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HomeMy Public PortalAboutUniCare OME Benefits Summary 2018-2019UNI CARE® UNICARE STATE INDEMNITY PLAN An Anthem Company PLAN BENEFITS - MEDICARE EXTENSION For UniCare State Indemnity Plan/Medicare Extension members Effective July 1, 2018 Summary of Medicare Extension benefits This summary shows the Medicare Extension plan benefits for many medical and behavioral health services. For a complete and detailed description of benefits and Plan provisions, see your member handbook. ❑ Allowed amounts and Medicare -approved amounts — All benefits shown in this summary are limited to the Medicare -approved amount or UniCare's allowed amount, whichever is less: • The Medicare -approved amount is the most that Medicare pays for a covered service. • The UniCare allowed amount is the most that UniCare pays for a covered service. ❑ Preapprovals — Services marked with a II phone symbol need to be preapproved. Benefits for medical care under Medicare Extension Service Your member costs with CIC Your member costs without CIC Ambulances No member costs All costs over $25 Anesthesia No member costs No member costs Bereavement counseling 20% coinsurance (limited to $1,500 for a family in a calendar year) 20% coinsurance (limited to $1,500 for a family in a calendar year) Cardiac rehab programs No member costs No member costs Chemotherapy No member costs 20% coinsurance Chiropractic care 20% coinsurance (limited to 20 visits in a calendar year) 20% coinsurance (limited to 20 visits in a calendar year) Diabetic supplies ■ Preferred vendors: No member costs ■ Non -preferred vendors: 20% coinsurance ■ Preferred vendors: No member costs ■ Non -preferred vendors: 20% coinsurance Dialysis No member costs 20% coinsurance Doctors — office visits $10 copay $10 copay Doctors — other ■ Emergency room care ■ Inpatient hospital care ■ Outpatient hospital care No member costs No member costs $10 copay No member costs No member costs $10 copay Durable medical equipment (DME) ■ Preferred vendors: No member costs ■ Non -preferred vendors: 20% coinsurance ■ Preferred vendors: No member costs ■ Non -preferred vendors: 20% coinsurance ec872 (04/18) PLAN BENEFITS - MEDICARE EXTENSION (continued) Service Your member costs with CIC Your member costs without CIC Early intervention programs Emergency room l► Enteral therapy Eye exams (routine) Eyeglasses and contact lenses Family planning services Fitness club reimbursement Hearing aids ■ Age 21 and under • Age 22 and over Hearing exams rr Home health care Home infusion therapy Hospice care Immunizations (vaccines) Ts Inpatient hospital care ■ At a hospital or rehab facility (semi -private room) • At a hospital or rehab facility (medically necessary private room) • At a skilled nursing or long-term care facility Lab services ■ Inpatient hospital ■ Outpatient hospital ■ Non -hospital -owned location No member costs (limited to $5,200 for each child in a calendar year, with a lifetime limit of $15,600 for each child) $50 copay • Preferred vendors: No member costs • Non -preferred vendors: 20% coinsurance $10 copay (limited to one exam every 24 months) No member costs (limited to the first lenses within six months after eye injury or cataract surgery) No member costs Reimbursed up to $100 per member in a calendar year No member costs (limited to $2,000 for each impaired ear every 24 months) No member costs for first $500, then 20% coinsurance of the next $1,500 (up to a limit of $1,700 every 24 months) $10 copay • Preferred vendors: No member costs • Non -preferred vendors: 20% coinsurance • Preferred vendors: No member costs • Non -preferred vendors: 20% coinsurance No member costs No member costs (you may have costs for an office visit) No member costs The dollar difference between the semi -private room rate and the private room rate • For days paid by Medicare: 20% coinsurance starting on 101st day • For days not paid by Medicare: 20% coinsurance (limited to $10,000 in a calendar year) No member costs No member costs No member costs No member costs (limited to $5,200 for each child in a calendar year, with a lifetime limit of $15,600 for each child) $50 copay • Preferred vendors: No member costs • Non -preferred vendors: 20% coinsurance $10 copay (limited to one exam every 24 months) 20% coinsurance (limited to the first lenses within six months after eye injury or cataract surgery) No member costs Reimbursed up to $100 per member in a calendar year No member costs (limited to $2,000 for each impaired ear every 24 months) No member costs for first $500, then 20% coinsurance of the next $1,500 (up to a limit of $1,700 every 24 months) $10 copay • Preferred vendors: No member costs • Non -preferred vendors: 20% coinsurance • Preferred vendors: No member costs • Non -preferred vendors: 20% coinsurance No member costs No member costs (you may have costs for an office visit) No member costs The dollar difference between the semi -private room rate and the private room rate • For days paid by Medicare: 20% coinsurance starting on 101st day • For days not paid by Medicare: 20% coinsurance (limited to $7,500 in a calendar year) No member costs 20% coinsurance 20% coinsurance Page 2 PLAN BENEFITS - MEDICARE EXTENSION (continued) Service Your member costs with CIC Your member costs without CIC Occupational therapy ■ If Medicare pays: No member costs ■ If Medicare doesn't pay: 20% coinsurance 20% coinsurance Office visits $10 copay $10 copay Oxygen ■ Preferred vendors: No member costs • Non -preferred vendors: 20% coinsurance ■ Preferred vendors: No member costs ■ Non -preferred vendors: 20% coinsurance Personal Emergency Response Systems (PERS) ■ Installation ■ Rental 20% coinsurance (limited to $50 each calendar year) No member costs (limited to $40 a month) 20% coinsurance (limited to $50 each calendar year) No member costs (limited to $40 a month) Physical therapy ■ If Medicare pays: No member costs ■ If Medicare doesn't pay: 20% coinsurance $20% coinsurance Prescription drugs Benefits administered by SilverScript. Call 877-876-7214 for information. Preventive care No member costs No member costs i Private duty nursing in a home setting 20% coinsurance (limited to $8,000 in a calendar year) 20% coinsurance (limited to $4,000 in a calendar year) Prosthetics and orthotics ■ Breast prosthetics ■ Other prosthetics and orthotics No member costs ■ If Medicare pays: No member costs ■ If Medicare doesn't pay: 20% coinsurance No member costs ■ If Medicare pays: No member costs ■ If Medicare doesn't pay: 20% coinsurance Radiation therapy No member costs 20% coinsurance Radiology and imaging ■ Inpatient hospital ■ Outpatient hospital or non -hospital -owned location No member costs No member costs No member costs 20% coinsurance Retail health clinic visits $10 copay $10 copay and 20% coinsurance Sleep studies No member costs 20% coinsurance Speech therapy No member costs 20% coinsurance (limited to $2,000 in a calendar year) (limited to $2,000 in a calendar year) Surgery ■ In Massachusetts ■ Outside Massachusetts No member costs No member costs ■ Medicare participating: No member costs ■ Medicare non -participating: 100% of the difference between the Plan's allowed amount and the provider's charge ■ Medicare participating: No member costs ■ Medicare non -participating: 20% of the difference between the Plan's allowed amount and the provider's charge Tobacco cessation counseling No member costs (limited to 300 minutes each calendar year) No member costs (limited to 300 minutes each calendar year) Page 3 PLAN BENEFITS - MEDICARE EXTENSION (continued) Service Your member costs with CIC Your member costs without CIC Transplants ■ At a Quality Center or Designated Hospital for transplants ■ At other hospitals Urgent care center visits Wigs (after cancer treatment) No member costs 20% coinsurance $10 copay 20% coinsurance (limited to $350 each calendar year) No member costs 20% coinsurance $10 copay and 20% coinsurance 20% coinsurance (limited to $350 each calendar year) Benefits for behavioral health care under Medicare Extension Behavioral health benefits are higher when you get your behavioral health care from providers in the Beacon Health Options network. Service Your member costs with in -network providers Your member costs with out -of -network providers ii Acute care services No member costs 20% coinsurance Emergency care ■ Hospital emergency room ■ Emergency service programs $50 copay No member costs $50 copay No member costs Medication management Visits 1-4: no member costs After 4 visits: $5 copay Visits 1-15: 20% coinsurance After 15 visits: 50% coinsurance Methadone maintenance No member costs No member costs Tr Outpatient services Visits 1-4: no member costs After 4 visits: $10 copay Visits 1-15: 20% coinsurance After 15 visits: 50% coinsurance Substance use disorder assessment / referral No member costs No member costs Therapy ■ Family therapy ■ Group therapy ■ Individual therapy Visits 1-4: no member costs After 4 visits: $10 copay Visits 1-15: 20% coinsurance After 15 visits: 50% coinsurance Visits 1-15: 20% coinsurance After 15 visits: 50% coinsurance Visits 1-15: 20% coinsurance After 15 visits: 50% coinsurance Visits 1-4: no member costs After 4 visits: $5 copay Visits 1-4: no member costs After 4 visits: $10 copay UNI CARE. An Anthem Company vim 1.11 Commonwealth of Massachusetts in.. Group Insurance Commission Page 4 For self -funded plans, claims are administered by UniCare Life & Health Insurance Company. Insurance coverage is provided by UniCare Life & Health Insurance Company. © 2018 UniCare