Y0066_SB_H3113_005_2017 Accepted

2017 Summary of

BENEFITSUnitedHealthcare Dual Complete® ONE (HMO SNP)

H3113-005

Our service area includes the following counties in:New Jersey: Atlantic, Bergen, Burlington, Camden, Essex, Gloucester, Hudson, Hunterdon, Mercer, Middlesex, Monmouth, Morris, Ocean, Passaic, Somerset, Union counties

This is a summary of drug coverages and health services provided by UnitedHealthcare Dual Complete® ONE (HMO SNP)January 1st, 2017 – December 31st, 2017For more information, please contact Customer Service at:

Toll-Free 1-800-514-4911, TTY 7118 a.m. – 8 p.m. local time, 7 days a week

www.UHCCommunityPlan.com

Summary of BenefitsJanuary 1, 2017 – December 31, 2017

We’re dedicated to providing clear and simple information about your plan so you always stay fully informed. The following information is a breakdown of what we cover.Keep in mind that this isn’t a full list of benefits we cover, it’s just an overview. To get a complete list of benefits and services, visit our website at www.UHCCommunityPlan.com to see the “Evidence of Coverage” or call customer service with any questions or to order a copy of the “Evidence of Coverage.”

About this plan.To join UnitedHealthcare Dual Complete® ONE (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, entitled to full Medicaid, live in our service area as listed on the cover, and be a United States citizen or are lawfully present in the United States.UnitedHealthcare Dual Complete® ONE (HMO SNP) is a Dual Eligible Special Needs Plan (D-SNP) for individuals who do not have any cost sharing responsibility.

What’s inside?

Plan Premiums and BenefitsSee plan costs including the monthly plan premium, deductible and maximum out-of-pocket limit.UnitedHealthcare Dual Complete® ONE (HMO SNP) has a network of doctors, hospitals, pharmacies, and other providers. If you use providers or pharmacies that are not in our network, the plan may not pay for these services or drugs.You can search for a network provider or pharmacy in the online directories at www.UHCCommunityPlan.com.

Drug CoverageWe provide coverage for many Part D drugs. In addition, we provide coverage for certain Part B drugs, such as chemotherapy and some drugs administered by your provider. Look to see what drugs are covered along with any restrictions in our plan formulary (list of Part D prescription drugs) found at www.UHCCommunityPlan.com.

UnitedHealthcare Dual Complete® ONE (HMO SNP)

Premiums and Benefits In-NetworkMonthly Plan Premium There is no monthly premium for this plan.

Annual Medical Deductible This plan does not have a deductible.

Maximum Out-of-pocket Amount (does not include prescription drugs)

As a UnitedHealthcare Dual Complete® ONE (HMO SNP) member, you have no out-of-pocket expenses. You will not be responsible for any co-payments or co-insurance for drugs or other covered services provided by plan providers.

UnitedHealthcare Dual Complete® ONE (HMO SNP)No prior authorizations or referrals are needed for covered services from plan providers.

Benefits In-NetworkInpatient Hospital Coverage $0 co-pay

Doctor Visits Primary $0 co-pay

Specialists $0 co-pay

Preventive Care Medicare-covered $0 co-pay

Routine physical $0 co-pay; 1 per year

Emergency Care $0 co-pay $0 co-pay for worldwide coverage per visit

Urgently Needed Services $0 co-pay

Diagnostic Tests, Lab and Radiology Services, and X-rays

Diagnostic radiology services (e.g., MRI)

$0 co-pay per service

Lab services $0 co-pay per service

Diagnostic tests and procedures

$0 co-pay per service

Therapeutic Radiology

$0 co-pay per service

Outpatient X-rays $0 co-pay per service

Hearing Services

Routine hearing exams, exams to diagnose and treat hearing and balance issues, exams for the purpose of fitting hearing aids, follow-up exams and adjustments, and repairs after warranty expiration.

Hearing aids, as well as associated accessories and supplies, are covered.

$0 co-pay

Benefits In-NetworkDental ServicesIncludes diagnostic, preventive, restorative, endodontic, periodontal, prosthetic, and oral and maxillofacial surgical services, including routine dental exams, cleanings, dental X-rays, fillings, dentures and fixed prosthodontics.

$0 co-pay

Vision ServicesCovers medically necessary eye care services for detection and treatment of disease or injury to the eye, including a comprehensive eye exam once per year. Optometric services and optical appliances are covered, including 1 pair of lenses/frames or contact lenses every 24 months for those age 19 through 59, and once per year for those 18 years of age or younger and those 60 years of age or older. Artificial eyes, low vision devices, vision training devices, and intraocular lenses are also covered.

Standard eyewear after cataract surgery is also covered.

$0 co-pay

Benefits In-NetworkMental Health CareInpatient Services• Covers services in a general

hospital, psychiatric unit of an acute care hospital, Short Term Care Facility, or critical access hospital.

• Inpatient psychiatric services in State, private, or county hospitals are covered for those under age 21, and those age 65 and older.

• Inpatient psychiatric services in a general hospital are covered for patients of any age.

• Inpatient mental health services are covered for all members by the plan for up to 190 days. Inpatient mental health services beyond 190 days are covered for members by Medicaid Fee-for-Service.

• Partial Hospitalization/Acute Partial Hospitalization is covered for all members by the plan.

• Inpatient Substance Abuse Treatment: Detoxification in a medical acute care inpatient setting is covered by the plan.

• Residential Substance Abuse Treatment: Treatment in a facility licensed to provide residential alcohol and substance abuse services is covered for members by Medicaid Fee-for-Service.

$0 co-pay

Benefits In-NetworkMental Health Care (cont.)Outpatient Services• Outpatient psychiatric services

in general hospitals and private psychiatric hospitals are covered for members of all ages.

• The plan covers mental health services in hospital-based and community-based settings. The plan covers mental health screenings, referrals, prescription drugs, and treatment of conditions.

• The plan covers outpatient psychiatric services in private psychiatric hospitals for members of all ages.

• The plan covers outpatient psychiatric services in general hospitals for members of all ages.

$0 co-pay

Skilled Nursing Facility (SNF) Care in a Skilled Nursing Facility is covered for all members, and that coverage includes long-term (custodial) care, beyond Medicare limits.

$0 co-pay

Rehabilitation Services

Occupational therapy

$0 co-pay

Physical therapy, speech and language therapy, and cognitive rehabilitation

$0 co-pay

Ambulance $0 co-pay

Routine TransportationCovered by Medicaid fee-for-service for routine/non-emergent ground transportation to medically necessary services.

$0 co-pay

Benefits In-NetworkFoot Care (podiatry services)

Covers routine exams and medically necessary podiatric services, as well as therapeutic shoes or inserts for those with severe diabetic foot disease, and exams to fit those shoes or inserts.

Routine hygienic foot care, such as the treatment of corns and calluses, trimming of nails, and care such as cleaning or soaking feet, is only covered when medically necessary as treatment for an associated condition.

$0 co-pay

Medical Equipment/Supplies

Durable Medical Equipment (e.g., wheelchairs, oxygen)

$0 co-pay

Prosthetics (e.g., braces, artificial limbs)

$0 co-pay

Wellness Programs

Fitness program through SilverSneakers®

Basic membership in a Fitness Program at a network location

Medicare Part B Drugs

Chemotherapy drugs

$0 co-pay

Other Part B drugs

$0 co-pay

Prescription Drugs

Annual pharmacy deductible Since you have no deductible, this doesn’t apply.

30-day supply from retail network pharmacy

Generic (including brand drugs treated as generic)

$0 co-pay

All other drugs $0 co-pay

Additional Benefits In-NetworkAcupuncture $0 co-pay

Clinical TrialsCovered for services rendered beyond Medicare Part B limits. Covered for Medicaid approved services.

$0 co-pay

Diabetes Management

Diabetes monitoring supplies

$0 co-pay

We only cover blood glucose monitors and test strips from the following brands: OneTouch Ultra®2 System, OneTouch Ultra Mini,® OneTouch Verio,® OneTouch Verio®Sync, OneTouch Verio®IQ, OneTouch Verio® Flex System Kit, ACCU-CHEK® Nano SmartView, ACCU-CHEK® Aviva Plus.

Diabetes Self-management training

$0 co-pay

Therapeutic shoes or inserts

$0 co-pay

Family Planning Services and SuppliesCovered services include medical history and physical examination (including pelvis and breast), diagnostic and laboratory tests, drugs and biologicals, medical supplies and devices (including pregnancy test kits, condoms, diaphragms, Depo-Provera injections, and other contraceptive supplies and devices), counseling, continuing medical supervision, continuity of care and genetic counseling. Covered for services rendered beyond Medicare Part B limits. Services furnished by out-of-network providers are covered by Medicaid Fee-for-Service.

$0 co-pay

Additional Benefits In-NetworkHome Health CareCovered for services rendered beyond Medicare Parts A and B limits. Includes nursing services and home health aide services. Physical therapy, speech-language pathology, and occupational therapy are also covered as part of this benefit.

$0 co-pay

HospiceCovered in the community as well as in institutional settings. Room and board services are included only when services are delivered in institutional (non-private residence) setting. Hospice care for children under 21 years of age shall cover both palliative and curative care.

$0 co-pay

Managed Long Term Services and Supports (MLTSS) Managed Long Term Services and Supports (MLTSS) is a program that provides Home and Community Based services for members that require the level of care typically provided in a Nursing Facility, and allows them to receive necessary care in a residential or community setting. MLTSS services include (but are not limited to): assisted living services; cognitive, speech, occupational, and physical therapy; chore services; home-delivered meals; residential modifications (such as the installation of ramps or grab bars); vehicle modifications; social adult day care; and non-medical transportation.

MLTSS is available to members who meet certain clinical and financial requirements.

For more information on MLTSS, call Customer Service (phone numbers are printed on the back cover of this booklet).

$0 co-pay

Additional Benefits In-NetworkMedical Day CareProvides preventive, diagnostic, therapeutic and rehabilitative services under medical and nursing supervision in an ambulatory care setting to meet the needs of individuals with physical and/or cognitive impairments in order to support their community living.

$0 co-pay

NurseLineSM Speak with a registered nurse (RN) 24 hours a day, 7 days a week

Nurse Midwife Services $0 co-pay

Outpatient Substance AbuseOutpatient group therapy visit

Outpatient individual therapy visit

Methadone cost, administration, and maintenance are covered by Medicaid Fee-for-Service; except for members with MLTSS, for whom it is covered by the plan.

$0 co-pay

Outpatient Surgery $0 co-pay

Over-the-Counter Benefit

Health Products Benefit

$141 credit per quarter on a debit card for approved products at network retail locations $175 credit per quarter to use on approved health products that can be ordered online or by mail.

Renal Dialysis $0 co-pay

Personal Care AssistantCovers health related tasks performed by a qualified individual in a beneficiary’s home, under the supervision of a registered professional nurse, as certified by a physician in accordance with a beneficiary’s written plan of care.

$0 co-pay

Additional Benefits In-NetworkPersonal Emergency Response $0 co-pay for emergency response services through

an electronic monitoring system 24 hours a day, seven days a week.

Private Duty NursingWhen authorized, available for members up to 21 years of age. This benefit is also available to Managed Long Term Services and Supports (MLTSS) members of any age.

$0 co-pay

Eligibility RequirementsBelow are the categories of people who can enroll in UnitedHealthcare Dual Complete® ONE (HMO SNP):

• Qualified Medicare Beneficiary Plus (QMB+): You get Medicaid coverage of Medicare cost-share and are also eligible for full Medicaid benefits. Medicaid pays your Part A and Part B premiums, deductibles, co-insurance and co-payment amounts.

• Full Benefits Dual Eligible (FBDE): Medicaid provides assistance with Medicare cost-sharing. Medicaid also provides full Medicaid benefits.

If you are a QMB+ or FBDE:

You are eligible for Medicare benefits, as well as full Medicaid benefits. As a member of the plan, you will have no cost-shares for covered services or Part D prescription drugs. You will have no premiums, deductibles, coinsurance, or co-payments.

You must recertify your Medicaid eligibility every year to remain a member of this plan.

You must also live in our Service Area which is shown on the front cover of this Summary of Benefits.

This information is not a complete description of benefits. Contact the plan for more information. Limitations and restrictions may apply. Benefits may change on January 1 of each year.

This information is available for free in other languages. Please call our customer service number at 1-800-514-4911 , TTY 711, 8 a.m. - 8 p.m. local time, 7 days a week.

Esta información está disponible sin costo en otros idiomas. Comuníquese con nuestro Servicio al Cliente al número 1-800-514-4911 , TTY 711, de 8 a.m. – 8 p.m. hora local, los 7 días de la semana.

The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

This plan is available to anyone who has both Medicare and full Medicaid eligibility. Premiums are covered for enrollees of UnitedHealthcare Dual Complete ONE (HMO SNP).

Plans are insured through UnitedHealthcare or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a contract with the State Medicaid Program. Enrollment in the plan depends on the plan’s contract renewal with Medicare.

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.

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 1-888-834-3721 (TTY 711) if you are not a member, or call us at 1-800-514-4911 (TTY 711) if you are already a member.

The company does not discriminate on the basis of race, color, national origin, sex, age, or disability in health programs and activities.

We provide free services to help you communicate with us. Such as, letters in other languages or large print. Or, you can ask for an interpreter. To ask for help, please call the toll-free phone number listed on your ID card TTY 711, Monday through Friday, 8 a.m. to 8 p.m.

ATENCIÓN: Si habla español (Spanish), hay servicios de asistencia de idiomas, sin cargo, a su disposición. Llame al número de teléfono gratuito que aparece en su tarjeta de identificación.

請注意：如果您說中文 (Chinese)，我們免費為您提供語言協助服務。請撥打會員卡所列的免付費會員電話號碼。

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 1-800-514-4911. 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 1-800-514-4911. 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 1-800-514-4911。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，您此我們提供免費的翻譯 服務。如需翻譯服務，請致電 1-800-514-4911。我們講中文的人員將樂意您您提供幫助。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 1-800-514-4911. 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 1-800-514-4911. 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 1-800-514-4911 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 1-800-514-4911. 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 전화 1-800-514-4911 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 1-800-514-4911. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная.

Arabic:

Hindi: हमारे स्वास्थ्य या दवा की योजना के बारे में आपके किसी भी प्रश्न के जवाब देने के लिए हमारे पास मुफ्त दुभाषिया सेवाएँ उपलब्ध हैं. एक दुभाषिया प्राप्त करने के लिए, बस हमें 1-800-514-4911 पर फोन करें. कोई व्यक्ति जो हिन्दी बोलता 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 1-800-514-4911. 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 1-800-514-4911. 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 1-800-514-4911. 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 1-800-514-4911. 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、1-800-514-4911 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。

1194-415-008-1

UHNJ17HM3865800_003

Vendor InformationBefore contacting any of the providers below you must be fully enrolled in UnitedHealthcare Dual Complete ONE (HMO SNP).

Benefit Type Vendor Name Contact InformationNurse Line NurseLineSM 1-877-440-9407 , TTY 711

24 hours a day, 7 days a week

Health Products Benefit Catalog

FirstLine Medical® 1-800-933-2914, TTY 7117 a.m. – 7 p.m. Central Standard Time, Monday – Friday; 7 a.m. – 4 p.m. Central Standard Time, Saturdaywww.HealthProductsBenefit.com

Over-the-Counter Benefit

UnitedHealthcare 1-800-514-4911, TTY 7118 a.m. – 8 p.m. local time, 7 days a week

Personal Emergency Response

Tunstall Americas 1-800-514-4911, TTY 7118 a.m. – 8 p.m. local time, 7 days a week

Fitness Membership

SilverSneakers® Fitness program

1-888-423-4632, TTY 7118 a.m. – 8 p.m. Eastern Standard Time, Monday – Fridaysilversneakers.com