnostic hearing exams
* $75 plan allowance for hearing aids every year
* Not covered under POS benefit
* Does not count toward out-of-pocket maximum
HIV screening

For people who ask for an HIV screening test or who are at increased risk for HIV infection, we cover:
  • One screening exam every 12 months
For women who are pregnant, we cover:
  • Up to three screening exams during a pregnancy


In-network:
There is no coinsurance, copayment, or deductible for members eligible for Medicare-covered preventive HIV screening.

Out-of-network:
There is 50% coinsurance for members eligible for Medicare-covered preventive HIV screening.
Home health agency care

Prior to receiving home health services, a doctor must certify that you need home health services and will order home health services to be provided by a home health agency. You must be homebound, which means leaving home is a major effort.
Covered services include, but are not limited to:
  • Part-time or intermittent skilled nursing and home health aide services (To be covered under the home health care benefit, your skilled nursing and home health aide services combined must total fewer than 8 hours per day and 35 hours per week)
  • Physical therapy, occupational therapy, and speech therapy
  • Medical and social services
  • Medical equipment and supplies


In-network:
$10 copayment for each Medicare-covered home care visit

Out-of-network:
50% coinsurance for each Medicare-covered home care visit
Prior authorization required.
Hospice care

You may receive care from any Medicare-certified hospice program. You are eligible for the hospice benefit when your doctor and the hospice medical director have given you a terminal prognosis certifying that you’re terminally ill and have 6 months or less to live if your illness runs its normal course. Your hospice doctor can be a network provider or an out-of-network provider.

Covered services include:
  • Drugs for symptom control and pain relief
  • Short-term respite care
  • Home care
For hospice services and for services that are covered by Medicare Part A or B and are related to your terminal prognosis: Original Medicare (rather than our plan) will pay for your hospice services and any Part A and Part B services related to your terminal prognosis. While you are in the hospice program, your hospice provider will bill Original Medicare for the services that Original Medicare pays for.

For services that are covered by Medicare Part A or B and are not related to your terminal prognosis: If you need non-emergency, non-urgently needed services that are covered under Medicare Part A or B and that are not related to your terminal prognosis, your cost for these services depends on whether you use a provider in our plan’s network:
  • If you obtain the covered services from a network provider, you only pay the plan cost-sharing amount for in-network services
  • If you obtain the covered services from an out-of-network provider, you pay the cost-sharing under Fee-for-Service Medicare (Original Medicare)
For services that are covered by KelseyCare Advantage Rx+Choice but are not covered by Medicare Part A or B: KelseyCare Advantage Rx+Choice will continue to cover plan-covered services that are not covered under Part A or B whether or not they are related to your terminal prognosis. You pay your plan cost-sharing amount for these services.

For drugs that may be covered by the plan’s Part D benefit: Drugs are never covered by both hospice and our plan at the same time. For more information, please see Chapter 5, Section 9.4 (What if you’re in Medicare-certified hospice).

Note: If you need non-hospice care (care that is not related to your terminal prognosis), you should contact us to arrange the services. Our plan covers hospice consultation services (one time only) for a terminally ill person who hasn’t elected the hospice benefit.


When you enroll in a Medicare-certified hospice program, your hospice services and your Part A and Part B services related to your terminal condition are paid for by Original Medicare, not KelseyCare Advantage Rx+Choice.


In-network:
$5 copayment amount may apply for a hospice consultation service prior to election of hospice

Out-of-network:
20% coinsurance may apply for hospice consultation service prior to the election of hospice
Immunizations

Covered Medicare Part B services include:
  • Pneumonia vaccine
  • Flu shots, once each flu season in the fall and winter, with additional flu shots if medically necessary
  • Hepatitis B vaccine if you are at high or intermediate risk of getting Hepatitis B
  • Other vaccines if you are at risk and they meet Medicare Part B coverage rules

We also cover some vaccines under our Part D prescription drug benefit.


In-network:
There is no coinsurance, copayment, or deductible for the pneumonia, influenza, and Hepatitis B vaccines.

Out-of-network:
There is 50% coinsurance for the pneumonia, influenza, Hepatitis B vaccines.
Inpatient hospital care

Includes inpatient acute, inpatient rehabilitation, long-term care hospitals and other types of inpatient hospital services. Inpatient hospital care starts the day you are formally admitted to the hospital with a doctor’s order. The day before you are discharged is your last inpatient day.

90 covered days per benefit period and 60 lifetime reserve days, which can only be used once each year. Covered services include but are not limited to:
  • Semi-private room (or a private room if medically necessary)
  • Meals including special diets
  • Regular nursing services
  • Costs of special care units (such as intensive care or coronary care units)
  • Drugs and medications
  • Lab tests
  • X-rays and other radiology services
  • Necessary surgical and medical supplies
  • Use of appliances, such as wheelchairs
  • Operating and recovery room costs
  • Physical, occupational, and speech language therapy
  • Inpatient substance abuse services
  • Under certain conditions, the following types of transplants are covered: corneal, kidney, kidney-pancreatic, heart, liver, lung, heart/lung, bone marrow, stem cell, and intestinal/multivisceral. If you need a transplant, we will arrange to have your case reviewed by a Medicare-approved transplant center that will decide whether you are a candidate for a transplant. Transplant providers may be local or outside of the service area. If our in-network transplant services are outside the community pattern of care, you may choose to go locally as long as the local transplant providers are willing to accept the Original Medicare rate. If KelseyCare Advantage Rx+Choice provides transplant services at a location outside the pattern of care for transplants in your community and you choose to obtain transplants at this distant location, we will arrange or pay for appropriate lodging and transportation costs for you and a companion
  • Blood - including storage and administration. Coverage of whole blood and packed red cells begins with the first pint of blood that you need
  • Physician services
Note: To be an inpatient, your provider must write an order to admit you formally as an inpatient of the hospital. Even if you stay in the hospital overnight, you might still be considered an "outpatient." If you are not sure if you are an inpatient or an outpatient, you should ask the hospital staff.

You can also find more information in a Medicare fact sheet called "Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask!" This fact sheet is available on the Web at https://www.medicare.gov/Pubs/pdf/11435.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week.


In-network:
$500 copayment per each in-network acute hospital admission
90 covered days per benefit period and 60 lifetime reserve days, which can only be used once each year.
Inpatient hospital care includes acute inpatient care, long-term acute care and inpatient rehabilitation.
Existing members in the plan may be in the middle of a Medicare benefit period when the plan year changes.
If you get authorized inpatient care at an out-of-network hospital after your emergency condition is stabilized your cost is the cost-sharing you would pay at a network hospital.
Your out-of-pocket costs may be higher if you are receiving care outside the United States.

Out-of-network:
$1,000 copayment per benefit period for inpatient hospital admission for days 1-60.
Days 61-90 has $250 per day copayment.
Days 91-150 has a $500 per day copayment.
If you see a network provider, without prior authorization, you are using your POS benefit. Any care ordered by the provider, including hospital admission, will be covered under your POS benefits, even if the care is provided at a network facility. For example, if the POS provider admits you for surgery at a network facility you will pay the POS coinsurance or copayments for the facility and physician services.
Prior authorization required for elective admissions.
Out-of-pocket costs for receiving care outside of the United States do not count toward your out-of-pocket maximum apart from your copayment.
Inpatient mental health care

Covered services include mental health care services that require a hospital stay. There is a 190-day lifetime limit for inpatient services in a psychiatric hospital. The 190-day limit does not apply to inpatient mental health services provided in a psychiatric unit of a general hospital.


In-network:
$500 copayment per each in-network acute inpatient mental health admission

Out-of-network:
$1,000 copayment per benefit period for inpatient hospital admission for days 1-60.
Days 61-90 has $250 per day copayment.
Days 91-150 has a $500 per day copayment.
If you see a non-network Provider using your POS benefit, any care ordered by the provider, including hospital admission, will be covered under your POS benefits, even if the care is provided at a network facility.
Prior authorization required.
Inpatient stay: Covered services received in a hospital or SNF during a non-covered inpatient stay
If you have exhausted your inpatient benefits or if the inpatient stay is not reasonable and necessary, we will not cover your inpatient stay. However, in some cases, we will cover certain services you receive while you are in the hospital or the skilled nursing facility (SNF). Covered services include, but are not limited to:
  • Physician services
  • Diagnostic tests (like lab tests)
  • X-ray, radium, and isotope therapy including technician materials and services
  • Surgical dressings
  • Splints, casts and other devices used to reduce fractures and dislocations
  • Prosthetics and orthotics devices (other than dental) that replace all or part of an internal body organ (including contiguous tissue), or all or part of the function of a permanently inoperative or malfunctioning internal body organ, including replacement or repairs of such devices
  • Leg, arm, back, and neck braces; trusses, and artificial legs, arms, and eyes including adjustments, repairs, and replacements required because of breakage, wear, loss, or a change in the patient’s physical condition
  • Physical therapy, speech therapy, and occupational therapy


In-network:
You pay 100% of facility charges.
Plan copayments or coinsurance apply for diagnostic testing, therapy, and Part B drugs.
20% coinsurance for Medicare-covered durable medical equipment.
20% coinsurance for Medicare-covered orthotics and prosthetics.

Out-of-network:
You pay 100% of facility charges.
20% coinsurance applies for diagnostic testing and Part B drugs.
50% coinsurance for all Medicare-covered outpatient rehabilitation services.
50% coinsurance for Medicare-covered durable medical equipment, orthotics and/or prosthetics.
Prior authorization required.
Facility charges do not count toward your out-of-pocket maximum after your inpatient benefits are exhausted.
See other amounts listed in this Medical Benefits Chart.
Medical nutrition therapy

This benefit is for people with diabetes, renal (kidney) disease (but not on dialysis), or after a kidney transplant when referred by your doctor.

We cover 3 hours of one-on-one counseling services during your first year that you receive medical nutrition therapy services under Medicare (this includes our plan, any other Medicare Advantage plan, or Original Medicare), and 2 hours each year after that. If your condition, treatment, or diagnosis changes, you may be able to receive more hours of treatment with a physician’s referral. A physician must prescribe these services and renew their referral yearly if your treatment is needed into the next calendar year.


In-network:
There is no coinsurance, copayment, or deductible for members eligible for Medicare-covered medical nutrition therapy services.

Out-of-network:
There is 50% coinsurance for members eligible for Medicare-covered medical nutrition therapy services.
Medicare Diabetes Prevention Program (MDPP)

MDPP services will be covered for eligible Medicare beneficiaries under all Medicare health plans.

MDPP is a structured health behavior change intervention that provides practical training in long-term dietary change, increased physical activity, and problem-solving strategies for overcoming challenges to sustaining weight loss and a healthy lifestyle.
There is no coinsurance, copayment, or deductible for members eligible for the MDPP benefit.
Medicare Part B prescription drugs

These drugs are covered under Part B of Original Medicare. Members of our plan receive coverage for these drugs through our plan. Covered drugs include:
  • Drugs that usually aren’t self-administered by the patient and are injected or infused while you are getting physician, hospital outpatient, or ambulatory surgical center services
  • Drugs you take using durable medical equipment (such as nebulizers) that were authorized by the plan
  • Clotting factors you give yourself by injection if you have hemophilia
  • Immunosuppressive Drugs, if you were enrolled in Medicare Part A at the time of the organ transplant
  • Injectable osteoporosis drugs, if you are homebound, have a bone fracture that a doctor certifies was related to post-menopausal osteoporosis, and cannot self-administer the drug
  • Antigens
  • Certain oral anti-cancer drugs and anti-nausea drugs
  • Certain drugs for home dialysis, including heparin, the antidote for heparin when medically necessary, topical anesthetics, and erythropoiesis-stimulating agents (such as Epogen®, Procrit®, Epoetin Alfa, Aranesp®, or Darbepoetin Alfa)
  • Intravenous Immune Globulin for the home treatment of primary immune deficiency diseases
Chapter 5 explains the Part D prescription drug benefit, including rules you must follow to have prescriptions covered. What you pay for your Part D prescription drugs through our plan is explained in Chapter 6.


In-network:
20% coinsurance for Part B covered drugs; including Part B covered Chemotherapy

Out-of-network:
20% coinsurance for Part B covered drugs; including Part B covered chemotherapy
Some services require prior authorization
Obesity screening and therapy to promote sustained weight loss

If you have a body mass index of 30 or more, we cover intensive counseling to help you lose weight. This counseling is covered if you get it in a primary care setting, where it can be coordinated with your comprehensive prevention plan. Talk to your primary care doctor or practitioner to find out more.


In-network:
There is no coinsurance, copayment, or deductible for preventive obesity screening and therapy.

Out-of-network:
There is 50% coinsurance for preventive obesity screening and therapy.
Outpatient diagnostic tests and therapeutic services and supplies

Covered services include, but are not limited to:
  • X-rays
  • Radiation (radium and isotope) therapy including technician materials and supplies.
  • Surgical supplies, such as dressings
  • Splints, casts, and other devices used to reduce fractures and dislocations
  • Laboratory tests
  • Blood - including storage and administration. Coverage of whole blood and packed red cells begins with the first pint of blood that you need
  • Other outpatient diagnostic tests


In-network:
$0 copayment for X-rays
$0 copayment for laboratory tests
$0 copayment for surgical supplies such as dressing, splints and casts provided in the physician office
Other outpatient copayments may apply if provided by a company for a physician.
$0 copayment for diagnostic sleep study at a non-hospital facility
$25 copayment for cardiac stress test
$150 copayment for CAT scan for each day of service
$150 copayment for MRI or MRA for each day of service
$150 copayment for Medicare-covered PET scan for each day of service
$50 copayment for radiation therapy treatment, including intensity modulated radiation therapy (IMRT) for each day of service
Diagnostic copayments may also apply for testing done prior, during or after radiation therapy.

Out-of-network:
20% for all outpatient diagnostic tests and therapeutic services and supplies
Some services require prior authorization.
Outpatient hospital services

We cover medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injury.

Covered services include, but are not limited to:
  • Services in an emergency department or outpatient clinic, such as observation services or outpatient surgery
  • Laboratory and diagnostic tests billed by the hospital
  • Mental health care, including care in a partial-hospi-talization program, if a doctor certifies that inpatient treatment would be required without it
  • X-rays and other radiology services billed by the hospital
  • Medical supplies such as splints and casts
  • Certain drugs and biologicals that you can’t give yourself
Note: Unless the provider has written an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing amounts for outpatient hospital services. Even if you stay in the hospital overnight, you might still be considered an "outpatient." If you are not sure if you are an outpatient, you should ask the hospital staff.

You can also find more information in a Medicare fact sheet called "Are You a Hospital Inpatient or Outpatient? If You Have Medicare – Ask!" This fact sheet is available on the Web at https://www.medicare.gov/Pubs/pdf/11435.pdf or by calling 1-800-MEDICARE (1-800-633-4227). TTY users call 1-877-486-2048. You can call these numbers for free, 24 hours a day, 7 days a week.


In-network:
$225 copayment for each Medicare-covered ambulatory surgical center visit
$300 copayment for each Medicare-covered outpatient hospital facility visit
$300 copayment for other outpatient hospital services, for example: chemotherapy, diagnostic sleep studies or observation stay

Out-of-network:
20% coinsurance for all Medicare-covered outpatient hospital services
Some services require prior authorization.
Outpatient mental health care

Covered services include:

Mental health services provided by a state-licensed psychiatrist or doctor, clinical psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or other Medicare-qualified mental health care professional as allowed under applicable state laws.


In-network:
$35 copayment for each Medicare-covered individual therapy visit
$20 copayment for each Medicare-covered group visit

Out-of-network:
50% coinsurance for all Medicare-covered outpatient mental health care services
Some services require prior authorization.
Outpatient rehabilitation services

Covered services include: physical therapy, occupational therapy, and speech language therapy.

Outpatient rehabilitation services are provided in various outpatient settings, such as hospital outpatient departments, independent therapist offices, and Comprehensive Outpatient Rehabilitation Facilities (CORFs).


In-network:
$35 copayment for physical, occupational or speech therapy for each visit
$35 copayment for comprehensive outpatient rehabilitation facility (CORF) services for each visit
$35 copayment for other approved therapy visits, including wound care and lymphedema provided by therapists

Out-of-network:
50% coinsurance for all Medicare-covered outpatient rehabilitation services received out-of-network
Some services require prior authorization.
Outpatient substance abuse services

Covered services include:

Substance abuse services provided by a state-licensed psychiatrist or doctor, clinical psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or other Medicare-qualified mental health care professional as allowed under applicable state laws.


In-network:
$35 copayment for each Medicare-covered individual therapy visit
$20 copayment for each Medicare-covered group visit

Out-of-network:
50% coinsurance for Medicare-covered outpatient substance abuse services
Some services require prior authorization.
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers

Note: If you are having surgery in a hospital facility, you should check with your provider about whether you will be an inpatient or outpatient. Unless the provider writes an order to admit you as an inpatient to the hospital, you are an outpatient and pay the cost-sharing amounts for outpatient surgery. Even if you stay in the hospital overnight, you might still be considered an "outpatient."


In-network:
$225 copayment for each Medicare-covered ambulatory surgery center visit
$300 copayment for each Medicare-covered outpatient hospital surgery visit
$300 copayment for other outpatient hospital services, for example: chemotherapy, diagnostic sleep studies or observation stay
You will not pay a copayment for a colonoscopy, even if certain procedures, such as a biopsy or a polyp removal, are done during your screening colonoscopy.
You will pay the outpatient surgery copayment if the colonoscopy is combined with another non-colonoscopy outpatient surgery procedure. The outpatient hospital surgery copayment of $300 or ambulatory surgery copayment of $225 will apply.

Out-of-network:
20% coinsurance for all Medicare-covered outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers
Prior authorization required.
Partial hospitalization services

"Partial hospitalization" is a structured program of active psychiatric treatment provided as a hospital outpatient service or by a community mental health center, that is more intense than the care received in your doctor’s or therapist’s office and is an alternative to inpatient hospitalization.


In-network:
$35 copayment for each day

Out-of-network:
50% coinsurance for each day
Prior authorization required.
Physician/Practitioner services, including doctor’s office visits

Covered services include:
  • Medically-necessary medical care or surgery services furnished in a physician’s office, certified ambulatory surgical center, hospital outpatient department, or any other location
  • Consultation, diagnosis, and treatment by a specialist
  • Basic hearing and balance exams performed by your PCP, if your doctor orders it to see if you need medical treatment
  • Second opinion by another network provider prior to surgery
  • Non-routine dental care (covered services are limited to surgery of the jaw or related structures, setting fractures of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician)


In-network:
$5 copayment for each primary care physician visit
$35 copayment for each specialist visit
$0 copayment for allergy testing and allergy serum
See Part B drugs for coinsurance amounts if a Part B drug is given during the visit.

Out-of-network:
50% coinsurance for each Medicare-covered primary care physician office visits
20% coinsurance for each Medicare-covered specialist visit
20% coinsurance for allergy testing and allergy serum
Some services require prior authorization
Podiatry services

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


In-network:
$35 copayment per visit

Out-of-network:
20% coinsurance per visit
Some services require prior authorization.
See Orthotic and Prosthetic coinsurance for any Medicare-covered orthotics provided during the visit.
Point-of-Service Benefit

You can use this benefit to get care from out-of-network providers and also to get care from certain in-network providers without getting an authorization. You will pay a higher cost for care.
The Point-of-Service benefit is not used for emergency room visits, emergency hospital admissions, urgent care or dialysis provided while you are temporarily outside of the service area, which are paid at network cost share. If you have an emergency managed by an out-of-network physician, we will cover the physician cost under your POS benefits. You can use any willing Medicare provider to obtain covered POS services within the United States. Some providers may not be willing to see you and/or bill our plan for your out-of-network care.
Point-of-Service benefits are available for Medicare-covered services. Elective or direct admission inpatient hospital services covered up to 90 days per benefit period. You also have coverage for days 90-150 days, which you can use once in a lifetime.


See benefit chart for your cost share when using your POS/Out-of-Network benefit.
If you see a provider outside of our network for non-emergency care without prior authorization, you are using your POS benefit. Any care ordered by the provider, including
hospital admission, will be covered under your POS benefits, even if the care is provided at a network facility. For example, if the POS provider admits you for surgery at a
network facility, you will pay the POS coinsurance or copayments for the facility and physician services. Prior authorization is required for facility care.
There is a $10,000 out-of-pocket maximum for out-of-network services.
Services not covered under POS benefits are noted in the benefit chart.
Prostate cancer screening exams

For men age 50 and older, covered services include the following - once every 12 months:
  • Digital rectal exam
  • Prostate Specific Antigen (PSA) test


In-network:
There is no coinsurance, copayment, or deductible for an annual PSA test.

Out-of-network:
There is 50% coinsurance for an annual PSA test.
Prosthetic devices and related supplies

Devices (other than dental) that replace all or part of a body part or function. These include, but are not limited to: colostomy bags and supplies directly related to colostomy care, pacemakers, braces, prosthetic shoes, artificial limbs, and breast prostheses (including a surgical brassiere after a mastectomy). Includes certain supplies related to prosthetic devices, and repair and/or replacement of prosthetic devices. Also includes some coverage following cataract removal or cataract surgery – see "Vision Care" later in this section for more detail.


In-network:
20% coinsurance

Out-of-network:
50% coinsurance
Prior authorization required.
Pulmonary rehabilitation services

Comprehensive programs of pulmonary rehabilitation are covered for members who have moderate to very severe chronic obstructive pulmonary disease (COPD) and a referral for pulmonary rehabilitation from the doctor treating the chronic respiratory disease.


In-network:
$35 copayment for each day of pulmonary rehabilitation up to Medicare visit limits

Out-of-network:
50% coinsurance for each day of pulmonary rehabilitation up to Medicare visit limits
Prior authorization required.
Screening and counseling to reduce alcohol misuse

We cover one (1) alcohol misuse screening for adults with Medicare (including pregnant women) who misuse alcohol, but aren’t alcohol dependent.

If you screen positive for alcohol misuse, you can get up to four brief face-to-face counseling sessions per year (if you’re competent and alert during counseling) provided by a qualified primary care doctor or practitioner in a primary care setting.


In-network:
There is no coinsurance, copayment, or deductible for the Medicare-covered screening and counseling to reduce alcohol misuse preventive benefit.

Out-of-network:
There is 50% coinsurance for the Medicare-covered screening and counseling to reduce alcohol misuse preventive benefit.
Screening for lung cancer with low dose computed tomography (LDCT)

For qualified individuals, a LDCT is covered every 12 months.

Eligible members are: people aged 55 – 77 years who have no signs or symptoms of lung cancer, but who have a history of tobacco smoking of at least 30 pack-years and who currently smoke or have quit smoking within the last 15 years, who receive a written order for LDCT during a lung cancer screening counseling and shared decision making visit that meets the Medicare criteria for such visits and be furnished by a physician or qualified non-physician practitioner.

For LDCT lung cancer screenings after the initial LDCT screening: the members must receive a written order for LDCT lung cancer screening, which may be furnished during any appropriate visit with a physician or qualified non-physician practitioner. If a physician or qualified non-physician practitioner elects to provide a lung cancer screening counseling and shared decision making visit for subsequent lung cancer screenings with LDCT, the visit must meet the Medicare criteria for such visits.


In-network:
There is no coinsurance, copayment, or deductible for the Medicare covered counseling and shared decision making visit or for the LDCT.

Out-of-network:
There is 50% coinsurance for the Medicare covered counseling and shared decision making visit or for the LDCT.
Screening for sexually transmitted infections (STIs) and counseling to prevent STIs

We cover sexually transmitted infection (STI) screenings for chlamydia, gonorrhea, syphilis, and Hepatitis B. These screenings are covered for pregnant women and for certain people who are at increased risk for an STI when the tests are ordered by a primary care provider. We cover these tests once every 12 months or at certain times during pregnancy.

We also cover up to 2 individual 20 to 30 minute, face-to-face high-intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. We will only cover these counseling sessions as a preventive service if they are provided by a primary care provider and take place in a primary care setting, such as a doctor’s office.


In-network:
There is no coinsurance, copayment, or deductible for the Medicare-covered screening for STIs and counseling for STIs preventive benefit.

Out-of-network:
There is 50% coinsurance for the Medicare-covered screening for STIs and counseling for STIs preventive benefit.
Services to treat kidney disease

Covered services include:
  • Kidney disease education services to teach kidney care and help members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime
  • Outpatient dialysis treatments (including dialysis treatments when temporarily out of the service area, as explained in Chapter 3)
  • Inpatient dialysis treatments (if you are admitted as an inpatient to a hospital for special care)
  • Self-dialysis training (includes training for you and anyone helping you with your home dialysis treatments)
  • Home dialysis equipment and supplies
  • Certain home support services (such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies, and check your dialysis equipment and water supply)
Certain drugs for dialysis are covered under your Medicare Part B drug benefit. For information about coverage for Part B Drugs, please go to the section, "Medicare Part B prescription drugs."


In-network:
$25 copayment for each renal dialysis treatment
$0 copayment for kidney disease education services

Out-of-network:50% coinsurance for each out-of-network renal dialysis treatment in service area. Renal dialysis treatment received at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area is covered at the in-network benefit level.
50% coinsurance for kidney disease education services received out-of-network

Some services require prior authorization.
Skilled nursing facility (SNF) care

(For a definition of "skilled nursing facility care," see Chapter 12 of this booklet. Skilled nursing facilities are sometimes called "SNFs.")

Covered services include but are not limited to:
  • Semiprivate room (or a private room if medically necessary)
  • Meals, including special diets
  • Skilled nursing services
  • Physical therapy, occupational therapy, and speech therapy
  • Drugs administered to you as part of your plan of care (This includes substances that are naturally present in the body, such as blood clotting factors.)
  • Blood - including storage and administration. Coverage of whole blood and packed red cells begins with the first pint of blood that you need
  • Medical and surgical supplies ordinarily provided by SNFs
  • Laboratory tests ordinarily provided by SNFs
  • X-rays and other radiology services ordinarily provided by SNFs
  • Use of appliances such as wheelchairs ordinarily provided by SNFs
  • Physician/Practitioner services
Generally, you will get your SNF care from network facilities. However, under certain conditions listed below, you may be able to pay in-network cost-sharing for a facility that isn’t a network provider, if the facility accepts our plan’s amounts for payment.
  • A nursing home or continuing care retirement community where you were living right before you went to the hospital (as long as it provides skilled nursing facility care)
  • A SNF where your spouse is living at the time you leave the hospital


In-network:
$0 copayment per day for days 1-20
$125 copayment per day for days 21-100
No prior hospital stay is required.

Out-of-network:
50% coinsurance for Medicare-covered Skilled Nursing Facility care received at an out-of-network facility
The plan covers 100 days per each Medicare benefit period for Medicare-covered skilled services.
Prior authorization required.
Smoking and tobacco use cessation (counseling to stop smoking or tobacco use)

If you use tobacco, but do not have signs or symptoms of tobacco-related disease: We cover two counseling quit attempts within a 12-month period as a preventive service with no cost to you. Each counseling attempt includes up to four face-to-face visits.

If you use tobacco and have been diagnosed with a tobacco-related disease or are taking medicine that may be affected by tobacco: We cover cessation counseling services. We cover two counseling quit attempts within a 12-month period, however, you will pay the applicable cost-sharing. Each counseling attempt includes up to four face-to-face visits.


In-network:
There is no coinsurance, copayment, or deductible for the Medicare-covered smoking and tobacco use cessation preventive benefits.

Out-of-network:
There is 50% coinsurance for the Medicare-covered smoking and tobacco use cessation preventive benefits.
Supervised Exercise Therapy (SET)

SET is covered for members who have symptomatic peripheral artery disease (PAD) and a referral for PAD from the physician responsible for PAD treatment.

Up to 36 sessions over a 12-week period are covered if the SET program requirements are met.

The SET program must:
  • Consist of sessions lasting 30-60 minutes, comprising a therapeutic exercise-training program for PAD in patients with claudication
  • Be conducted in a hospital outpatient setting or a physician’s office
  • Be delivered by qualified auxiliary personnel necessary to ensure benefits exceed harms, and who are trained in exercise therapy for PAD
  • Be under the direct supervision of a physician, physician assistant, or nurse practitioner/clinical nurse specialist who must be trained in both basic and advanced life support techniques
SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider.


In-network:
$35 copayment for each supervised exercise therapy session/visit

Out-of-network:
50% coinsurance for all Medicare-covered supervised exercise therapy services received out-of-network
Some services require prior authorization.
Telehealth benefit

Telehealth refers to services that are:
  • Communication/Evaluation of a patient in a setting other than the traditional office space that consist of a telephone, email, and video
  • E-visit -Asynchronous consultation/evaluation of a primary care provider that is requested by the patient using electronic messaging and questionnaires
  • E-consult -Asynchronous consultation/evaluation of a specialist that can be requested by either the primary care provider or self-directed by the patient themselves using electronic messaging and questionnaires
  • Video Visit -Synchronous visit with a provider (primary care or specialty) about a specific condition using a face to face video interface
E-Visits and Video Visits are a covered benefit for Kelsey-Seybold primary care and specialty physicians and for contracted mental health providers.
PCP E-Visit: $0 copay
Specialty E-Visit: $25 copay
PCP Video Visit: $0 copay
Specialty Video Visit: $35 copay
Transportation

Non-emergency, routine transportation coverage is provided for transportation to medical appointments and medical facilities within the service area. Non-emergency, routine transportation is limited to medical appointments and medical facilities within the service area.


*$0 copayment for up to 20 one-way trips to plan approved locations every year

*Does not count toward out-of-pocket-maximum
Urgently needed services

Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury, or condition that requires immediate medical care. Urgently needed services may be furnished by network providers or by out-of-network providers when network providers are temporarily unavailable or inaccessible. Cost sharing for necessary urgently needed services furnished out-of-network is the same as for such services furnished in-network.
Urgent care is only covered within the United States.


In-network:
$50 copayment
Vision care

Covered services include:
  • Outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration. Original Medicare doesn’t cover routine eye exams (eye refractions) for eyeglasses/contacts
  • For people who are at high risk of glaucoma, we will cover one glaucoma screening each year. People at high risk of glaucoma include: people with a family history of glaucoma, people with diabetes, African-Americans who are age 50 and older and Hispanic Americans who are 65 or older
  • For people with diabetes, screening for diabetic retinopathy is covered once per year
  • One (1) pair of eyeglasses or contact lenses after each cataract surgery that includes insertion of an intraocular lens. (If you have two separate cataract operations, you cannot reserve the benefit after the first surgery and purchase two eyeglasses after the second surgery.) Corrective lenses/frames (and replacements) needed after a cataract removal without lens implant
  • Routine vision exam one (1) time per year


In-network:
$35 copayment for in-network exams to diagnose and treat diseases and conditions of the eye.
See Part B drug coinsurance for any medication given during the office visit.
$0 copayment for glasses, lenses or contact lenses after cataract surgery. Covered at 100% up to the Medicare-allowable amount.
* $0 copayment for one (1) routine eye exam every year
* $75 plan coverage limit for eyewear, glasses and/or contact lenses every year unrelated to post-cataract surgery. Allowance can only be used on one date of service.

Out-of-network:
20% coinsurance for exams to diagnose and treat diseases and conditions of the eye. 50% coinsurance for glasses, lenses or contact lenses after cataract surgery. Covered up to the Medicare-allowable amount.
* Does not count toward out-of-pocket maximum
* Routine eye care not covered under POS benefit
"Welcome to Medicare" Preventive Visit

The plan covers the one-time "Welcome to Medicare" preventive visit. The visit includes a review of your health, as well as education and counseling about the preventive services you need (including certain screenings and shots), and referrals for other care if needed.

Important: We cover the "Welcome to Medicare" preventive visit only within the first 12 months you have Medicare Part B. When you make your appointment, let your doctor’s office know you would like to schedule your "Welcome to Medicare" preventive visit.


In-network:
There is no coinsurance, copayment, or deductible for the "Welcome to Medicare" preventive visit. when performed by a network physician.

Out-of-network:
50% coinsurance for a "Welcome to Medicare" preventive visit when performed by a physician outside of our network.

Section 3.1 - Services we do not cover (exclusions)

This section tells you what services are "excluded" from Medicare coverage and therefore, are not covered by this plan. If a service is "excluded," it means that this plan doesn’t cover the service.

The chart below lists services and items that either are not covered under any condition or are covered only under specific conditions.

If you get services that are excluded (not covered), you must pay for them yourself. We won’t pay for the excluded medical services listed in the chart below except under the specific conditions listed. The only exception: we will pay if a service in the chart below is found upon appeal to be a medical service that we should have paid for or covered because of your specific situation. (For information about appealing a decision we have made to not cover a medical service, go to Chapter 9, Section 5.3 in this booklet.)

All exclusions or limitations on services are described in the Benefits Chart or in the chart below.

Even if you receive the excluded services at an emergency facility, the excluded services are still not covered and our plan will not pay for them.


Services not covered by Medicare Not covered under any condition Covered only under specific conditions
Services considered not reasonable and necessary, according to the standards of Original Medicare
Experimental medical and surgical procedures, equipment and medications.
Experimental procedures and items are those items and procedures determined by our plan and Original Medicare to not be generally accepted by the medical community.

May be covered by Original Medicare under a Medicare-approved clinical research study or by our plan.
(See Chapter 3, Section 5 for more information on clinical research studies.)
Private room in a hospital.
Covered only when medically necessary.
Personal items in your room at a hospital or a skilled nursing facility, such as a telephone or a television.
Full-time nursing care in your home.
*Custodial care is care provided in a nursing home, hospice, or other facility setting when you do not require skilled medical care or skilled nursing care.
Homemaker services include basic household assistance, including light housekeeping or light meal preparation.
Fees charged for care by your immediate relatives or members of your household.
Cosmetic surgery or procedures
  • Covered in cases of an accidental injury or for improvement of the functioning of a malformed body member.
  • Covered for all stages of reconstruction for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance.
Routine dental care, such as cleanings, fillings or dentures.
Non-routine dental care
Dental care required to treat illness or injury may be covered as inpatient or outpatient care.
Routine chiropractic care
Manual manipulation of the spine to correct a subluxation is covered.
Routine foot care
Some limited coverage provided according to Medicare guidelines, (e.g., if you have diabetes).
Home-delivered meals
Orthopedic shoes
If shoes are part of a leg brace and are included in the cost of the brace, or the shoes are for a person with diabetic foot disease.
Supportive devices for the feet
Orthopedic or therapeutic shoes for people with diabetic foot disease.
Eyeglasses, radial keratotomy, LASIK surgery and other low vision aids.
Eye exam and one pair of eyeglasses (or contact lenses) are covered for people after cataract surgery.
Reversal of sterilization procedures and or non-prescription contraceptive supplies.
Acupuncture
Naturopath services (uses natural or alternative treatments).

*Custodial care is personal care that does not require the continuing attention of trained medical or paramedical personnel, such as care that helps you with activities of daily living, such as bathing or dressing.