Transcription
2013 Summary ofBenefitsHealth Net Seniority Plus Ruby (HMO)Kern County, CABenefits effective January 1, 2013H0562 Health Net of California, Inc.Material ID # H0562 2013 0170 CMS Accepted 09192012 1
2
Section IIntroduction toSummary of BenefitsThank you for your interest in Health Net Seniority Plus Ruby(HMO). Our plan is offered by HEALTH NET OF CALIFORNIA,a Medicare Advantage Health Maintenance Organization(HMO) that contracts with the Federal government. ThisSummary of Benefits tells you some features of our plan.It doesn’t list every service that we cover or list every limitationor exclusion. To get a complete list of our benefits, pleasecall Health Net Seniority Plus Ruby (HMO) and ask for the“Evidence of Coverage”.YOU HAVE CHOICES INYOUR HEALTH CAREAs a Medicare beneficiary, you canchoose from different Medicareoptions. One option is the Original(fee-for-service) Medicare Plan.Another option is a Medicare healthplan, like Health Net Seniority PlusRuby (HMO). You may have otheroptions too. You make the choice. Nomatter what you decide, you are stillin the Medicare Program.You may join or leave a plan onlyat certain times. Please callHealth Net Seniority Plus Ruby(HMO) at the telephone numberlisted at the end of this introductionor 1-800-MEDICARE(1-800-633-4227) for moreinformation.TTY/TDD users should call1-877-486-2048. You can call thisnumber 24 hours a day, 7 days aweek.HOW CAN I COMPAREMY OPTIONS?You can compare Health NetSeniority Plus Ruby (HMO) and theOriginal Medicare Plan using thisSummary of Benefits. The charts inthis booklet list some important healthbenefits. For each benefit, you can seewhat our plan covers and what theOriginal Medicare Plan covers.Our members receive all of thebenefits that the Original MedicarePlan offers. We also offer morebenefits, which may change fromyear to year. 3
WHERE IS Health NetSeniority Plus Ruby(HMO) AVAILABLE?WHAT HAPPENS IF I GOTO A DOCTOR WHO’SNOT IN YOUR NETWORK?The service area for this planincludes: Kern County, CA. You mustlive in this area to join the plan.If you choose to go to a doctoroutside of our network, you must payfor these services yourself. Neitherthe plan nor the Original MedicarePlan will pay for these services exceptin limited situations (for example,emergency care).WHO IS ELIGIBLE TOJOIN Health NetSeniority Plus Ruby(HMO)?You can join Health Net SeniorityPlus Ruby (HMO) if you are entitledto Medicare Part A and enrolledin Medicare Part B and live in theservice area. However, individualswith End-Stage Renal Disease aregenerally not eligible to enroll inHealth Net Seniority Plus Ruby(HMO) unless they are members ofour organization and have been sincetheir dialysis began.CAN I CHOOSEMY DOCTORS?Health Net Seniority Plus Ruby(HMO) has formed a network ofdoctors, specialists, and hospitals.You can only use doctors who arepart of our network. The healthproviders in our network can changeat any time.You can ask for a current providerdirectory. For an updated list, visitus at www.healthnet.com/medicare.Our customer service number islisted at the end of this introduction. 4 WHERE CAN I GET MYPRESCRIPTIONS IF I JOINTHIS PLAN?Health Net Seniority Plus Ruby(HMO) has formed a networkof pharmacies. You must use anetwork pharmacy to receive planbenefits. We may not pay for yourprescriptions if you use an out-ofnetwork pharmacy, except in certaincases. The pharmacies in our networkcan change at any time. You can askfor a pharmacy directory or visitus at https://www.healthnet.com/medicare/pharmacy. Our customerservice number is listed at the endof this introduction.Health Net Seniority Plus Ruby(HMO) has a list of preferredpharmacies. At these pharmacies,you may get your drugs at a lowerco-pay or co-insurance. You may goto a non-preferred pharmacy, butyou may have to pay more for yourprescription drugs.
DOES MY PLAN COVERMEDICARE PART B ORPART D DRUGS?Health Net Seniority Plus Ruby(HMO) does cover both MedicarePart B prescription drugs andMedicare Part D prescription drugs.WHAT IS A PRESCRIPTIONDRUG FORMULARY?Health Net Seniority Plus Ruby(HMO) uses a formulary. Aformulary is a list of drugs coveredby your plan to meet patient needs.We may periodically add, remove, ormake changes to coverage limitationson certain drugs or change howmuch you pay for a drug. If we makeany formulary change that limitsour members’ ability to fill theirprescriptions, we will notify theaffected members before the changeis made. We will send a formulary toyou and you can see our completeformulary on our Web site athttp://www.healthnet.com/medicare/pharmacy.If you are currently taking a drugthat is not on our formulary orsubject to additional requirementsor limits, you may be able to geta temporary supply of the drug.You can contact us to request anexception or switch to an alternativedrug listed on our formulary withyour physician’s help. Call us to see ifyou can get a temporary supply of thedrug or for more details about ourdrug transition policy.HOW CAN I GETEXTRA HELP WITH MYPRESCRIPTION DRUGPLAN COSTS OR GETEXTRA HELP WITHOTHER MEDICARECOSTS?You may be able to get extra helpto pay for your prescription drugpremiums and costs as well as gethelp with other Medicare costs. Tosee if you qualify for getting extrahelp, call: 1-800-MEDICARE(1-800-633-4227). TTY/TDDusers should call 1-877-486-2048,24 hours a day/7 days a week andsee www.medicare.gov ‘Programsfor People with Limited Incomeand Resources’ in the publicationMedicare & You. The Social Security Administrationat 1-800-772-1213 between7 a.m. and 7 p.m., Monday throughFriday. TTY/TDD users should call1-800-325-0778 or Your State Medicaid Office.WHAT ARE MYPROTECTIONS INTHIS PLAN?All Medicare Advantage Plans agreeto stay in the program for a fullcalendar year at a time. Plan benefitsand cost-sharing may change fromcalendar year to calendar year. Eachyear, plans can decide whether tocontinue to participate with MedicareAdvantage. A plan may continue in 5
their entire service area (geographicarea where the plan acceptsmembers) or choose to continue onlyin certain areas. Also, Medicare maydecide to end a contract with a plan.Even if your Medicare AdvantagePlan leaves the program, you willnot lose Medicare coverage. If aplan decides not to continue for anadditional calendar year, it must sendyou a letter at least 90 days beforeyour coverage will end. The letter willexplain your options for Medicarecoverage in your area.As a member of Health Net SeniorityPlus Ruby (HMO), you have theright to request an organizationdetermination, which includes theright to file an appeal if we denycoverage for an item or service,and the right to file a grievance.You have the right to request anorganization determination if youwant us to provide or pay for an itemor service that you believe shouldbe covered. If we deny coveragefor your requested item or service,you have the right to appeal andask us to review our decision. Youmay ask us for an expedited (fast)coverage determination or appealif you believe that waiting for adecision could seriously put yourlife or health at risk, or affect yourability to regain maximum function.If your doctor makes or supports theexpedited request, we must expediteour decision. Finally, you have theright to file a grievance with us ifyou have any type of problem withus or one of our network providersthat does not involve coverage foran item or service. If your probleminvolves quality of care, you also havethe right to file a grievance with the 6 Quality Improvement Organization(QIO) for your state. Please refer tothe Evidence of Coverage (EOC) forthe QIO contact information.As a member of Health Net SeniorityPlus Ruby (HMO), you have the rightto request a coverage determination,which includes the right to requestan exception, the right to file anappeal if we deny coverage for aprescription drug, and the right tofile a grievance. You have the rightto request a coverage determinationif you want us to cover a Part Ddrug that you believe should becovered. An exception is a type ofcoverage determination. You mayask us for an exception if you believeyou need a drug that is not on ourlist of covered drugs or believe youshould get a non-preferred drug ata lower out-of-pocket cost. You canalso ask for an exception to costutilization rules, such as a limit onthe quantity of a drug. If you thinkyou need an exception, you shouldcontact us before you try to fill yourprescription at a pharmacy. Yourdoctor must provide a statement tosupport your exception request. If wedeny coverage for your prescriptiondrug(s), you have the right to appealand ask us to review our decision.Finally, you have the right to filea grievance if you have any typeof problem with us or one of ournetwork pharmacies that does notinvolve coverage for a prescriptiondrug. If your problem involvesquality of care, you also have theright to file a grievance with theQuality Improvement Organization(QIO) for your state. Please refer tothe Evidence of Coverage (EOC) forthe QIO contact information.
WHAT IS A MEDICATIONTHERAPY MANAGEMENT(MTM) PROGRAM?A Medication Therapy Management(MTM) Program is a free servicewe offer. You may be invited toparticipate in a program designed foryour specific health and pharmacyneeds. You may decide not toparticipate but it is recommendedthat you take full advantage of thiscovered service if you are selected.Contact Health Net Seniority PlusRuby (HMO) for more details.WHAT TYPES OF DRUGSMAY BE COVERED UNDERMEDICARE PART B?Some outpatient prescription drugsmay be covered under MedicarePart B. These may include, butare not limited to, the followingtypes of drugs. Contact Health NetSeniority Plus Ruby (HMO) for moredetails.if you have hemophilia. Injectable Drugs: Most injectabledrugs administered incident to aphysician’s service. Immunosuppressive Drugs:Immunosuppressive drug therapyfor transplant patients if thetransplant took place in a Medicarecertified facility and was paid for byMedicare or by a private insurancecompany that was the primarypayer for Medicare Part A coverage. Some Oral Cancer Drugs:If the same drug is availablein injectable form. Oral Anti-Nausea Drugs:If you are part of an anti-cancerchemotherapeutic regimen. Inhalation and Infusion Drugsadministered through DurableMedical Equipment. Some Antigens: If they are preparedby a doctor and administered bya properly instructed person(who could be the patient) underdoctor supervision. Osteoporosis Drugs: Injectableosteoporosis drugs for some women. Erythropoietin (Epoetin Alfa orEpogen ): By injection if you haveend-stage renal disease (permanentkidney failure requiring eitherdialysis or transplantation) andneed this drug to treat anemia. Hemophilia Clotting Factors:Self-administered clotting factors 7
WHERE CAN I FINDINFORMATION ONPLAN RATINGS?The Medicare program rates howwell plans perform in differentcategories (for example, detectingand preventing illness, ratings frompatients and customer service). If youhave access to the web, you may usethe web tools on www.medicare.govand select “Health and Drug Plans”then “Compare Drug and HealthPlans” to compare the plan ratingsfor Medicare plans in your area.You can also call us directly to obtaina copy of the plan ratings for thisplan. Our customer service numberis listed below.Please call Health Net of California for more information about Health NetSeniority Plus Ruby (HMO).Visit us at www.healthnet.com/medicare or, call us:Customer Service Hours for October 1 - February 14:Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday,8:00 a.m. - 8:00 p.m. PacificCustomer Service Hours for February 15 - September 30:Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday,8:00 a.m. - 8:00 p.m. PacificCurrent members should call locally or toll-free (800)-275-4737 for questions relatedto the Medicare Advantage Program. (TTY/TDD (800)-929-9955)Prospective members should call locally or toll-free (800)-977-6738 for questionsrelated to the Medicare Advantage Program. (TTY/TDD (800)-929-9955)Current members should call locally or toll-free (800)-275-4737 for questions relatedto the Medicare Part D Prescription Drug program. (TTY/TDD (800)-929-9955)Prospective members should call locally or toll-free (800)-865-9431 for questionsrelated to the Medicare Part D Prescription Drug program. (TTY/TDD (800)-929-9955)For more information about Medicare, please call Medicare at 1-800-MEDICARE(1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours aday, 7 days a week.Or, visit www.medicare.gov on the web.This document may be available in other formats such as Braille, large print or other alternate formats.This document may be available in a non-English language. For additional information, call customerservice at the phone number listed above.Este documento puede estar disponible en un idioma distinto al inglés. Para obtener informaciónadicional, llame a servicio al cliente al número de teléfono que aparece anteriormente. 8
If you have any questions about this plan’s benefits or costs, please contactHealth Net of California for details.Section IISummary of BenefitsBenefitOriginal MedicareHealth Net Seniority PlusRuby (HMO)IMPORTANT INFORMATION1. P remium andOther ImportantInformationIn 2012 the monthly Part B Premium was 99.90 and may change for 2013 andthe annual Part B deductible amount was 140 and may change for 2013.General 0 monthly plan premium inaddition to your monthly MedicarePart B premium.If a doctor or supplier does not acceptassignment, their costs are often higher,which means you pay more.Most people will pay thestandard monthly Part B premiumin addition to their MA planpremium. However, some peoplewill pay higher Part B and Part Dpremiums because of their yearlyincome (over 85,000 for singles, 170,000 for married couples).Most people will pay the standardmonthly Part B premium. However,some people will pay a higher premiumbecause of their yearly income (over 85,000 for singles, 170,000 formarried couples). For more informationabout Part B premiums based on income,call Medicare at 1-800-MEDICARE(1-800-633-4227). TTY users shouldcall 1-877-486-2048. You may alsocall Social Security at 1-800-772-1213.TTY users should call 1-800-325-0778.For more information about PartB and Part D premiums basedon income, call Medicare at1-800-MEDICARE(1-800-633-4227). TTY usersshould call 1-877-486-2048. Youmay also call Social Security at1-800-772-1213. TTY users shouldcall 1-800-325-0778.In-Network 3,400 out-of-pocket limit. All planservices included.2. D octor andHospital Choice(For moreinformation, seeEmergency Care –#15 and UrgentlyNeeded Care –#16.)You may go to any doctor, specialist, orhospital that accepts Medicare.In-NetworkYou must go to network doctors,specialists, and hospitals.Referral required for networkhospitals and specialists (forcertain benefits). 9
BenefitOriginal MedicareHealth Net Seniority PlusRuby (HMO)SUMMARY OF BENEFITSINPATIENT CARE3. InpatientHospital Care(includesSubstance Abuseand RehabilitationServices)In 2012 the amounts for each benefitperiod were:Days 1 - 60: 1156 deductibleDays 61 - 90: 289 per dayDays 91 - 150: 578 per lifetime reservedayThese amounts may change for 2013.Call 1-800-MEDICARE(1-800-633-4227) for informationabout lifetime reserve days.Lifetime reserve days can only beused once.A “benefit period” starts the day yougo into a hospital or skilled nursingfacility. It ends when you go for 60 daysin a row without hospital or skillednursing care. If you go into the hospitalafter one benefit period has ended, anew benefit period begins. You must paythe inpatient hospital deductible for eachbenefit period. There is no limit to thenumber of benefit periods you can have. 10 In-NetworkNo limit to the number of dayscovered by the plan eachhospital stay.For Medicare-coveredhospital stays: Days 1-5: 100 copay per day Days 6-90: 0 copay per day 0 copay for each additionalhospital day.Except in an emergency, yourdoctor must tell the plan that youare going to be admitted to thehospital.
BenefitOriginal Medicare4. Inpatient MentalHealth CareIn 2012 the amounts for each benefitperiod were:Days 1 - 60: 1156 deductibleDays 61 - 90: 289 per dayDays 91 - 150: 578 per lifetime reservedayThese amounts may change for 2013.You get up to 190 days of inpatientpsychiatric hospital care in a lifetime.Inpatient psychiatric hospital servicescount toward the 190-day lifetimelimitation only if certain conditions aremet. This limitation does not apply toinpatient psychiatric services furnishedin a general hospital.Health Net Seniority PlusRuby (HMO)In-NetworkYou get up to 190 days ofinpatient psychiatric hospital carein a lifetime. Inpatient psychiatrichospital services count towardthe 190-day lifetime limitationonly if certain conditions are met.This limitation does not applyto inpatient psychiatric servicesfurnished in a general hospital. 900 copay for each Medicarecovered hospital stay.Except in an emergency, yourdoctor must tell the plan that youare going to be admitted to thehospital. 11
BenefitOriginal Medicare5. S killed NursingFacility (SNF)(in a Medicarecertified skillednursing facility)In 2012 the amounts for each benefitperiod after at least a 3-day coveredhospital stay were:Days 1 - 20: 0 per dayDays 21 - 100: 144.50 per dayThese amounts may change for 2013.100 days for each benefit period.A “benefit period” starts the day yougo into a hospital or SNF. It ends whenyou go for 60 days in a row withouthospital or skilled nursing care. If yougo into the hospital after one benefitperiod has ended, a new benefit periodbegins. You must pay the inpatienthospital deductible for each benefitperiod. There is no limit to the numberof benefit periods you can have. 0 copay.6. H ome HealthCare(includes medicallynecessaryintermittentskilled nursingcare, home healthaide services,and rehabilitationservices, etc.)7. HospiceYou pay part of the cost for outpatientdrugs and inpatient respite care.You must get care from a Medicarecertified hospice. 12 Health Net Seniority PlusRuby (HMO)GeneralAuthorization rules may apply.In-NetworkPlan covers up to 100 dayseach benefit periodNo prior hospital stay is required.For Medicare-covered SNF stays: Days 1 - 20: 0 copay per day Days 21 - 100: 75 copay perdayGeneralAuthorization rules may apply.In-Network 0 copay for each Medicarecovered home health visitGeneralYou must get care from aMedicare-certified hospice. Yourplan will pay for a consultative visitbefore you hospice.
BenefitOriginal MedicareHealth Net Seniority PlusRuby (HMO)OUTPATIENT CARE8. D octor OfficeVisits20% coinsuranceGeneralAuthorization rules may apply.In-Network 0 copay for each Medicarecovered primary care doctor visit.9. ChiropracticServices10. PodiatryServicesSupplemental routine care not covered20% coinsurance for manualmanipulation of the spine to correctsubluxation (a displacement ormisalignment of a joint or body part)if you get it from a chiropractor orother qualified providers.Supplemental routine care not covered.20% coinsurance for medicallynecessary foot care, including carefor medical conditions affecting thelower limbs. 0 copay for each Medicarecovered specialist visit.GeneralAuthorization rules mayapply.In-Network 10 copay for each Medicarecovered chiropractic visitMedicare-coveredchiropractic visits are formanual manipulationof the spine to correctsubluxation (a displacementor misalignment of a jointor body part) if you get itfrom a chiropractor.GeneralAuthorization rules may apply.In-Network 0 copay for each Medicarecovered podiatry visit 0 copay for up to 12supplemental routine podiatryvisit(s) every yearMedicare-covered podiatry visitsare for medically-necessary footcare. 13
BenefitOriginal MedicareHealth Net Seniority PlusRuby (HMO)11. OutpatientMental HealthCare35% coinsurance for most outpatientmental health servicesGeneralAuthorization rules may apply.Specified copayment for outpatientpartial hospitalization program servicesfurnished by a hospital or communitymental health center (CMHC). Copaycannot exceed the Part A inpatienthospital deductible.In-Network 25 copay for each Medicarecovered individual therapy visit“Partial hospitalization program” is astructured program of active outpatientpsychiatric treatment that is more intensethan the care received in your doctor’s ortherapist’s office and is an alternative toinpatient hospitalization.12. OutpatientSubstanceAbuse Care20% coinsurance 25 copay for each Medicarecovered group therapy visit 25 copay for each Medicarecovered individual therapy visitwith a psychiatrist 25 copay for each Medicarecovered group therapy visit with apsychiatrist 0 copay for Medicare-coveredpartial hospitalization programservicesGeneralAuthorization rules may apply.In-Network 25 copay for Medicare-coveredindividual substance abuseoutpatient treatment visits 25 copay for Medicare-coveredgroup substance abuse outpatienttreatment visits13. OutpatientServices20% coinsurance for the doctor’s servicesSpecified copayment for outpatienthospital facility servicesCopay cannot exceed the Part Ainpatient hospital deductible.20% coinsurance for ambulatory surgicalcenter facility services 14 GeneralAuthorization rules may apply.In-Network 50 copay for eachMedicare-covered ambulatorysurgical center visit 100 copay for eachMedicare-covered outpatienthospital facility visit
BenefitOriginal Medicare14. ces)15. Emergency Care(You may go toany emergencyroom if youreasonablybelieve you needemergency care.)20% coinsuranceHealth Net Seniority PlusRuby (HMO)GeneralAuthorization rules may apply.In-Network 200 copay for Medicare-coveredambulance benefits.20% coinsurance for thedoctor’s servicesSpecified copayment for outpatienthospital facility emergency services.Emergency services copay cannotexceed Part A inpatient hospitaldeductible for each service providedby the hospital.You don’t have to pay the emergencyroom copay if you are admitted to thehospital as an inpatient for the samecondition within 3 days of the emergencyroom visit.Not covered outside the U.S. exceptunder limited circumstances.20% coinsurance, or a set copayGeneral 65 copay for Medicarecovered emergency room visits 50,000 plan coverage limit forsupplemental emergency servicesoutside the U.S. and its territoriesevery year.If you are immediately admittedto the hospital, you pay 0 for theemergency room visit.16. UrgentlyNeeded CareNOT covered outside the U.S. except(This is NOTemergency care, under limited circumstances.and in mostcases, is out ofthe service area.)General 10 copay for Medicare-coveredurgently-needed-care visits17. Outpatient20% apy, PhysicalTherapy, Speechand LanguageTherapy)GeneralAuthorization rules may apply.If you are immediatelyadmitted to the hospital, youpay 0 for the urgently-neededcare visit.In-Network 0 copay for Medicare-coveredOccupational Therapy visits 0 copay for Medicare-coveredPhysical Therapy and/or Speechand Language Pathology visits 15
BenefitOriginal MedicareHealth Net Seniority PlusRuby (HMO)OUTPATIENT MEDICAL SERVICES AND SUPPLIES18. D urable Medical 20% coinsuranceEquipment(includeswheelchairs,oxygen, etc.)19. Prosthetic20% coinsuranceDevices(includes braces,artificial limbsand eyes, etc.)20. DiabetesPrograms andSupplies20% coinsurance for diabetesself-management trainingGeneralAuthorization rules may apply.In-Network20% of the cost for Medicarecovered durable medicalequipmentGeneralAuthorization rules may apply.In-Network20% of the cost for Medicarecovered prosthetic devicesGeneralAuthorization rules may apply.In-Network 0 copay for Medicare-covered20% coinsurance for diabetic therapeuticDiabetes self-managementshoes or insertstraining20% coinsurance for diabetes supplies 0 copay for Medicare-coveredDiabetes monitoring supplies20% of the cost for Medicarecovered Therapeutic shoes orinserts 16
BenefitOriginal MedicareHealth Net Seniority PlusRuby (HMO)21. DiagnosticTests, X-Rays,Lab Services,and RadiologyServices20% coinsurance for diagnostic testsand X-raysGeneralAuthorization rules may apply. 0 copay for Medicare-covered labservicesIn-Network 0 copay for Medicare-covered labservices22. Cardiac andPulmonaryRehabilitationServicesLab Services: Medicare covers medicallynecessary diagnostic lab services thatare ordered by your treating doctorwhen they are provided by a ClinicalLaboratory Improvement Amendments(CLIA) certified laboratory thatparticipates in Medicare. Diagnosticlab services are done to help yourdoctor diagnose or rule out a suspectedillness or condition. Medicare does notcover most supplemental routinescreening tests, like checking yourcholesterol.20% coinsurance for CardiacRehabilitation services20% coinsurance for PulmonaryRehabilitation services20% coinsurance for IntensiveCardiac Rehabilitation servicesThis applies to program servicesprovided in a doctor’s office.Specified cost sharing for programservices provided by hospitaloutpatient departments. 0 copay for Medicare-covereddiagnostic procedures and tests 0 copay for Medicare-coveredX-rays 60 copay for Medicare-covereddiagnostic radiology services (notincluding X-rays) 60 copay for Medicare-coveredtherapeutic radiology servicesGeneralAuthorization rules may apply.In-Network 0 copay for Medicare-coveredCardiac Rehabilitation Services 0 copay for Medicare-coveredIntensive Cardiac RehabilitationServices 0 copay for Medicare-coveredPulmonary Rehabilitation Services 17
BenefitOriginal MedicareHealth Net Seniority PlusRuby (HMO)PREVENTIVE SERVICES, WELLNESS/EDUCATION ANDOTHER SUPPLEMENTAL BENEFIT PROGRAMS23. PreventiveServices,Wellness/Educationand otherSupplementalBenefitPrograms 18 No coinsurance, copayment ordeductible for the following: Abdominal Aortic Aneurysm Screening Bone Mass Measurement. Coveredonce every 24 months (more often ifmedically necessary) if you meet certainmedical conditions. Cardiovascular Screening Cervical and Vaginal Cancer Screening.Covered once every 2 years. Coveredonce a year for women with Medicareat high risk. Colorectal Cancer Screening Diabetes Screening Influenza Vaccine Hepatitis B Vaccine for people withMedicare who are at risk HIV Screening. 0 copay for the HIVscreening, but you generally pay 20%of the Medicare-approved amountfor the doctor’s visit. HIV screening iscovered for people with Medicare whoare pregnant and people at increasedrisk for the infection, including anyonewho asks for the test. Medicare coversthis test once every 12 months or upto three times during a pregnancy. Breast Cancer Screening(Mammogram). Medicare coversscreening mammograms onceevery 12 months for all womenwith Medicare age 40 and older.Medicare covers one baselinemammogram for women betweenages 35-39. Medical Nutrition Therapy ServicesNutrition therapy is for people whohave diabetes or kidney disease (butaren’t on dialysis or haven’t had akidney transplant) when referred by adoctor. These services can be given byGeneralAuthorization rules may apply. 0 copay for all preventive servicescovered under Original Medicareat zero cost sharing.Any additional preventive servicesapproved by Medicare mid-yearwill be covered by the plan or byOriginal Medicare.In-NetworkThe plan covers the followingsupplemental education/wellnessprograms: Health Education Additional Smoking and TobaccoUse Cessation Visits Nursing Hotline 0 copay for Additional PapSmears and Additional PelvicExams.Contact plan for details.
Health Net Seniority PlusRuby (HMO)BenefitOriginal Medicare23. PreventiveServicesWellness/Educationand otherSupplementalBenefitPrograms(continued)a registered dietitian and may includea nutritional assessment and counselingto help you manage your diabetes orkidney disease Personalized Prevention Plan Services(Annual Wellness Visits) Pneumococcal Vaccine. You may onlyneed the Pneumonia vaccine oncein your lifetime. Call your doctor formore information. Prostate Cancer Screening – ProstateSpecific Antigen (PSA) test only.Covered once a year for all menwith Medicare over age 50. Smoking and Tobacco Use Cessation(counseling to stop smoking andtobacco use). Covered if ordered byyour doctor. Includes two counselingattempts within a 12-month period.Each counseling attempt includes up tofour face-to-face visits. Screening and behavioral counselinginterventions in primary care to reducealcohol misuse Screening for depression in adults Screening for sexually transmittedinfections (STI) and high-intensitybehavioral counseling to prevent STIs Intensive behavioral counseling forCardiovascular Disease (bi-annual) Intensive behavioral therapy for obesity Welcome to Medicare Preventive Visits(initial preventive physical exam)When you join Medicare Part B, thenyou are eligible as follows. Duringthe first 12 months of your new Part Bcoverage, you can get either a Welcometo Medicare Preventive Visit or anAnnual Wellness Visit. After your first12 months, you can get one AnnualWellness Visit every 12 months.20% coinsurance for renal dialysisGeneralAuthorization rules may apply.20% coinsurance for kidney disease24. K idney Diseaseand Conditionseducation servicesIn-Network10% of the cost for Medicarecovered renal dialysis 0 copay for Medicare-coveredkidney disease education services 19
BenefitOriginal MedicareHealth Net Seniority PlusRuby (HMO)PRESCRIPTION DRUG BENEFITS25. OutpatientPrescriptionDrugsMost drugs are not covered underOriginal Medicare. You can addprescription drug coverage toOriginal Medicare by joining aMedicare Prescription Drug Plan,or you can get all your Medicarecoverage, including prescriptiondrug coverage, by joining aMedicare Advantage Plan or aMedicare Cost Plan that offersprescription drug coverage.Drugs covered under MedicarePart BGeneral20% of the cost for MedicarePart B chemotherapy drugs andother Part B drugs
Health net Seniority Plus ruby (Hmo) unless they are members of our organization and have been since their dialysis began. CAn I CHooSe my doCtorS? Health net Seniority Plus ruby (Hmo) has formed a network of doctors, specialists, and hospitals. you can only use doctors who are part of our network. The
