UPMC for Life Dual (HMO SNP) Plan Benefit

2016
UPMC for Life Dual (HMO SNP)
Plan Benefit Guide
H4279_16_1026 Accepted
Have questions? Ready to enroll?
• Call us toll-free at 1-866-405-8762 seven days a week from 8 a.m. to
8 p.m.* TTY users should call 1-866-407-8762.
• Meet with an authorized UPMC for Life Dual representative at the time
and location of your choosing. For times and locations, call the phone
number above.
• Stop by one of our conveniently located UPMC Health Plan Connect
Service and Sales Centers. We have locations at Century III Mall, The
Mall at Robinson, Millcreek Mall, Monroeville Mall, Ross Park Mall,
and South Hills Village.
• Visit us online at www.upmchealthplan.com/snp.
Here’s how to get started
Thank you for your interest in UPMC for Life Dual. It’s important to
understand what options are available to you as a beneficiary of Medicare
and your state’s Medical Assistance (Medicaid) program.
1. Review the plan benefits included in this brochure.
2. Learn about the extra benefits and services you can get when you join
UPMC for Life Dual.
3. Get information on how Medicare works and when you can enroll.
If you have questions or need help, we have knowledgeable, licensed
representatives who can give you answers. Call us toll-free at
1-866-405-8762 seven days a week from 8 a.m. to 8 p.m.* TTY users
should call 1-866-407-8762.
Table of Contents
Plan Information
UPMC for Life Dual Plan overview.......................................................... 5
Extra Benefits & Services
Routine vision coverage..............................................................................6
Preventive dental coverage ........................................................................6
Transportation service................................................................................7
Emergency travel coverage ........................................................................7
Fitness benefits ...........................................................................................8
Preventive services .....................................................................................8
Health coaching .........................................................................................8
Online member tools .................................................................................9
Health care experts ....................................................................................9
Enrollment
How to enroll ...........................................................................................10
What to expect when enrolling ...............................................................11
Understanding Medicare
Part A hospital coverage ......................................................................... 12
Part B medical coverage...........................................................................13
Part C Medicare Advantage plans ...........................................................14
Part D prescription drug coverage ..........................................................15
Extra help with prescription drug costs ..................................................15
1
What makes UPMC for Life Dual
the right choice for you?
Top-ranked care from UPMC
Make sure you have access to the providers you know and trust – now and
in the future. UPMC for Life Dual members can feel secure in knowing
they have in-network access to the doctors and hospitals of UPMC. For
16 years, UPMC has been one of the top-ranked hospitals in the nation
(U.S. News & World Report, America’s Best Hospitals 7-21-15).
We work closely with the doctors and hospitals in our network. This
means you get the care you need from a team of highly trained and
devoted professionals. Our commitment is to provide you with the best
care possible.
Award-winning customer service
2015 WINNER
Small-to-Medium Contact Center
Each UPMC for Life Dual member has a team of Health Care
Concierges who are dedicated to answering your questions and helping
you understand your benefits. This means you speak with a local
representative who is knowledgeable about Medicare and how your
health plan works. Our goal is to get you the information you need in
just one call. We can help you find a participating provider, check to
see if a prescription drug is covered, schedule important preventive care
appointments, and give you details about member programs.
For the second time in four years, the UPMC Health Plan Call Center
was named the Global Call Center of the Year in the large call center
category by the International Customer Management Institute (ICMI).
For more information, visit www.icmi.com.**
2
Health care that suits your needs
You have a specific set of health care needs. With this in mind,
UPMC for Life Dual has partnered with doctors and hospitals in
your community to provide you with access to quality health care.
Our focus is on making it easy for you to get the care you need
where and when you need it. You have the opportunity to choose
the doctors, pharmacies, and services that best suit your health
care needs.
Doctors and hospitals
As a UPMC for Life Dual member, you can receive your medical
care at UPMC facilities, plus additional community hospitals.
Our Medicare Advantage network includes over 8,700 doctors
and 87 hospitals in Pennsylvania. You can see providers in our
network without a referral.
Prescriptions and pharmacies
Our covered Part D prescription drug list includes brand-name
and generic medications. It is developed by UPMC physicians
and pharmacists in the community and includes thousands
of brand-name and generic drugs. Updates are made to our
formulary on a monthly basis. If you do not see your drug listed,
please call us for more information.
You can fill prescriptions at your local pharmacy or
through our mail-order program, making it easier to take
your medications on time. You can take advantage of 60,000
pharmacies nationwide. You can get your prescriptions filled at
any of these national and regional pharmacy chains: CVS,
Giant Eagle, Kmart, Rite Aid, Sam’s Club, Target, Walgreens,
and Walmart.
3
A Medicare Advantage plan that
provides more benefits than Original
Medicare alone
•Routine vision coverage (see page 6)
•Preventive dental coverage for cleanings and exams (see page 6)
•Emergency travel coverage 24/7 while traveling worldwide (see
page 7)
•Fitness benefits like membership to a local participating fitness facility
at no additional cost (see page 8)
•Preventive services and health coaching (see page 8)
•Online member tools and health care expertise (see page 9)
Original Medicare
Part A and B
UPMC for Life Dual
Outpatient medical services
✓
✓
Inpatient medical services
✓
✓
Benefit
Prescription drug coverage
✓
Routine dental, plus a $1,500 yearly allowance for bridges,
crowns, dentures, and tooth extractions
✓
Routine vision benefits
✓
A complimentary gym membership
✓
Transportation to plan-approved locations
✓
A 24/7 nurse advice line
✓
Customized care plans for every member
✓
A secure member website that provides you with access to
your personal health information
✓
Email a trusted UPMC provider right from your computer
✓
4
UPMC for Life Dual Plan overview
Plan Information
We’ve chosen some of the most important plan features to help
you compare your choices. Not all benefits are listed. To see a
complete list of benefits, see the Summary of Benefits.
Benefit
UPMC for Life Dual
Plan Premium (in addition to your Medicare Part B
premium)
$0 per month
Annual Deductible
No deductible
Primary Care Doctor
$0 per visit
Specialist Doctor
$0 per visit
Preventive Services, Immunizations,
and Screenings
$0 per service
Inpatient Hospital and Inpatient
Mental Health Care
$0 per stay
Outpatient Surgery
$0 per visit
Emergency Care
$0 per visit
Urgent Care
$0 per visit
Lab Services
$0 for lab services
X-rays
$0 per x-ray
Advanced Imaging (includes CT scans, MRIs,
MRAs, and PET scans)
$0 per service
Outpatient Rehabilitation
$0 per visit
Durable Medical Equipment
You pay nothing
Diabetes Supplies
You pay nothing
Annual Out-of-Pocket Maximum (the most you
will have to pay during the coverage year for
covered services)
$3,400 for Medicare-covered services, including
copays and coinsurance
In-Network Retail Pharmacy
(30-day supply)
$0 or $1.20 or $2.95 generic (tier 1);
$0 or $3.60 or $7.40 preferred brand (tier 2);
$0 or $3.60 or $7.40 non-preferred brand (tier 3);
$0 or $1.20 or $2.95 or $3.60 or $7.40 specialty (tier 4);
$0 select care drugs (tier 5)
In-Network Retail Pharmacy
(90-day supply)
$0 or $1.20 or $2.95 generic (tier 1);
$0 or $3.60 or $7.40 preferred brand (tier 2);
$0 or $3.60 or $7.40 non-preferred brand (tier 3);
$0 select care drugs (tier 5)
Mail-Order Pharmacy
(90-day supply)
$0 or $1.20 or $2.95 generic (tier 1);
$0 or $3.60 or $7.40 preferred brand (tier 2);
$0 or $3.60 or $7.40 non-preferred brand (tier 3);
$0 select care drugs (tier 5)
Prescription drug copays are dependent on your income.
5
E
Award-Winning
Generic Drug
Call Us
Routine vision coverage
Vision
Dental
Emergency Travel
Fitness
You receive routine vision coverage and an allowance every two years. You
can get a routine vision exam every two years at no cost to you. Make sure
you see a provider who participates in the vision provider network.
Preventivea participating
Health Coaching vision
Online
Tools
Healthwww.upmchealthplan.com/snp
Care Expert
Find
provider
at
or call us at 1-866-405-8762 seven days a week from 8 a.m. to 8 p.m.*
TTY users should call 1-866-407-8762.
What is the routine vision allowance amount?
Meet Representative
Stop By
Go Online
Confirmation Letter
UPMC for Life Dual members have an allowance up to $135 every two
years for contact lenses and eyewear, including lenses and frames.
Welcome Kit
Health Survey
E
Award-Winning
Vision
Generic Drug
Preventive
Member ID Card
Preventive dental coverage
Dental
Emergency Travel
Fitness
Health Coaching
Online Tools
Health Care Expert
The UPMC for Life Dual plan includes preventive dental coverage
for cleanings and exams. Members can visit one of our participating
UPMC Dental Advantage Medicare providers to take advantage of the
benefits below.
Go to www.upmchealthplan.com/snp to find participating dental
providers. Or call us at 1-866-405-8762 seven days a week from 8 a.m. to
8 p.m.* TTY users should call 1-866-407-8762.
Call Us
Meet Representative
Your preventive dental benefits include:
Stop By
Go Online
Confirmation Letter
•$0 copay for one oral exam and cleaning every six months
•$0 copay for one bitewing x-ray every six months
Welcome Kit
Health Survey
•$0 copay for fillings and simple extractions
Member ID Card
•A $1,500 yearly allowance for additional services like dentures,
bridges, root canals, and crowns
6
al
By
D Card
Having trouble getting to your doctor’s appointment? You can get a ride
at no cost. We cover 11 one-way trips to plan-approved locations. Trip
service is offered Monday through Friday from 7 a.m. to 7 p.m. You can
be covered for rides to medical services. Rides to receive physical therapy,
pick-up prescriptions, and get blood work completed are included too.
Emergency travel coverage
Emergency Travel
Fitness
Assist America provides help when you travel more than 100 miles from
home or even to another country. Help is available 24 hours a day, 365
days a year, anywhere in the world. Assist America provides these services:
Extra Benefits & Services
aching
Transportation service
•Emergency medical evacuation
Online Tools
Health Care Expert
•Hospital admission assistance
•Medical monitoring
•Round-trip transportation for a family member or friend (if
traveling
alone)
Go Online
Confirmation Letter
•Help replacing forgotten prescriptions (additional costs may apply)
•Assistance with local language communications
•Member transportation if medically necessary
•Arranging for transport of mortal remains
Assist America does not replace your UPMC for Life Dual emergency
benefits. If you have an emergency, go to the nearest hospital or urgent
care facility. You will be covered under your UPMC for Life Dual
medical coverage.
7
E
rd-Winning
neric Drug
Fitness benefits
Vision
Dental
Emergency Travel
Preventive
Health Coaching
Online Tools
Fitness
UPMC for Life Dual members can join a local participating fitness
facility at no additional cost. The Active&Fit® program can help you get
physically fit and stay active. Here are some membership perks:
•Aerobic and strength training equipment
Health Care Expert
•Exercise classes (where available)
•Access to dance studios, yoga studios, and swimming pools
(where available)
Call Us
Meet Representative
Stop By
Go Online
•Amenities such as saunas, steam rooms, and whirlpools
(where available)
Confirmation Letter
•Website support at www.ActiveandFit.com (includes fitness facility
E search, exercise trackers, and health trackers)
lcome Kit
Health Survey
Member ID Card
Award-Winning
•The option to work out at home with the Active&Fit Home
Dental
Emergency Travel
Fitness
Fitness Program
Vision
Preventive services
Generic Drug
E
Call Us
Award-Winning
Vision
Welcome Kit
8
Generic Drug
Preventive
Call Us
Meet Representative
Welcome Kit
Health Survey
Preventive
Health Coaching
Online Tools
Health Care Expert
UPMC for Life Dual covers many preventive services at 100 percent. This
means you pay nothing for your annual wellness exam and immunizations
like the flu and pneumonia vaccines. You can also receive the following
screenings (this is a partial list) at no additional cost: mammogram, blood
Meet
Representative
By
Go Online
Confirmation Letter glaucoma, obesity, bone mass
pressure,
colonStopcancer,
depression,
diabetes,
measurement, Pap, pelvic, and prostate cancer. Check with your primary
care
to see
what preventive
care is right for you.
Dentaldoctor Emergency
Travel
Fitness
Health Survey
Health Coaching
Health coaching
Member ID Card
Online Tools
Health Care Expert
A health coach can help you make changes to improve your health and
sustain your quality of life. You can sign up for health coaching for free as
a UPMC for Life Dual member. Your health coach can help you create a
plan to achieve your goals and stay motivated. We also have programs for
chronic
healthGo Online
conditions
likeLetterdiabetes, cardiovascular disease, respiratory
Stop By
Confirmation
issues, and low back pain.
Member ID Card
al
aching
By
Travel
Emergency Travel
Fitness
Online member tools
Online Tools
Health Care Expert
MyHealth OnLine is your one-stop destination for health care tools. This
secure member website allows you to view your plan benefits. You also
have access to health and wellness tools, your plan benefits, claims, and
much more. Once you become a UPMC for Life Dual member, we’ll send
Go
Online
Confirmationon
Letter how to log in and get started.
you
information
Fitness
Health care experts
ools
D Card
Health Care Expert
ne
Confirmation Letter
Extra Benefits & Services
As a UPMC for Life Dual member, you can call the MyHealth Advice Line
for health advice 24/7. You can get general health information or facts
about a specific medical issue. Experienced, registered nurses are on hand
24/7 to provide you with prompt and efficient service.
9
E
Award-Winning
Vision
Dental
Emergency Travel
Fitness
Health Coaching
Online Tools
Health Care Expert
How to enroll
E
Generic Drug
Award-Winning
E
Generic Drug
Award-Winning
Vision
Vision
Call Us
Preventive
Dental
Welcome Kit
Generic Drug
Call Us
Preventive
Meet Representative
Health Coaching
E
Award-Winning
Vision
Call Us
Generic Drug
Preventive
Welcome Kit
10
Dental
Emergency Travel
Preventive
Call us
Dental
Health Survey
Get personal help in completing your application. You can meet
Stop By
Go Online
Confirmation Letter
Tools
Health Care UPMC
Expert
withOnline
an
authorized
for Life Dual representative. For times
and locations, call the phone number above.
Stop by
Fitness
StopMember
by IDone
of our conveniently located UPMC Health Plan
Card
Go Online
Confirmation Letter
Connect Service and Sales Centers. We have locations at
Century III Mall, The Mall at Robinson, Millcreek Mall,
Monroeville Mall, Ross Park Mall, and South Hills Village.
Health Coaching
Online Tools
Health Care Expert
Member ID Card
Go online
Meet Representative
Stop By
Welcome Kit
Health Survey
Member ID Card
Go Online
Member ID Card
Meet with a representative
Health Survey
Stop By
Call Us
Fitness
We have licensed representatives who work with Medicare
Meet Representative
By
Go Online
Confirmation Letter
beneficiaries
everyStop
day.
We can
answer your
questions and help
you apply for enrollment. Call toll-free at 1-866-405-8762
seven
days
from
8 a.m.
toExpert
8 p.m.* TTY users should call
Health
Coaching a week
Online
Tools
Health Care
Emergency Travel
Fitness
1-866-407-8762.
Welcome Kit
Meet Representative
Health Survey
Emergency Travel
Visit us online at www.upmchealthplan.com/snp. You can view
plan
benefits, check providers, and apply for enrollment.
Confirmation Letter
Travel
ools
Fitness
E
Award-Winning
Vision
ne
ug
Fitness
E
What
to expect when enrolling
Vision
Confirmation Letter
Call Us
Preventive
Dental
Welcome Kit
Meet Representative
e
Emergency Travel
Health Care Expert
Generic Drug
ing
Dental
Health Coaching
Confirmation letter
Preventive
Dental
Health Coaching
Emergency Travel
Online Tools
Health Care Expert
Fitness
You will receive a letter within 10 days of UPMC for Life Dual
receiving your application. It will let you know if you are eligible
for this coverage. If your enrollment is confirmed, you can use
theMeetletter
as proof Stop
ofByyour coverage.
YouConfirmation
cannot
use the letter
Representative
Go Online
Letter
Health Coaching
Online Tools
Health Care Expert
as proof of coverage before your effective date.
Emergency Travel
Welcome kit
Fitness
Once your enrollment in UPMC for Life Dual has been
Health Survey
Member ID Card
confirmed,
you will
receiveConfirmation
a welcome
kit. In this kit, you will find
Stop By
Go Online
Letter
documents that help explain the benefits offered by your plan.
Online Tools
Health Care Expert
Health Assessment Survey
it
tative
ey
Health Survey
Stop By
This survey allows us to better understand your health. It also
Member ID Card
helps
us to provide you with the health management services you
may Goneed.
Please
fill out the survey and mail it back to us in the
Online
Confirmation Letter
postage-paid envelope provided.
Member ID card
Member ID Card
Shortly after you enroll, you will receive a member ID card.
Show your member ID card whenever you visit your doctor,
medical provider, the hospital, or the pharmacy. This card is used
in place of your red, white, and blue Medicare card. You cannot
use your ID card until your coverage effective date.
Enrollment
11
What is Medicare?
Medicare is a federal health insurance program. In order to qualify,
you must:
•Be age 65 or older, or
•Be under 65 with certain disabilities, or
•Have permanent kidney failure requiring dialysis
Medicare has four parts:
•Part A hospital coverage
•Part B medical coverage
•Part C Medicare Advantage plans
•Part D prescription drug coverage
Part A hospital coverage
Most people do not pay a monthly premium for Part A. If you or your
spouse worked for 10 years and paid Medicare taxes, you will not have to
pay a premium.
What does Part A pay for?
•Inpatient hospital care
•Skilled nursing facility care
•Home health care
•Hospice care
12
Part B medical coverage
Part B helps cover:
•Doctor and other health care provider services
•Outpatient surgery
•Lab and x-ray services
•Ambulance services
•Some preventive services
•Durable medical equipment like prosthetics, wheelchairs, and
hospital beds
Services that are NOT covered by Medicare include:
•Routine hearing, dental, and vision exams
•Hearing aids or glasses (except for glasses after cataract surgery)
•Emergency assistance while traveling outside the U.S.
•Fitness club membership
•Long-term care (such as a nursing home)
•Prescription drug coverage
Enrollment in Original Medicare
Contact the Social Security Administration to sign up for Original
Medicare. Call toll-free at 1-800-772-1213 Monday through Friday from
7 a.m. to 7 p.m. TTY users should call 1-800-325-0778.
Understanding Medicare
13
Part C Medicare Advantage plans
Part C is referred to as Medicare Advantage plans. Medicare Advantage
plans are Medicare-approved private health plans. They allow you to get
all of your Part A hospital, Part B medical, and Part D prescription drug
coverage combined into one plan. They can also provide you with some
additional benefits and services that Original Medicare does not cover.
UPMC for Life Dual is a Medicare Special Needs Plan. These Medicare
Advantage plans are designed specifically for individuals with Medicare
and Medical Assistance (Medicaid) from the state.
To join a Medicare Dual Eligible Special Needs Plan,
you must:
•Be enrolled in Medicare Parts A and B
•Be enrolled in your state’s Medical Assistance (Medicaid) program
•Permanently reside in the plan’s service area
•Not have permanent kidney failure (some exceptions may apply)
Medicare Advantage plans help cover:
•All services that Parts A and B cover, except hospice care (which is
covered by Medicare)
•Additional benefits and services that Medicare does not cover, such as:
–Dental and vision exams
–Contact lenses or glasses (except for glasses after cataract surgery)
–Emergency assistance while traveling outside the U.S.
–Fitness club membership
Medicare Advantage plans can give you more benefits
than Original Medicare.
14
Part D prescription drug coverage
Part D coverage is offered through Medicare-approved private insurance
companies. Part D helps cover brand-name and generic medications.
Prescription coverage varies by plan; each plan has a formulary that lists
the drugs that are covered by that plan.
Extra help with prescription
drug costs
Centers for Medicare & Medicaid Services (CMS)
The government offers extra help for Part D prescription drug costs. To
see if you qualify, call 1-800-MEDICARE (1-800-633-4227), 24 hours a
day, seven days a week. TTY users should call 1-877-486-2048. Or you
can visit online at www.medicare.gov.
Medical Assistance (Medicaid)
Call the HELPLINE at 1-800-692-7462 Monday through Friday from
8:30 a.m. to 4:45 p.m. TTY users should call 1-800-451-5886.
PACE/PACENET
Pennsylvania offers help to older adults for prescription drug coverage.
Call 1-800-225-7223 from 8:30 a.m. to 8 p.m., Monday through Friday,
and 9 a.m. to 3 p.m. on Saturday. TTY users should call 1-800-222-9004.
Or you can visit online at https://pacecares.magellanhealth.com/.
Veterans Administration (VA)
To see if you qualify for Veterans Administration benefits, visit online at
www.va.gov or go to your local VA facility.
Understanding Medicare
15
Our hours of operation change twice a year. You can call us October 1
through February 14, seven days a week from 8 a.m. to 8 p.m. From
February 15 through September 30, you can call us Monday through
Friday from 8 a.m. to 8 p.m.
*
This award was not given by Medicare. For more information about
UPMC for Life’s CMS Star Rating, go to www.Medicare.gov.
**
This information is not a complete description of benefits. Contact the
plan for more information. Limitations, copayments, and restrictions may
apply. Benefits, premium and/or copayments/coinsurance may change on
January 1 of each year. The formulary, pharmacy network, and/or provider
network may change at any time. You will receive notice when necessary.
This plan is available to anyone who has both Medical Assistance
(Medicaid) from the state and Medicare. UPMC for Life Dual is an HMO
SNP plan with a Medicare contract and a contract with the Pennsylvania
Medical Assistance (Medicaid) program. Enrollment in UPMC for Life
Dual depends on contract renewal. UPMC for Life Dual is a product of
and operated by UPMC for You Inc.
The Active&Fit program is provided by American Specialty Health
Fitness Inc., a subsidiary of American Specialty Health Incorporated
(ASH). All programs and services are not available in all areas. Individuals
appearing in this brochure are not Active&Fit members. Active&Fit and
the Active&Fit logo are federally registered trademarks of ASH.
16
To find out more about UPMC for Life Dual
(HMO SNP), call toll-free 1-866-405-8762
seven days a week from 8 a.m. to 8 p.m.
TTY users should call 1-866-407-8762.
Our hours of operation change twice a year.
You can call us October 1 through
February 14, seven days a week from
8 a.m. to 8 p.m. From February 15
through September 30, you can call us
Monday through Friday from 8 a.m. to 8 p.m.
U.S. Steel Tower, 600 Grant Street
Pittsburgh, PA 15219
www.upmchealthplan.com/snp
Copyright 2015 UPMC Health Plan Inc. All rights reserved.
2016_SNPADVSLGRD_15SNPID0030 (MCG) 9/21/15 10.5M HP