Summary of Benefits PENNSYLVANIA. Gateway Health Medicare Assured Ruby SM. (HMO SNP) Gateway Health Medicare Assured Diamond SM (HMO SNP)

April 29, 2017 | Author: Camron Gilbert | Category: N/A
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Download Summary of Benefits PENNSYLVANIA. Gateway Health Medicare Assured Ruby SM. (HMO SNP) Gateway Health Medicare As...

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2015

Summary of Benefits PENNSYLVANIA

Gateway Health Medicare Assured Ruby (HMO SNP) Gateway Health Medicare Assured Diamond (HMO SNP) SM

SM

For Medicare beneficiaries who are also eligible for Medicaid or assistance from the State. Y0097_396_PA Accepted

SECTION I – INTRODUCTION TO SUMMARY OF BENEFITS

You have choices about how to get your Medicare benefits. One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government. Another choice is to get your Medicare benefits by joining a Medicare health plan (such as Gateway Health Medicare Assured DiamondSM (HMO SNP) and Gateway Health Medicare Assured RubySM (HMO SNP)).

Tips for comparing your Medicare choices This Summary of Benefits booklet gives you a summary of what Gateway Health Medicare Assured DiamondSM (HMO SNP) and Gateway Health Medicare Assured RubySM (HMO SNP) covers and what you pay. If you want to compare our plan with other Medicare health plans, ask the other plans for their Summary of Benefits booklets. Or, use the Medicare Plan Finder on http://www.medicare.gov. If you want to know more about the coverage and costs of Original Medicare, look in your current "Medicare & You" handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048.

Sections in this booklet 

Things to Know About Gateway Health Medicare Assured DiamondSM (HMO SNP) and Gateway Health Medicare Assured RubySM (HMO SNP)



Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services



Covered Medical and Hospital Benefits



Prescription Drug Benefits 1

SECTION I – INTRODUCTION TO SUMMARY OF BENEFITS

This document is available in other formats such as Braille and large print. This document may be available in a non-English language. For additional information, call us at (877) 935-2168 (prospective members); (800) 685-5209 (current members).

Things to Know About Gateway Health Medicare Assured DiamondSM (HMO SNP) and Gateway Health Medicare Assured RubySM (HMO SNP). Hours of Operation  From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. 

From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time.

Gateway Health Medicare Assured DiamondSM (HMO SNP) and Gateway Health Medicare Assured RubySM (HMO SNP) Phone Numbers and Website If you are a member of this plan, call toll-free (800) 685-5209. If you are not a member of this plan, call toll-free (877) 935-2168. Our website: http://www.MedicareAssured.com

2

SECTION I – INTRODUCTION TO SUMMARY OF BENEFITS

Who can join? To join Gateway Health Medicare Assured DiamondSM (HMO SNP) or Gateway Health Medicare Assured RubySM (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and Pennsylvania Medical Assistance (Medicaid) and live in our service area. Our service area includes the following counties in Pennsylvania: Adams, Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bucks, Butler, Cambria, Chester, Clarion, Crawford, Cumberland, Dauphin, Delaware, Erie, Fayette, Forest, Greene, Huntingdon, Indiana, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Mercer, Montgomery, Northampton, Northumberland, Perry, Philadelphia, Schuylkill, Somerset, Venango, Washington, Westmoreland, and York.

Which doctors, hospitals, and pharmacies can I use? Gateway Health Medicare Assured DiamondSM (HMO SNP) and Gateway Health Medicare Assured RubySM (HMO SNP) have a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services. You must generally use network pharmacies to fill your prescriptions for covered Part D drugs. You can see our plan's provider and pharmacy directory at our website (www.MedicareAssured.com). Or, call us and we will send you a copy of the provider and pharmacy directories.

3

SECTION I – INTRODUCTION TO SUMMARY OF BENEFITS

What do we cover? Like all Medicare health plans, we cover everything that Original Medicare covers - and more. Our plan members get all of the benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet. We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website, http://www.MedicareAssured.com. Or, call us and we will send you a copy of the formulary.

How will I determine my drug costs? The amount you pay depends on the drug's tier and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur after you meet your deductible: Initial Coverage, Coverage Gap, and Catastrophic Coverage. If you have any questions about this plan's benefits or costs, please contact Gateway Health Medicare Assured DiamondSM (HMO SNP) and Gateway Health Medicare Assured RubySM (HMO SNP) for detail.

4

SECTION II – SUMMARY OF BENEFITS

Benefit How much is the monthly premium? How much is the deductible?

Gateway Health Medicare Assured RubySM (HMO SNP) $0.00 per month. In addition, you must keep paying your Medicare Part B premium.

Gateway Health Medicare Assured DiamondSM (HMO SNP) $0.00 per month. This plan does not have a deductible.

This plan does not have a deductible.

This plan does not have a deductible for chemotherapy and other drugs administered in your doctor's office (Part B drugs). This plan does not have a deductible for Part D prescription drugs.

Is there any limit on how much I will pay for my covered services?

Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-ofpocket costs for medical and hospital care. In this plan, you may pay nothing for Medicarecovered services, depending on your level of Pennsylvania Medical Assistance (Medicaid) eligibility. Refer to the "Medicare & You" handbook for Medicare-covered services. For Pennsylvania Medical Assistance (Medicaid)-covered services, refer to the Medicaid Coverage section in this document.

5

Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. In this plan, you may pay nothing for Medicare-covered services, depending on your level of Pennsylvania Medical Assistance (Medicaid) eligibility. Refer to the "Medicare & You" handbook for Medicarecovered services. For Pennsylvania Medical Assistance (Medicaid)-covered services, refer to the Medicaid Coverage section in this document.

SECTION II - SUMMARY OF BENEFITS

Benefit Is there any limit on how much I will pay for my covered services? (continued)

Is there a limit on how much the plan will pay?

Gateway Health Medicare Assured RubySM (HMO SNP)

Gateway Health Medicare Assured DiamondSM (HMO SNP)

Your yearly limit(s) in this plan: $6,700 for services you receive from in-network providers.

Your yearly limit(s) in this plan: $3,400 for services you receive from in-network providers.

If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.

If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.

Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.

Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.

Gateway Health Medicare Assured DiamondSM (HMO SNP) and Gateway Health Medicare Assured Ruby SM (HMO SNP) are HMO plans with a Medicare contract. Gateway Health Medicare Assured Diamond SM (HMO SNP) and Gateway Health Medicare Assured Ruby SM (HMO SNP) are HMO plans with a Medicare contract and a contract with Pennsylvania Medicaid. Enrollment in Gateway Health Medicare Assured Diamond SM (HMO SNP) and Gateway Health Medicare Assured Ruby SM (HMO SNP) depends on contract renewal.

6

SECTION II - SUMMARY OF BENEFITS Gateway Health Medicare Assured RubySM (HMO SNP)

Benefit

Gateway Health Medicare Assured DiamondSM (HMO SNP)

COVERED MEDICAL AND HOSPITAL BENEFITS NOTE: SERVICES WITH A 1 MAY REQUIRE PRIOR AUTHORIZATION. SERVICES WITH A 2 MAY REQUIRE A REFERRAL FROM YOUR DOCTOR. OUTPATIENT CARE AND SERVICES Acupuncture and Other Alternative Therapies

Not covered

Not covered

Ambulance1

$0 or $200 copay

You pay nothing

Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $0 or $20 copay

Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): You pay nothing

The enrollee is covered for manual spine manipulation to correct a subluxation.

The enrollee is covered for manual spine manipulation to correct a subluxation.

Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): You pay nothing

Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): You pay nothing

Preventive dental services: Cleaning (for up to 1 every six months): You pay nothing Dental x-ray(s) (for up to 1 every six months): You pay nothing

Preventive dental services: Cleaning (for up to 1 every six months): You pay nothing Dental x-ray(s) (for up to 1 every six months): You pay nothing

1

Chiropractic Care

Dental Services

7

SECTION II - SUMMARY OF BENEFITS

Benefit Dental Services (continued)

Diabetes Supplies and Services

Gateway Health Medicare Assured RubySM (HMO SNP) Oral exam (for up to 1 every six months): You pay nothing

Gateway Health Medicare Assured DiamondSM (HMO SNP) Oral exam (for up to 1 every six months): You pay nothing

See the Additional Information Section of this booklet for other covered dental benefits.

See the Additional Information Section of this booklet for other covered dental benefits.

Diabetes monitoring supplies: 0% or 20% of the cost Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: 0% or 20% of the cost. With regard to limiting Diabetic Supplies and Services: If the member receives diabetic supplies and services at a DME provider, there is no limit to manufacturer. If the member receives diabetic supplies and services from a pharmacy, specified manufacturers are limited.

Diabetes monitoring supplies: You pay nothing Diabetes self-management training: You pay nothing Therapeutic shoes or inserts: You pay nothing With regard to limiting Diabetic Supplies and Services: If the member receives diabetic supplies and services at a DME provider, there is no limit to manufacturer. If the member receives diabetic supplies and services from a pharmacy, specified manufacturers are limited.

If the doctor provides you services in addition to diabetes self-management training, separate cost share of $15 or $30 copayment may apply. Diagnostic Tests, Lab and Radiology Services, and XRays1

Diagnostic radiology services (such as MRIs, CT scans): $0 or $140 copay

Diagnostic radiology services (such as MRIs, CT scans): You pay nothing

Diagnostic tests and procedures: You pay nothing Lab services: You pay nothing Outpatient x-rays: $0 or $30 copay Therapeutic radiology services (such as radiation treatment for cancer): $0 or $60 copay

Diagnostic tests and procedures: You pay nothing Lab services: You pay nothing Outpatient x-rays: You pay nothing Therapeutic radiology services (such as radiation treatment for cancer): You pay nothing

8

SECTION II - SUMMARY OF BENEFITS Gateway Health Medicare Assured RubySM (HMO SNP)

Gateway Health Medicare Assured DiamondSM (HMO SNP)

There is no copayment for Medicare-approved clinical/diagnostic lab services. Depending on the type of physician/professional service provided, a separate cost share may apply. If the doctor provides you services in addition to outpatient diagnostic procedures, tests and lab services, sometimes separate cost sharing of $0 or $15 may apply.

There is no copayment for Medicare-approved clinical/diagnostic lab services. Depending on the type of physician/professional service provided, a separate cost share may apply.

Primary care physician visit: $0 or $15 copay Specialist visit: $0 or $30 copay There is no authorization if service is from the Gateway HealthSM specialist network.

Primary care physician visit: You pay nothing Specialist visit: You pay nothing There is no authorization if service is from the Gateway HealthSM specialist network.

Durable Medical Equipment (wheelchairs, oxygen, etc.) 1

0% or 20% of the cost Authorization from Gateway HealthSM is required for DME services $500.00 or greater for a single item or multiple quantities of a single item.

You pay nothing Authorization from Gateway HealthSM is required for DME services $500.00 or greater for a single item or multiple quantities of a single item.

Emergency Care

$0 or $65 copay

You pay nothing

Foot exams and treatment if you have diabetesrelated nerve damage and/or meet certain conditions: $0 or $30 copay Routine foot care: $30 copay There is no authorization if service is from the Gateway HealthSM specialist network.

Foot exams and treatment if you have diabetesrelated nerve damage and/or meet certain conditions: You pay nothing Routine foot care: 20% of the cost There is no authorization if service is from the Gateway HealthSM specialist network.

Exam to diagnose and treat hearing and balance issues: You pay nothing Routine hearing exam: You pay nothing

Exam to diagnose and treat hearing and balance issues: You pay nothing Routine hearing exam: You pay nothing

Benefit Diagnostic Tests, Lab and Radiology Services, and XRays1 (continued)

Doctor's Office Visits

Foot Care (podiatry services)

Hearing Services

9

SECTION II - SUMMARY OF BENEFITS Gateway Health Medicare Assured RubySM (HMO SNP)

Benefit Hearing Services (continued)

Home Health Care1 1

Mental Health Care

Gateway Health Medicare Assured DiamondSM (HMO SNP)

Hearing aid fitting/evaluation: You pay nothing Hearing aid: You pay nothing Our plan pays up to $1,000 every two years for hearing aids.

Hearing aid fitting/evaluation: You pay nothing Hearing aid: You pay nothing Our plan pays up to $1,000 every two years for hearing aids.

You pay nothing

You pay nothing

Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.

Inpatient visit: Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.

Our plan covers 90 days for an inpatient hospital stay.

Our plan covers 90 days for an inpatient hospital stay.

Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.

Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.

$0 or $225 copay per day for days 1 through 6 You pay nothing per day for days 7 through 90

You pay nothing

Outpatient group therapy visit: $0 or $30 copay Outpatient individual therapy visit: $0 or $30 copay 10

Outpatient group therapy visit: You pay nothing Outpatient individual therapy visit: You pay nothing

SECTION II - SUMMARY OF BENEFITS Gateway Health Medicare Assured RubySM (HMO SNP)

Benefit Mental Health Care1 (continued)

1

Outpatient Rehabilitation

Medicare beneficiaries may only receive 190 days in a freestanding Psychiatric Hospital in a lifetime. Except in an emergency, authorization by Gateway HealthSM is required before service is received.

Medicare beneficiaries may only receive 190 days in a freestanding Psychiatric Hospital in a lifetime. Except in an emergency, authorization by Gateway HealthSM is required before service is received.

Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $0 or $30 copay

Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): You pay nothing.

Occupational therapy visit: $0 or $30 copay Physical therapy and speech and language therapy visit: $0 or $30 copay

Outpatient Substance Abuse1 Outpatient Surgery

Over-the-Counter Items

Gateway Health Medicare Assured DiamondSM (HMO SNP)

Occupational therapy visit: You pay nothing Physical therapy and speech and language therapy visit: You pay nothing The Medicare-defined Part B deductible and facility cost share amount of 20% will apply for all occupational therapy services.

Group therapy visit: $0 or $30 copay Individual therapy visit: $0 or $30 copay

Group therapy visit: You pay nothing Individual therapy visit: You pay nothing

Ambulatory surgical center: $0 or $175 copay Outpatient hospital: $0 or $175 copay Other cost sharing may apply to non-surgery services.

Ambulatory surgical center: You pay nothing Outpatient hospital: You pay nothing

Please visit our website to see our list of covered over-the-counter items. Members receive $10 every 3 months for purchasing Medicare-approved non-prescription over-the-counter medication and health-related items through catalog purchasing.

Please visit our website to see our list of covered over-the-counter items. Members receive $10 every 3 months for purchasing Medicare-approved non-prescription over-the-counter medication and health-related items through catalog purchasing.

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SECTION II - SUMMARY OF BENEFITS

Benefit Prosthetic Devices (braces, artificial limbs, etc.) 1

Renal Dialysis 1

Transportation

Gateway Health Medicare Assured RubySM (HMO SNP)

Gateway Health Medicare Assured DiamondSM (HMO SNP)

Prosthetic devices: 0% or 20% of the cost Related medical supplies: 0% or 20% of the cost Authorization from Gateway HealthSM is required for DME services $500.00 or greater for a single item or multiple quantities of a single item.

Prosthetic devices: You pay nothing Related medical supplies: You pay nothing Authorization from Gateway HealthSM is required for DME services $500.00 or greater for a single item or multiple quantities of a single item.

0% or 20% of the cost

You pay nothing

You pay nothing 24 one-way trips per year. Authorization and scheduling rules apply.

You pay nothing 24 one-way trips per year. Authorization and scheduling rules apply.

Urgent Care

$0 or $30 copay

You pay nothing

Vision Services

Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0 or $30

Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing

Routine eye exam (for up to 1 every three months): You pay nothing

Routine eye exam (for up to 1 every three months): You pay nothing

Contact lenses (for up to 1 every year): You pay nothing

Contact lenses (for up to 1 every year): You pay nothing

Eyeglasses (frames and lenses) (for up to 1 every year): You pay nothing

Eyeglasses (frames and lenses) (for up to 1 every year): You pay nothing

Eyeglasses or contact lenses after cataract surgery: You pay nothing

Eyeglasses or contact lenses after cataract surgery: You pay nothing

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SECTION II - SUMMARY OF BENEFITS

Benefit Vision Services (continued)

Preventive Care

Gateway Health Medicare Assured RubySM (HMO SNP) Our plan pays up to $150 every year for contact lenses and eyeglasses (frames and lenses). Vendor frames and standard lenses or standard contact lenses at no cost per calendar year.

Gateway Health Medicare Assured DiamondSM (HMO SNP) Our plan pays up to $150 every year for contact lenses and eyeglasses (frames and lenses). Vendor frames and standard lenses or standard contact lenses at no cost per calendar year.

$90 toward non-vendor frames or $150 toward specialty contact lenses per calendar year.

$90 toward non-vendor frames or $150 toward specialty contact lenses per calendar year.

You pay nothing Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA)

You pay nothing Our plan covers many preventive services, including: Abdominal aortic aneurysm screening Alcohol misuse counseling Bone mass measurement Breast cancer screening (mammogram) Cardiovascular disease (behavioral therapy) Cardiovascular screenings Cervical and vaginal cancer screening Colonoscopy Colorectal cancer screenings Depression screening Diabetes screenings Fecal occult blood test Flexible sigmoidoscopy HIV screening Medical nutrition therapy services Obesity screening and counseling Prostate cancer screenings (PSA)

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SECTION II - SUMMARY OF BENEFITS Benefit Preventive Care (continued)

Hospice

Gateway Health Medicare Assured RubySM (HMO SNP) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)

Gateway Health Medicare Assured DiamondSM (HMO SNP) Sexually transmitted infections screening and counseling Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)

Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots

Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots

"Welcome to Medicare" preventive visit (onetime) Yearly "Wellness" visit

"Welcome to Medicare" preventive visit (onetime) Yearly "Wellness" visit

Any additional preventive services approved by Medicare during the contract year will be covered.

Any additional preventive services approved by Medicare during the contract year will be covered.

Annual physical exam: You pay nothing

Annual physical exam: You pay nothing

You pay nothing for hospice care from a Medicarecertified hospice. You may have to pay part of the cost for drugs and respite care.

You pay nothing for hospice care from a Medicarecertified hospice. You may have to pay part of the cost for drugs and respite care.

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SECTION II - SUMMARY OF BENEFITS

Benefit

Gateway Health Medicare Assured RubySM (HMO SNP)

Gateway Health Medicare Assured DiamondSM (HMO SNP)

Our plan covers an unlimited number of days for an inpatient hospital stay. $0 or $225 copay per day for days 1 through 6 You pay nothing per day for days 7 through 90 You pay nothing per day for days 91 and beyond

Our plan covers an unlimited number of days for an inpatient hospital stay.

For inpatient mental health care, see the "Mental Health Care" section of this booklet.

For inpatient mental health care, see the "Mental Health Care" section of this booklet.

Our plan covers up to 100 days in a SNF. You pay nothing per day for days 1 through 20 $0 or $156.50 copay per day for days 21 through 100

Our plan covers up to 100 days in a SNF. You pay nothing

INPATIENT CARE Inpatient Hospital Care1

Inpatient Mental Health Care Skilled Nursing Facility (SNF)1

You pay nothing 10% of the cost per day for days 91 and beyond

PRESCRIPTION DRUG BENEFITS How much do I pay?

For Part B drugs such as chemotherapy drugs1: 0% or 20% of the cost Other Part B drugs1: 0% or 20% of the cost Pre-authorization is required by Gateway HealthSM for certain prescription drugs.

15

For Part B drugs such as chemotherapy drugs1: You pay nothing Other Part B drugs1: You pay nothing Pre-authorization is required by Gateway HealthSM for certain prescription drugs.

SECTION II - SUMMARY OF BENEFITS Benefit Initial Coverage

Catastrophic Coverage

Gateway Health Medicare Assured RubySM Gateway Health Medicare Assured DiamondSM (HMO SNP) (HMO SNP) Depending on your income and institutional status, Depending on your income and institutional status, you pay the following: you pay the following: For generic drugs (including brand drugs treated as generic), either: $0 copay; or $1.20 copay; or $2.65 copay

For generic drugs (including brand drugs treated as generic), either: $0 copay; or $1.20 copay; or $2.65 copay

For all other drugs, either: $0 copay; or $3.60 copay; or $6.60 copay You may get your drugs at network retail pharmacies.

For all other drugs, either: $0 copay; or $3.60 copay; or $6.60 copay You may get your drugs at network retail pharmacies.

If you reside in a long-term care facility, you pay the same as at a retail pharmacy.

If you reside in a long-term care facility, you pay the same as at a retail pharmacy.

You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.

You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,700, you pay nothing for all drugs. Or, you may pay the greater of $2.65 for generic or a preferred multi-source drug, and $6.60 for all other drugs, or 5%.

16

You pay nothing.

Additional Information About Gateway Health Medicare Assured RubySM (HMO SNP) and Gateway Medicare Assured DiamondSM (HMO SNP)

Benefit Bathroom Safety Products

Gateway Health Medicare Assured RubySM (HMO SNP)

Gateway Health Medicare Assured DiamondSM (HMO SNP)

Bathroom Safety benefit provides up to $100.00 per calendar year for bathroom safety products such as bath/shower chairs, bathtub rails and bathtub stools or bench.

Bathroom Safety benefit provides up to $200.00 per calendar year for bathroom safety products such as bath/shower chairs, bathtub rails and bathtub stools or bench.

In addition to those items described in Section II:

In addition to those items described in Section II:

1 dental bite-wing x-ray per side, every 6 months. 1 panoramic x-ray every 5 years.

1 dental bite-wing x-ray per side, every 6 months. 1 panoramic x-ray every 5 years. Comprehensive dental coverage is $500 every 2 years, limited to fillings, simple extractions and denture repair. Dental services, such as root canals, crowns, surgical extractions & gum treatments, not covered. Dentures, up to 1 complete set every 5 years. Partial dentures are not a covered benefit.

Provides membership at participating network fitness centers at no cost, including: o Basic fitness membership to one Plan approved fitness facility per month o Orientation to the fitness center and instructions about how to use equipment and services o One @Home Pak per year for those members with limited access to a network fitness center.

Provides membership at participating network fitness centers at no cost, including: o Basic fitness membership to one Plan approved fitness facility per month o Orientation to the fitness center and instructions about how to use equipment and services o One @Home Pak per year for those members with limited access to a network fitness center.

Dental Services

Health Club Membership / Fitness Classes

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SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H5932, PLANS 001 AND 009

The benefits described below are covered by Medicaid. The benefits described in the Covered Medical and Hospital Benefits section of the Summary of Benefits are covered by Medicare. For each benefit listed below, you can see what the Pennsylvania Department of Public Welfare (DPW) Medical Assistance Program (Medicaid) covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility. The services listed below are available only to those SNP members eligible under Title XIX Medicaid for medical services. Medically-necessary, Medicaid-covered services must be obtained through the Pennsylvania Department of Public Welfare, fee-forservice Medicaid Program – Gateway Health Medicare Assured Ruby and Gateway Health Medicare Assured Diamond cannot provide Medicaid-covered services for our Medicare members. Medicaid is usually the payer of last resort – this means, as a member of our plan, you must access benefits that are covered by both programs through Medicare (Gateway Health Medicare Assured RubySM or Gateway Health Medicare Assured DiamondSM) first and Medicaid (DPW) last. As applicable, for services that are reimbursed by both Medicare and Medicaid for dual eligible members, providers will bill Gateway Health Medicare Assured Ruby or Gateway Health Medicare Assured Diamond for the Medicare portion of the bill. Providers may not seek additional payments for the Medicare Cost Sharing Obligations. Providers will bill the Pennsylvania Department of Public Welfare for the Medicaid portion of the bill. If you have questions about how your benefits are coordinated between programs, contact  Medicare - Gateway Health Medicare Assured RubySM and Gateway Health Medicare Assured DiamondSM Member Services at 1-(800) 685-5209, 8am - 8pm, 7 days a week. TTY users call 711.  Medicaid – 1-800-692-7462, TTY users call 1-800-451-5886.

18

S

SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H5932, PLANS 001 AND 009

Benefit

Medicaid State Plan Benefit Limits

Gateway Health Medicare Assured RubySM***

Gateway Health Medicare Assured DiamondSM**

Inpatient Acute Hospital

N/A

Unlimited number of days for an inpatient hospital stay $0 or $225 copayment per days 1 through 6 $0 for days 7 and beyond

Unlimited number of days for an inpatient hospital stay $0 coinsurance- days 1-90 10% of the cost per day for days 91 and beyond copayment

Inpatient Rehab Hospital

N/A

Unlimited number of days for an inpatient hospital stay $0 or $225 copayment for days 1 through 6 $0 for days 7 and beyond

Unlimited number of days for an inpatient hospital stay $0 coinsurance- days 1-90 10% of the cost per day for days 91 and beyond copayment

Inpatient Psych

30 Days per Fiscal Year

Up to 190 days in a lifetime for inpatient mental healthcare in a psychiatric hospital. The inpatient psychiatric hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay.

Up to 190 days in a lifetime for inpatient mental healthcare in a psychiatric hospital. The inpatient psychiatric hospital care limit does not apply to inpatient mental services provided in a general hospital. Our plan covers 90 days for an inpatient hospital stay.

$0 or $225 copayment for days 1 through 6 $0 for days 7 through 90

19

$0 copayment

SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H5932, PLANS 001 AND 009

Benefit

Medicaid State Plan Benefit Limits

Gateway Health Medicare Assured RubySM***

Gateway Health Medicare Assured DiamondSM**

Inpatient Drug & Alcohol

30 Days per Fiscal Year

Unlimited number of days for inpatient stay $$0 or 225 copayment for days 1 through 6 $0 for days 7 through 90

Unlimited number of days for an inpatient hospital stay $0 coinsurance- days 1-90 10% of the cost per day for days 91 and beyond

Emergency Room

N/A

$0 or $65 copayment

$0 copayment

Outpatient Hospital Short Procedure Unit and Ambulatory Surgical Center

N/A

Outpatient Hospital: $0 or $175 copayment Ambulatory surgical center: $0 or $175 copayment

$0 copayment

Outpatient Hospital Clinic

18 visits per Fiscal Year*

Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $0 or $30 copayment Outpatient therapy visit, physical therapy and speech and language visit: $0 or $30 copayment

Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $0 copayment Outpatient therapy visit, physical therapy and speech and language visit: $0 copayment

Outpatient Psych Clinic

5 hours psychotherapy per 30 days

$0 or $30 copayment

$0 copayment

Psych Partial

540 hours per Fiscal Year

Partial Hospitalization $0 or $55 per day copayment

Partial Hospitalization $0 per day copayment

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SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H5932, PLANS 001 AND 009

Benefit

Medicaid State Plan Benefit Limits

Gateway Health Medicare Assured RubySM***

Gateway Health Medicare Assured DiamondSM**

Outpatient Drug & Alcohol Clinic

8 hours psychotherapy per 30 days 7 methadone visits per week 42 opiate detox visits per 365 days

$0 or $30 copayment for individual or group sessions.

$0 copayment or individual or group sessions.

Independent Medical Clinic

18 visits per Fiscal Year*

$0 or $15 copayment for PCP visit

$0 copayment for PCP visit

$0 or $30 copayment for specialist visit

$0 copayment for specialist visit copayment

Federally Qualified Health Center/ Rural Health Center

18 visits per Fiscal Year*

$0 or $15 copayment for PCP visit

$0 copayment for PCP visit $0 copayment for specialist visit

Family Planning Clinic

18 visits per Fiscal Year*

$0 or $30 copayment for specialist visit Plan does not provide counseling or referral services related to contraceptive services, female sterilization services, male sterilization services or abortion services. To the extent these services are covered by Medicare, they will be covered through an alternative process.

21

Plan does not provide counseling or referral services related to contraceptive services, female sterilization services, male sterilization services or abortion services. To the extent these services are covered by Medicare, they will be covered through an alternative process.

l

SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H5932, PLANS 001 AND 009

Medicaid State Plan Benefit Limits N/A

Gateway Health Medicare Assured RubySM*** N/A

Gateway Health Medicare Assured DiamondSM** N/A

Physician Services

18 visits per Fiscal Year*

Primary Care Physician: $0 or $15 copayment Specialist: $0 or $30 copayment

Primary Care Physician: $0 copayment Specialist: $0 copayment

Certified Registered Nurse Practitioner Services

18 visits per Fiscal Year*

$0 or $40

$0 copayment

Optometrist Services

18 visits per Fiscal Year*

1 routine eye exam every 3 months, $0 copayment

1 routine eye exam every 3 months, $0 copayment

Podiatrist Services

18 visits per Fiscal Year*

$0 or $30 copayment

$0 copayment

Renal Dialysis

N/A

0% or 20% co-insurance

0% co-insurance

Hospice

N/A

$0 copayment

$0 copayment

Skilled Nursing Facility / Long Term Care

N/A

Up to 100 days, Days 1 – 20, $0 copayment Days 21- 100, $0 or $156.50 per day copayment

Up to 100 days, $0 copayment

Benefit Maternity Physician, Certified Nurse Midwife, Birth Center

22

l

SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H5932, PLANS 001 AND 009

Benefit

Medicaid State Plan Benefit Limits

Gateway Health Medicare Assured RubySM***

Gateway Health Medicare Assured DiamondSM**

Intermediate Care Facility / Mental Retardation and Intermediate Care Facility / Other Related Conditions

N/A

Not covered

Not covered

Laboratory

N/A

$0 copayment

$0 copayment

Radiology (x-ray)

N/A

$0 or $30 copayment for outpatient x-rays

$0 copayment

Home Health Agency

N/A

$0 copayment

$0 copayment

Medical Supplies

Categorically Needy unlimited

0% or 20% coinsurance

$0 copayment

0% or 20% coinsurance

$0 copayment

Medically Needy - only in conjunction with Home Health Agency services Durable Medical Equipment

Categorically Needy unlimited Medically Needy - only in conjunction with Home Health Agency services

23

l

SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H5932, PLANS 001 AND 009

Medicaid State Plan Benefit Limits N/A

Gateway Health Medicare Assured RubySM*** $0 or $200 copayment

Gateway Health Medicare Assured DiamondSM** $0 copayment

Non-Emergency Medical Treatment

N/A

Primary Care Physician: $0 or $15 copayment Specialist: $0 or $30

Primary Care Physician: $0 copayment Specialist: $0 copayment

Pharmacy

Categorically Needy N/A1 Medically Needy - Not covered

Generic drugs: $0, $1.20 or $2.65 copayment Brand drugs:

Generic drugs: $0, $1.20 or $2.65 copayment Brand drugs:

$0, $3.60 or $6.60 copayment

$0, $3.60 or $6.60 copayment

Audiologist Services

Under age 21 only

$0 copayment

$0 copayment

Case Management (Targeted Case Management)

Limited to target groups

N/A

N/A

Chiropractor Services

18 visits per Fiscal Year*

Limited to manipulation of the spine to correct a subluxation, $0 or $20 copayment

Limited to manipulation of the spine to correct a subluxation, $0 copayment

Benefit Ambulance (emergency)

24

l

SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H5932, PLANS 001 AND 009

Benefit Dentist Services (office)

Eyeglasses

Medicaid State Plan Benefit Limits

Gateway Health Medicare Assured RubySM***

Gateway Health Medicare Assured DiamondSM**

Categorically Needy unlimited Medically Needy - only in conjunction with Home Health Agency services 2 New dental limits will apply to adults effective 9/30/11: Dental exams and prophylaxis are limited to 1 per 180 days, per recipient; crowns, endodonic and periodontal services will not be covered; and dentures will be limited to one upper arch or partial and one lower arch or partial, or one full set of dentures per lifetime. A Benefit Limit Exceptions process will be available. These dental changes do not apply to adults who live in a nursing facility, ICF/MR or ICF/ORC settings.

Preventive dental services, $0 copayment, includes: Cleaning: 1 every 6 months Dental x-ray: 1 dental bite-wing xray per side, every 6 months, 1 panoramic x-ray every 5 years Oral exam: 1 every 6 months

Preventive dental services, $0 copayment, includes: Cleaning: 1 every 6 months Dental x-ray: 1 dental bite-wing xray per side, every 6 months, 1 panoramic x-ray every 5 years Oral exam: 1 every 6 months

Under age 21 only

Comprehensive dental coverage is $500 every 2 years, limited to fillings, simple extractions and denture repair. Dental services, such as root canals, crowns, surgical extractions & gum treatments, not covered. Dentures, up to 1 complete set every 5 years. Partial dentures are not a covered benefit.

Eyeglasses (frames and lenses), 1 per year. Plan pays up to $150 every year for contact lenses and eyeglasses 25

Eyeglasses (frames and lenses), 1 per year. Plan pays up to $150 every year for contact lenses and eyeglasses

l

SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H5932, PLANS 001 AND 009

Benefit

Medicaid State Plan Benefit Limits

Gateway Health Medicare Assured RubySM***

Gateway Health Medicare Assured DiamondSM**

Hearing Aids

Under age 21 only

Plan pays up to $1000 every two years for hearing aids

Plan pays up to $1000 every two years for hearing aids

Personal Care

Under age 21 only

Not Available

Not Available

Private Duty Nursing

Under age 21 only

Not Available

Not Available

Psychologist Services (office)

Under age 21 only

$0 or $30 copayment

$0 copayment

Residential Treatment Facility

Under age 21 only

Not Available

Not Available

Social Worker Services

Under age 21 only

Not Available

Not Available

Therapy (Speech, Language, Hearing)

Under age 21 only

Outpatient therapy visit, physical therapy and speech and language visit: $0 or $30 copayment

Outpatient therapy visit, physical therapy and speech and language visit: $0 copayment

N/A

N/A

Home and Community-Based Services

Personal Assistance Services Home Health Accessibility Adaptations, Equipment, Technology, and Medical Supplies

26

l

SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H5932, PLANS 001 AND 009

Benefit Home and Community-Based Services ( continued)

Medicaid State Plan Benefit Limits Respite Therapeutic and Counseling Services Financial Management Services Community Transition Services

Gateway Health Medicare Assured RubySM*** N/A

Gateway Health Medicare Assured DiamondSM** N/A

Personal Emergency Response System (PERS) Adult Daily Living TeleCare Non-Medical Transportation Community Integration Supported Employment Education Services Service Coordination Home Delivered Meals Prevocational Services ParticipantDirected Community Supports ParticipantDirected Goods and Services Residential Habilitation Structured Day Habilitation 27

l

SUMMARY OF MEDICAID-COVERED BENEFITS FOR CONTRACT H5932, PLANS 001 AND 009

* Combined total of specific evaluation, management and consultation procedures y physicians, podiatrists, optometrists, CRNPS, chiropractors, outpatient and independent clinics, RHCs and FQHCs. Limit applies to adults, excluding adults who are pregnant or live in a nursing facility, ICF/MR or ICF/ORC settings. A Benefit Limit Exceptions process is available. 1

A 6 RX limit per month will apply to adults effective 1/1/12. A Benefit Limit Exceptions process will be available.

** In this plan, you may pay nothing for Medicare-covered services, depending on your level of Medicaid eligibility *** In this plan, what you pay for covered services may depend on your level of Medicaid eligibility.

28

Multi-language Interpreter Services English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-800-685-5209. Someone who speaks English/Language can help you. This is a free service. Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1800-685-5209. Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Chinese Mandarin: 我们提供免费的翻译服务,帮助您解答关于健康或药物保险的任何疑 问。如果您需要此翻译服务,请致电1-800-685-5209。我们的中文工作人员很乐意帮助您。 这是一项免费服务。 Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問,為此我們提供免費的翻譯 服務。如需翻譯服務,請致電1800-685-5209。我們講中文的人員將樂意為您提供幫助。這 是一項免費服務。 Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-800-685-5209. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo. French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au 1-800-685-5209. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit. Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-800-685-5209 sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí .

German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-800-685-5209. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos. Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를 제공하고 있습니다. 통역 서비스를 이용하려면 전화1-800-685-5209 번으로 문의해 주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다. Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону 1-800-685-5209. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная. Arabic1:

‫ ليس عليك سوى‬،‫ للحصول على مترجم فوري‬.‫إننا نقدم خدمات المترجم الفوري المجانية لإلجابة عن أي أسئلة تتعلق بالصحة أو جدول األدوية لدينا‬ ‫ سيقوم شخص ما يتحدث العربية‬.5006-605-000-1 ‫ هذه خدمة مجانية االتصال بنا على‬.‫بمساعدتك‬. Hindi1: हमारे स्वास््य या दवा की योजना के बारे में आपके ककसी भी प्रश्न के जवाब दे ने के लिए हमारे पास मुफ्त दभ ु ाषिया सेवाएँ उपिब्ध हैं.

एक दभ ु ाषिया प्राप्त करने के लिए, बस हमें 1-800-685-5209 पर फोन करें . कोई व्यक्तत जो हहन्दी बोिता है आपकी मदद कर सकता है . यह एक मुफ्त सेवा है .

Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-800-685-5209. Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito. Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do

número 1-800-685-5209. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito. French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-800-685-5209. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis. Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-800-685-5209. Ta usługa jest bezpłatna.

Japanese: 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするため に、無料の通訳サービスがありますございます。通訳をご用命になるには、1-800-6855209にお電話ください。日本語を話す人 者 が支援いたします。これは無料のサー ビスです。

NOTES

Four Gateway Center 444 Liberty Avenue, Suite 2100 Pittsburgh, PA 15222-1222

1-888-905-1302/TTY: 711 8 a.m. - 8 p.m., 7 days a week www.MedicareAssured.com

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