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2016Medicare AdvantageSpecial Needs Plans (SNP)Full Dual Medicare & MedicaidMaricopa CountySpecial Needs Plans for Dual Eligible beneficiaries are an HMO plan that limits theirmembership to people who are eligible for both Medicare and Medicaid (AHCCCS).The Special Needs Plan must be designed to provide Medicare health care and servicesto people who can benefit the most from things like special expertise of the plan’sproviders, and focused care management. In some cases, you may have to choose aprimary care doctor or have a care coordinator help you develop personal care plans andcoordinate your care. You generally must get your care and services from doctors orhospitals in the plan’s network (except emergency or urgent care).Most current revision 10/12/15BENEFITS ASSISTANCE PROGRAMA State Health Insurance Assistance Program (SHIP)A program of the Area Agency on Aging, Region One1366 East Thomas, Suite 108, Phoenix, AZ 85014602-264-2255The Benefits Assistance Program, part of the AZ State Health Insurance and Assistance Program(SHIP), does not recommend or endorse any particular company or plan and is not responsible for theservice provided by these companies. These comparison sheets are provided as a guide to assist you inmaking your health care decisions. This publication has been created or produced by the Area Agencyon Aging, Region One with financial assistance, in whole or in part, through a grant from theAdministration for Community Living.-1-

Full Dual Special Needs Plans (SNP)Page1. Bridgeway Health Solutions Advantage (Bridgeway ALTCS)32. Health Choice Generations (Aligned with Health Choice)53. Health Net Amber (Aligned with Health Net)74. Maricopa Care Advantage (Aligned with Maricopa Health Plan)95. Mercy Care Advantage Plan (Aligned with Mercy Care & MMIC) 116. Care1st (Aligned with Care 1st)137. Phoenix Advantage Plus (Aligned with Phoenix Health Plan)158. United Healthcare Dual Complete (Aligned with UHC CP)17-2-

Bridgeway Health Solutions Advantage SNP (HMO)Plan Number H5590-002STAR RATING 3.5 STARSMust be eligible for Medicare and be enrolled in an ALTCS health planPremiums, co-pays and coinsurance will be paid by AHCCCSProviders must have contract with Bridgeway ALTCS planMonthly Premium for this planInpatient HospitalDeductible day for days 1 – 90Skilled Nursing FacilityCo-pay per day for days 1 – 20 (3 day prior hospital stay required)Co-pay per day for days 21 – 100 (100 days per benefit period)Outpatient Mental HealthCo-pay per visitEmergency/Urgent CareCo-pay per hospital emergency room visit (waived if admitted)Co-pay per visit for urgent careAmbulance ServicesCo-pay per tripPhysician ServicesCo-pay for Primary Care PhysicianCo-pay for SpecialistPhysical, Occupational, Speech TherapyCo-pay per visitRoutine Podiatry ServiceCo-pay per visitChiropractic CareCo-pay per visitDiagnostic Tests, X-Rays, and Lab ServicesClinical/diagnostic lab serviceOutpatient ServicesFacility co-pay at ambulatory surgical centerFacility co-pay per outpatient hospital facility visitPrescription DrugsHome Health CareCo-pay per visitDurable Medical Equipment (DME)Co-pay per item for Diabetic suppliesCo-pay per piece of equipmentCo-pay per prosthetic deviceVision ServicesCo-pay per Medicare covered eye examCo-pay per annual vision examFrames/lensesContact LensesHearing ServicesCo-pay for Medicare covered hearing examCo-pay for annual hearing examHearing aid applianceTransportationDentalCleaning and Oral Exam every 6 months-3-Bridgeway Health1-877-935-8020advantage.bridgewayhs.com 0.00 1.20 or 3.60 0.00 0.00 150.00 annual limit 150 annual limit 0.00 0.00No coverageNo coverage 0.00

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Health Choice Generations SNP (HMO)Plan Number H5587-002STAR RATING 3 STARSMust be eligible for Medicare and be enrolled in an AHCCCS health planPremiums, co-pays and coinsurance will be paid by AHCCCSProviders must have contract with Health Choice AHCCCS planMonthly Premium for this planInpatient HospitalCo-pay per day for days 1 – 90Skilled Nursing FacilityCo-pay per day for days 1 – 20 (no prior hospital stay required)Co-pay per day for days 21 – 100 (100 days per benefit period)Outpatient Mental HealthCo-pay per visitEmergency/Urgent CareCo-pay per hospital emergency room visit (waived if admitted)Co-pay per visit for urgent careAmbulance ServicesCo-pay per tripPhysician ServicesCo-pay for Primary Care PhysicianCo-pay for SpecialistPhysical, Occupational, Speech TherapyCo-pay per visitRoutine Podiatry ServiceCo-pay per visitChiropractic CareCo-pay per visitDiagnostic Tests, X-Rays, and Lab ServicesClinical/diagnostic lab serviceOutpatient ServicesFacility co-pay at ambulatory surgical centerFacility co-pay per outpatient hospital facility visitPrescription DrugsHome Health CareCo-pay per visitDurable Medical Equipment (DME)Co-pay per item for Diabetic suppliesCo-pay per piece of equipmentCo-pay per prosthetic deviceVision ServicesCo-pay per Medicare covered eye examCo-pay per annual vision examFrames/lenses/contacts benefitHearing ServicesCo-pay for Medicare covered hearing examCo-pay for annual hearing examHearing aid appliance (annual benefit)TransportationDentalCleaning and oral exam every year-5-Health Choice1-800-656-8991healthchoicegenerations.com 0.00 1.20 or 3.60 0.00 0.00 175 annual limit 0.00 0.00 500.00No coverage 0.00

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Health Net of Arizona1-800-333-3930healthnet.com/medicareHealth Net Amber SNP (HMO)Plan Number H0351-029STAR RATING 3.5 STARSMust be eligible for Medicare and be enrolled in an AHCCCS health planPremiums, co-pays and coinsurance will be paid by AHCCCSProviders must have contract with Health Net AHCCCS plan 0.00Monthly Premium for this planInpatient HospitalAbrazo, Dignity, and St. Lukes Hospital Networks OnlyDeductible day for days 1 – 90Skilled Nursing FacilityCo-pay per day for days 1 – 20 (3 day prior hospital stay required)Co-pay per day for days 21 – 100 (100 days per benefit period)Outpatient Mental HealthCo-pay per visitEmergency/Urgent CareCo-pay per hospital emergency room visit (waived if admitted)Co-pay per visit for urgent careAmbulance ServicesCo-pay per tripPhysician ServicesCo-pay for Primary Care PhysicianCo-pay for SpecialistPhysical, Occupational, Speech TherapyCo-pay per visitRoutine Podiatry ServiceCo-pay per visitChiropractic CareCo-pay per visitDiagnostic Tests, X-Rays, and Lab ServicesClinical/diagnostic lab serviceOutpatient ServicesFacility co-pay at ambulatory surgical centerFacility co-pay per outpatient hospital facility visit 1.20 or 3.60Prescription DrugsHome Health CareCo-pay per visitDurable Medical Equipment (DME)Co-pay per item for Diabetic suppliesCo-pay per piece of equipmentCo-pay per prosthetic deviceVision ServicesCo-pay per Medicare covered eye exam 0.00Co-pay per annual vision examNo coverageFrames/lenses/contactsNo coverageHearing ServicesCo-pay for Medicare covered hearing exam 0.00Co-pay for annual hearing exam 0.00Hearing aid appliance benefit 1,000 (every 3 years)No coverageTransportationDentalAnnual Dental Benefit 2,000.00-7-

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Maricopa Care Advantage SNP – (HMO)Plan Number H6623-001STAR RATING 3 STARSMust be eligible for Medicare and enrolled in an AHCCCS health planPremiums, co-pays and coinsurance will be paid by AHCCCSProviders must have contract with Maricopa Health AHCCCS planMonthly Premium for this planInpatient HospitalCo-pay per day for days 1 – 90Skilled Nursng FacilityCo-pay per day for days 1 – 20 (no prior hospital stay required)Co-pay for days 32 – 100Outpatient Mental HealthCo-pay per visitEmergency/Urgent CareCo-pay per hospital emergency room visit (waived if admitted)Co-pay per visit for urgent careAmbulance ServicesCo-pay per trip (waived if admitted)Physician ServicesCo-pay for Primary Care PhysicianCo-pay for SpecialistPhysical Occupational Speech TherapyCo-pay per visitRoutine Podiatry ServiceCo-pay per visitChiropractic CareCo-pay per visitDiagnostic Tests, X-Rays, and Lab ServicesClinical/diagnostic lab serviceOutpatient ServicesFacility co-pay at ambulatory surgical centerFacility co-pay per outpatient hospital facility visitPrescription DrugsHome Health CareCo-pay per visitDurable Medical Equipment (DME)Co-pay per item for Diabetic suppliesCo-pay per piece of equipmentCo-pay per prosthetic deviceVision ServicesCo-pay per Medicare covered eye examCo-pay per annual vision examFrames/lenses/contactsHearing ServicesCo-pay for Medicare covered hearing examCo-pay for annual hearing examHearing aid applianceTransportationDentalLimited dental benefits-9-University of Arizona877-874-3938universitycareadvantage.com 0.00 1.20 or 3.60 0.00No coverageNo coverage 0.00No coverageNo coverageNo coverage 0.00 to 20%

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Mercy Care Advantage866-571-5781Mercy Care Advantage SNP (HMO)Plan Number H5580-001STAR RATING 3 STARSmercycareadvantage.comMust be eligible for Medicare and be enrolled in an AHCCCS health planPremiums, co-pays and coinsurance will be paid by AHCCCSProviders must have contract with Mercy Care AHCCCS planMonthly Premium for this planInpatient HospitalCo-pay per day for days 1 – 60Skilled Nursing FacilityCo-pay per day for days 1 – 20 (3 day hospital stay required)Co-pay per day for days 21 – 100 (100 days per benefit period)Outpatient Mental HealthCo-pay per visitEmergency/Urgent CareCo-pay per hospital emergency room visit (waived if admitted)Co-pay per visit for urgent careAmbulance ServicesCo-pay per tripPhysician ServicesCo-pay for Primary Care PhysicianCo-pay for SpecialistPhysical, Occupational, Speech TherapyCo-pay per visitRoutine Podiatry ServiceCo-pay per visitChiropractic CareCo-pay per visitDiagnostic Tests, X-Rays, and Lab ServicesClinical/diagnostic lab serviceOutpatient ServicesFacility co-pay at ambulatory surgical centerFacility co-pay per outpatient hospital facility visitPrescription DrugsHome Health CareCo-pay per visitDurable Medical Equipment (DME)Co-pay per item for Diabetic suppliesCo-pay per piece of equipmentCo-pay per prosthetic deviceVision ServicesCo-pay per Medicare covered eye examCo-pay per annual vision examBenefit for frames/lenses/contactsHearing ServicesCo-pay for Medicare covered hearing examCo-pay for annual hearing examHearing aid appliance benefitTransportationDentalCleaning and oral exam every 6 months- 11 - 0.00 1.20 or 3.60 0.00 0.00 200 (every 2 years) 0.00 0.00 1,200 (every 3 years)No coverage 0.00

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