Transcription of 2018 Summary of Benefits H1587 002 - …
1 For more information, contact Horizons (HMO-POS) from 8:00 to 8:00 , 7 days a week at 1-877-372-1033 (TTY users call 711) or visit Accepted2018 Summary of Benefits H1587 002 January 1, 2018-December 31, 2018 2 This is a Summary of drug and health services covered byHorizons (HMO-POS),January 1, 2018 - December 31, 2018 Horizons (HMO-POS) is a Medicare Advantage HMO plan with a Medicare contract. Enrollment in the Plan depends on contract renewal. The benefit information provided is a Summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the Evidence of Coverage.
2 To join Horizons (HMO-POS), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in Arkansas. Horizons (HMO-POS) has 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 all Medicare health plans, we cover everything that Original Medicare covers. (If you want to know more about the coverage and costs of Original Medicare, look in your Medicare & You 2018 Handbook. View it online at or ask for 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.)3 Premiums and BenefitsHorizons (HMO-POS)What you should knowMonthly Plan PremiumYou pay $ must continue to pay your Medicare Part B $0 This plan does not have a Out-of-Pocket Responsibility (does not include prescription drugs)$6,700 annuallyThe most you pay for copays, coinsurance and other costs for medical services for the Hospital Coverage*You pay $0 deductibleYou pay $360 per day for days 1 - 5 You pay $0 copay per day for days 6 90 You pay $658 copay per lifetime reserve day (days 91-150)
3 Doctor Visits Primary SpecialistsYou pay $0 copay per visit You pay $50 copay per visitPreventive CareYou pay nothingAny additional preventive services approved by Medicare during the contract year will be covered. There are some items not covered at $0 Care$80 per visitUrgently Needed Services You pay $35 copay per visitDiagnostic Services/Labs/Imaging Diagnostic radiologyservice ( , MRI) Lab services Diagnostic tests andprocedures Outpatient x-raysYou pay $100 copayYou pay 20% of covered servicesYou pay 20% of covered servicesYou pay 20% of covered servicesPrior authorization is required for some services by your doctor or other network provider.
4 Please contact the plan for more Services Diagnostic Hearing /Balance examYou pay 20% of covered servicesPrior Authorization is required4 BenefitsHorizons (HMO-POS)What you should knowDental Services Oral exam & cleaning Fillings Complete dentures$1,200 annual benefit for Comprehensive Dental includes: Preventive Services 2 Annual Cleanings Restorative Services Endodontics / Periodontics / Extractions / Prosthodontics Other Oral / Maxillofacial Surgery, or Other ServicesVision ServicesMental Health Services Inpatient Hospital* Outpatient group therapyvisit Outpatient individualtherapy visito You pay $0 deductibleo You pay $230 for days 1-7o You pay $0 copay per day fordays 8-90o You pay $658 copay perlifetime reserve day (days 91and beyond)You pay $40 per sessionYou pay $40 per sessionPrior Authorization is required for hospital based (inpatient)
5 ServicesProvider is encouraged to bill the plan for covered servicesMember reimbursement is allowed with receipt and supporting is encouraged to bill the plan for covered servicesMember reimbursement is allowed with receipt and supporting documentation.$25 annual benefit toward eye exams$75 annual benefit for Eyeglasses (lenses and/or frames)Annual benefit inclusive of services provided by either in-network or out-of-network (POS) providers5 BenefitsHorizons (HMO-POS)What you should knowSkilled Nursing Facility*Rehabilitation Services You pay $40 per sessionYou pay $40 per sessionYou pay $40 per sessionAmbulanceYou pay $250 per tripTransportationTwelve (12) one-way trips are provided at no cost and inclusive of services provided by either in-network or out-of-network (POS) providers Over the Counter (OTC)
6 Medication / Supplies /Equipment$ monthly benefit fo ele t me i tion lie n e i mentMedical Equipment / Supplies Durable Medical Equipment( , wheelchairs, oxygen) Prosthetics ( , braces,artificial limbs) Diabetes suppliesPrior authorization required for billed charges in excess of $1,000 Long term care residents covered as if in private residenceM i r P r r sYou pay 20% of covered services Occupational therapy visit Physical therapy visit speech / language therapyFoot Care (podiatry services) O e by llin Member^e i e Eo Zeimb ement fo e on l h e Zero hospitals days required prior to SNF admission. Plan covers 100 days in SNF per benefit periodPrior Authorization is required for stays greater than 20 days per benefit periodYou pay 20% of covered servicesYou pay 20% of covered servicesYou pay 20% of covered servicesYou must allow 48 hours notice for any transportation scheduling assistanceYou pay $35 copay per visitCardiac / Pulmonary RehabYou pay 20% of covered servicesYou pay nothing for the first 20 days of each benefit periodYou pay $160 per day for days 21-100 You pay all costs for each day after day 1006 Outpatient Prescription DrugsStage 1 Yearly DeductibleStage Stage 2 InitialCoverageStage Stage 3 CoverageGapStage Stage 4
7 CatastrophicCoverageStageYour Cost for Initial Coverage StageBecause there is no deductible for the plan, this payment stage does not apply to this stage, the plan will pay most of the costs of your drugs for the rest of the calendar year (through December 31, 2018).Your costs for covered prescriptions:Preferred Generic$ $ Brand$ Drug$100 Specialty Tier33%You begin in this stage when you fill your first prescription of the year. During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost (see charges to the right).You stay in this stage until your year-to-date "total drug costs" total $3, this stage, you pay 35% of the price for brand name drugs and 44% of the price for genericYou stay in this stage until your Year-to-date "out-of-pocket costs" total $5,000 Anti-Discrimination Notice as defined in Section 1557 of the Affordable Care Act of 2010 English Horizons complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
8 Horizons does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Horizons: Provides free aids and services to people with disabilities to communicate effectivelywith us, such as:oQualified sign language interpretersoWritten information in other formats (large print, audio, accessible electronicformats, other formats) Provides free language services to people whose primary language is not English,such as:oQualified interpretersoInformation written in other languagesIf you need these services, contact Raquel Chapman. If you believe that Horizons has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Raquel Chapman, Corporate Compliance Director, 1 Riverfront Place, Suite 525, North Little Rock, AR 72116, 1-877-372-1033, (TTY: 711), Fax-1-800-413-8347, Youcan file a grievance in person or by mail, fax, or email.
9 If you need help filing a grievance,Raquel Chapman, Corporate Compliance Director is available to help can also file a civil rights complaint with the Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at , or by mail or phone at: Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, 20201 1-800-368-1019, 800-537-7697 (TDD)Complaint forms are available at Interpreter Services Espa ol (Spanish) Si usted, o alguien a quien usted est ayudando, tiene preguntas acerca de Horizons HMO POS, tiene derecho a obtener ayuda e informaci n en su idioma sin costo alguno.
10 Para hablar con un int rprete, llame al 1-877-372-1033 (TTY:711). Ti ng Vi t (Vietnamese) N u qu v , hay ng i m qu v ang gi p , c c u h i v Horizons HMO POS, qu v s c uy n c gi p v c th m th ng tin b ng ng n ng c a m nh mi n ph . n i chuy n v i m th ng ch vi n, xin g i 1-877-372-1033 (TTY:711). (Marshallese) e kwe, ak bar juon eo kw j jipa e, ew r an kajjit k k n Horizons HMO POS, ew r a jimwe in b k jipa im kein k je ko ilo kajin eo a ejje k w n. an k nono ipp n juon ri-uk t, kwon kaa k an 1-877-372-1033 (TTY:711). (Chinese) [ SBM Horizons HMO POS, [ 1-877-372-1033 (TTY:711) (Laotian) , , Ho rizons HMO POS.]]
