2018 Summary of Benefits - Memorial Hermann Health …

1 2018 Summary of BenefitsMEMORIAL Hermann ADVANTAGE HMO AND Summary of Benefits document provides an outline of Health and drug services covered by Memorial Hermann Advantage HMO plan January 1, 2018 December 31, 2018. Memorial Hermann Advantage HMO is provided by Memorial Hermann Health Plan, Inc., a Medicare Advantage organization with a Medicare contract. Enrollment in this plan depends on contract renewal. This booklet gives you a Summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the "Evidence of Coverage." To join Memorial Hermann Advantage HMO, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. This information is not a complete description of Benefits .

2 Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits , premiums and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. Our service area includes the following counties in Texas: Fort Bend, Harris, and Montgomery. Y0110_FL_SBCAHMO18_CMS Accepted 09/19/2017 17E1-AHMO-SBC 2018 Summary of Benefits Memorial Hermann Advantage HMO H7115-001 1 Page Who can join?To join Memorial Hermann Advantage HMO, you must be entitled to Medicare Part A, be enrolled in Medicare Part B, and live in our service area. Our services areas are listed on the front cover of this Summary of 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.

3 For some ofthese Benefits , you may pay more in our plan than you would in Original Medicare. Forothers, you may pay less. Our plan members also get more than what is covered by Original Medicare. Some of theextra Benefits are outlined in this 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 anyrestrictions on our website, Or, call us and we will send you a copy of the doctors, hospitals, and pharmacies can I use? Memorial Hermann Advantage HMO 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 services. The formulary, pharmacy network, and/or provider network may change at any time.

4 You will receive notice when necessary. You must generally use network pharmacies to fill your prescriptions for covered Part Ddrugs. You can see our plan's provider directory at our website( ). You can see our plan's pharmacy directory at our website ( ).Or, call us and we will send you a copy of the provider and pharmacy will I determine my drug costs? Our plan groups each medication into one of five "tiers." You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. 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. 2 Page Things to Know About Memorial Hermann Advantage HMO Memorial Hermann Advantage HMO Phone Numbers, Days and Hours of Operations and Website information If you have question regarding becoming a member of Memorial Hermann Advantage HMO call us t oll-free at , TTY/TDD 711.

5 We are open from October 1 to February 14, 7 days a week from 8:00 to 8:00 Central time. During February 15 to September 30, you can call us Monday through Friday from 8:00 to 8:00 Central time. A licensed agent may answer your call. If you are a member of this plan, and would like an explanation of your requested Summary of Benefits call Customer Service toll-free at (TTY: 711). We are open from October 1 to February 14, 7 days a week from 8:00 to 8:00 Central time. During February 15 to September 30, you can call us Monday through Friday from8:00 to 8:00 Central time. Or, you may visit our website at 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 (TTY: 711). If you want to know more about the coverage and costs of Original Medicare, look in your current Medicare & You handbook.

6 View it online at or get a copy by calling ( ), 24 hours a day, 7 days a week. TTY users should call 3 Page Sections in this booklet Monthly Premium and Max Out of Pocket Preventative Care Hearing, Dental and Vision Benefits Medical and Hospital Benefits Prescription Drug Benefits 4 Page Premiums and Benefits Memorial Hermann Advantage HMO What you should know Monthly Plan Premium You pay nothing You must continue to pay your Medicare Part B premium. Deductible No deductible This plan does not have a medical deductible. Maximum Out-of-Pocket Responsibility (does not include Part D prescription drugs) You pay no more than $6,700 annually. The most you pay for copays, coinsurance, and other costs for medical services for the year. Inpatient Hospital Coverage You pay $250 per day for days 1 through 5 You pay nothing for days 6 through 90 Our plan covers an unlimited number of days for an inpatient hospital stay.

7 Requires prior authorization. Doctors Visits Primary Care Physician Visit: You pay $5 per visit Specialist Visit: You pay $50 per visit Cost share may apply for Part B injectables. For detailed information regarding additional cost shares for the other covered in office procedures/services provided by the Physician/Specialist, see the Medical Benefits Chart in Chapter 4 of the Evidence of Coverage. Preventive Care You pay nothing Preventive services include, but are not limited to: yearly wellness visit, colorectal screenings, flu vaccines, and many more. Any additional preventive services approved by Medicare during the contract year will be covered. 5 Page Outpatient Hospital Coverage You pay $300 for each Medicare-covered outpatient hospital facility pay $80 per visit If you are admitted to the hospital within 48 hours, you do not have to pay your share of the cost for emergency care.

8 Hearing Services Basic hearing and balance exam performed by a primary care doctor: You pay $5 Hearing to diagnose and treat hearing and balance issues: You pay $50 Annual Hearing Exam: You pay $50 Hearing Aid(s ) per year: $400 annual benefit $400 annual benefit to go towards the purchase of hearing aids. 6 Page Diagnostic Services/Labs/Imaging Blood services (transfusions) Non-radiologic diagnostic procedures/tests Diagnostic radiology services (MRI, CT, PET) Lab services Therapeutic radiology services (radiation) Outpatient X-rays You pay nothing You pay $75* You pay $200* You pay $5* You pay $25* You pay $10* Costs for these services may be different if received in an outpatient surgery setting. *per test*per test/procedureprior authorization required*per lab service*per session*per x-rayUrgently Needed Services You pay $35 per visit Emergency Care For Colorectal Screenings, please note that a colonoscopy conducted for polyp removal or biopsy is a sur gical procedure subject to the outpatient surgery cost sharing described later in this benefit grid.

9 Preventive Care (cont.) Dental Services Comprehensive Services: You pay $75 In general, preventive dental services (such as cleaning, routine dental exams, and dental x-rays) are not covered by Original Medicare. We cover: Medicare-covered dental services limited to surgery of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician. Prior Authorization required. Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing Eye Exam Performed by Optician/Optometrist/ Ophthalmologist: You pay $50 Eyewear per year(Contact Lenses, Eyeglasses (frames and lenses)): $200 annual benefit $200 annual benefit to go towards the purchase of eye-wear and contacts.

10 7 Page Limited dental services (does not include services in connection with care, treatment, filling, removal, or replacement of teeth). Skilled Nursing Facility You pay nothing for days 1 through 20 You pay $100 per day for days 21 through 100 Our plan covers up to 100 days in a skilled nursing facility per 60 day benefit Authorization required. Rehabilitation Services Cardiac (heart) Rehab Services: You pay $25 per visit Pulmonary Services: You pay $25 per visitOccupational Therapy Visit: You pay $25 per visit Physical Therapy and Speech and Language Therapy Visit: You pay $25 per visit 8 Page Mental Health Services (including Inpatient) Inpatient Services: You pay $250 per day for days 1 through 5 You pay nothing for days 6 through 90 Outpatient Services Outpatient group therapy visit: You pay $40 Outpatient individual therapy visit: You pay $40 Inpatient visit: Our plan covers an unlimited number of days for an inpatient hospital stay.