MEDICARE ADVANTAGE PLANS

2017 Summary of Benefits: Presbyterian Dual Plus (HMO SNP)

This is a summary of health and drug services covered by Presbyterian Dual Plus (HMO SNP) January 1, 2017 to December 31, 2017.

To enroll in Presbyterian Dual Plus (HMO SNP):

• You must be entitled to Medicare Part A and enrolled in Medicare Part B.

• You must have one of the following Medicaid Eligibility Categories: – Qualified Medicare Beneficiary (QMB+) – Specified Low-Income Medicare Beneficiary (SLMB+) – or Other Full Benefit Dual Eligible (FBDE)

• You must live in one of these New Mexico counties: Bernalillo, Sandoval, Torrance or Valencia.

Presbyterian Dual Plus (HMO SNP) has a network of doctors, hospitals, pharmacies, and other providers. If you use providers that are not in our network, the plan may not pay for these services.

Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. This information is not a complete description of benefits. Limitations, copayments, and restrictions may apply.

To get a complete list of benefits and services we cover, contact the plan or please refer to the Evidence of Coverage. You may easily download a copy of the Evidence of Coverage from our website, www.phs.org/medicare, and select For Members at the top of the page. You may also request a copy.

Presbyterian Dual Plus is an HMO Special Needs Plan (SNP) with a Medicare contract and a contract with the New Mexico State Department of Human Services Medicaid program. Enrollment in Presbyterian Dual Plus depends on contract renewal. Such services are funded in part with the State of New Mexico. You must also continue to pay your Medicare Part B premium.

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MEDICARE ADVANTAGE PLANS

BenefitsIf you qualify for full Medicaid benefits –

You Pay

If you DO NOT qualify for full Medicaid benefits –

You Pay the 2017 Medicare deductibles, coinsurance, or copayment amounts

Deductible $0 $166This amount may change for 2017

Maximum Annual Out-of-Pocket

$6,700This amount may change for 2017.

This is the most you will pay in a calendar year for covered medical and hospital services. It does not

include prescription drugs.

Inpatient Hospital Care Deductible

After Deductible• Days 1 – 60• Days 61 – 90• Days 91 and beyond

$0

$0 copayment per day$0 copayment per day$0 copayment per day

This amount may change for 2017$1,288 deductible for each

benefit period

$0 copayment per day$322 copayment per day$644 copayment per day

Doctor Visits• Primary Care• Specialists• Video Visits

$0 copayment$0 copayment$0 copayment

20% coinsurance20% coinsurance0% coinsurance

Preventive Care $0 copayment $0 copayment

Emergency Care (This copay is waived if admitted to the hospital.)

$0 copayment $75 copayment

Urgently Needed Services $0 copayment20% coinsurance to

$65 copayment

2017 Summary of Benefits Presbyterian Dual Plus (HMO SNP)

Monthly Plan Premium is $0 to $22.80Based on your Low-Income Subsidy (LIS) level, your plan premium could be paid by Medicare

MEDICARE ADVANTAGE PLANS

BenefitsIf you qualify for full Medicaid benefits –

You Pay

If you DO NOT qualify for full Medicaid benefits –

You Pay the 2017 Medicare deductibles, coinsurance, or copayment amounts

Diagnostic Services/ Labs/Imaging

$0 copayment $0 copayment

Routine Hearing Services• Hearing aid

$0 copaymentNot covered

$0 copaymentNot covered

Routine Dental Services Not covered Not covered

Vision Services• Annual routine exam • Diagnosis and treatment of diseases and conditions of eye• Eyeglasses or contact lenses after cataract surgery

$0 copayment$0 copayment

$0 copayment

$0 copayment20% coinsurance

20% coinsurance

Mental Health Services• Inpatient visit • Outpatient group therapy visit• Outpatient individual therapy visit

Same as InpatientHospital Care$0 copayment

$0 copayment

Same as InpatientHospital Care

20% coinsurance

20% coinsurance

Skilled Nursing Facility (SNF)• Days 1 - 20• Days 21 - 100• Days 101 and beyond

$0 copayment per day$0 copayment per day

100% of the costs

This amount may change for 2017

$0 copayment$161 copayment per day

100% of the costs

Rehabilitation Services• Cardiac and Pulmonary rehab• Occupational, Physical, and Speech and Language therapy visits

$0 copayment

$0 copayment

20% coinsurance

20% coinsurance

2017 Summary of Benefits Presbyterian Dual Plus (HMO SNP)

MEDICARE ADVANTAGE PLANS

BenefitsIf you qualify for full Medicaid benefits –

You Pay

If you DO NOT qualify for full Medicaid benefits –

You Pay the 2017 Medicare deductibles, coinsurance, or copayment amounts

Ambulance $0 copayment 20% coinsurance

Transportation Not covered Not covered

Foot Care (podiatry services)• Foot exams and treatment• Routine foot care

$0 copaymentNot covered

20% coinsuranceNot covered

Medical Equipment/Supplies• Durable Medical Equipment (e.g., wheelchairs, oxygen)• Prosthetics (e.g., braces, artificial limbs)• Diabetes supplies, services, and training

$0 copayment

$0 copayment

$0 copayment

20% coinsurance

20% coinsurance

20% coinsurance

Chiropractic (to correct subluxation)

$0 copayment 20% coinsurance

Home Health Care $0 copayment $0

HospiceCovered by

Original MedicareCovered by

Original Medicare

Outpatient Surgery $0 copayment 20% coinsurance

Medicare Part B Drugs and Chemotherapy Drugs

0% - 10% 0% - 5%

2017 Summary of Benefits Presbyterian Dual Plus (HMO SNP)

MEDICARE ADVANTAGE PLANS

Presbyterian Dual Plus (HMO SNP) Prescription Drug Benefits

Deductible Depending on your Low-Income Subsidy Level – You Pay: $0 - $400

Initial Coverage Depending on your Low-Income Subsidy Level, you pay the following:

Generic drugs (including brand drugs treated as generic), either• $0 copayment; or• $1.20 copayment; or• $3.30 copayment

For all other drugs, either• $0 copayment; or• $3.70 copayment; or• $8.25 copayment

You may get your drugs at network retail pharmacies and mail order pharmacies.

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.

Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,950, you pay nothing for all drugs.

MEDICARE ADVANTAGE PLANS

Supplemental Benefits Benefit

Acupuncture(limited to 20 visits/year)

You pay $0 copayment.

MealsUp to 55 meals delivered to your home

• You pay $0 copayment. • You will receive up to 55 meals delivered to your home after a hospital stay.• This program is uniquely designed to keep you. healthy and strong while you are recovering from an inpatient hospital stay. • The meal benefit is available during the 4 (four) week period following a hospital stay. • This benefit is offered through Meals on Wheels.

Over-the-Counter (OTC) Debit Card($35 per month)

• You will receive an OTC debit card that can be used to purchase non-prescription medications and health-related items.• The OTC debit card is reloaded with $35 each month. • Any unused balance is not carried over from month to month. • You may use the OTC debit card at Walgreens, Walmart, CVS, Family Dollar, Dollar General and other stores in the network.

Eyewear allowance • You will receive a $250 allowance every year. • You can use your allowance to purchase contact lenses, eyeglasses, lenses and frames.

Wellness Programs SilverSneakers® Fitness Membership Program is included. For participating locations visit www.silversneakers.com

2017 Summary of Benefits Presbyterian Dual Plus (HMO SNP)

MEDICARE ADVANTAGE PLANS

January 1, 2017 – December 31, 2017

SUMMARY OF NEW MEXICO MEDICARE/MEDICAID BENEFITS

Your state Medicaid program is called Centennial Care.

A person who is entitled to both Medicare and medical assistance from a State Medicaid plan is considered a dual eligible. As a dual eligible beneficiary your services are paid first by Medicare and then by Medicaid. Your Medicaid coverage varies depending on your income, resources, and other factors. Below is a list of Medicaid eligibility categories for beneficiaries who may enroll in the Presbyterian Dual Plus (HMO SNP) Plan. Typically, your cost-sharing is covered by both Medicare and Medicaid except for Part D prescription drug copayments.

• Qualified Medicare Beneficiary+ (QMB+)

• Specified Low-Income Medicare Beneficiary+ (SLMB+)

• Full-Benefit Dual Eligible (FBDE)

Eligibility Changes:

It is important to read and respond to all mail that comes from Social Security and your state Medicaid office and to maintain your Medicaid eligibility status.

Periodically, as required by CMS, we will check the status of your Medicaid eligibility as well as your dual eligible coverage category. If you are dual eligible coverage category changes, your cost-share may change if you lose Medicaid coverage entirely. You will be given a grace period to reapply for Medicaid.

If you no longer qualify for Medicaid you may be involuntarily disenrolled from the Plan. Your state Medicaid agency will send you notification of your loss of Medicaid or change in dual eligible coverage category.

If you are currently entitled to receive full Medicaid benefits please see your Medicaid member handbook or other state Medicaid documents for full details on your Medicaid benefits, limitations, restrictions, and exclusions.

MEDICARE ADVANTAGE PLANS

Financial assistance

As a Medicare beneficiary, you may qualify for money-saving programs based on your income to help you pay your plan premiums and drug copays.

Extra Help / Low-Income Subsidy (LIS)If you qualify for Extra Help, also called Low-Income Subsidy (LIS), your plan premium and drug copays will be reduced. The coverage gap (also known as the donut hole) in your prescription drug coverage is also eliminated. You must be on a plan that includes prescription drug coverage to qualify for Extra Help.

Qualifying income levels for 20161 – To qualify, your annual income and resources / assets need to be at or below the following:

Single Married

Monthly Income1: $1,485 Monthly Income1: $ 2,002.50

Resources / Assets2: $13,640 Resources / Assets2: $ 27,250.00

1 Income limits may change in 2017.2 The house you live in, the car you drive, life insurance policies, and burial plots do not count toward the resource / asset limit. Contact Social Security for other income / resource exclusions.

Medicaid and Other Medicare Savings Programs (MSP)Those who qualify for Extra Help may also qualify for Medicare Savings Programs that help pay Part A and/or Part B premiums. Medicaid programs may also lower your copays, depending on the level for which you qualify.

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 www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, seven days a week. TTY users should call 1-877-486-2048.

MEDICARE ADVANTAGE PLANS

For more information about Presbyterian Medicare Advantage plans, please call us at the phone numbers below or visit us at www.phs.org/medicare.

Presbyterian Medicare Sales Consultants

(505) 923-8458 or 1-800-347-4766 (TTY 711), 8 a.m. to 8 p.m., seven days a week

Presbyterian Customer Service Center (for members)

(505) 923-7675 or 1-855-465-7737 (TTY 711), 8 a.m. to 8 p.m., seven days a week

You can see our plan’s provider and pharmacy directory if you visit our website at www.phs.org/medicare and select Providers at the top of the page.

We cover Part D drugs on certain plans. 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 if you visit our website at www.phs.org/medicare and select Prescription Drugs at the top of the page.

This information is available for free in other languages.

To learn how we safeguard your Protected Health Information and your rights, call us at (505) 923-7675 or 1-855-465-7737 (TTY 711) or visit www.phs.org/medicare and select Privacy Notice at the bottom of the page.

FIND OUT IF YOU QUALIFY FOR ASSISTANCE

Presbyterian offers a personal service that helps you find out if you qualify for these money-saving programs. A trusted partner since 2006, My Advocate™, helps you apply for Extra Help / Low-Income Subsidy and Medicare Savings Programs.

Call My Advocate™ at 1-866-851-0324.________________________________________________________________________

You also have the option to contact:• 1-800-Medicare (1-800-633-4227), 24 hours a day, seven days a week

(TTY 1-877-486-2048)• Social Security, 1-800-772-1213 (TTY 1-800-325-0778)• NM State Human Services Department, 1-888-997-2583 (TTY 1-800-659-8331)

MEDICARE ADVANTAGE PLANS

MULTI-LANGUAGE INTERPRETER SERVICESMulti-language Interpreter Services

English ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 505-923-5420, 1-855-592-7737 (TTY: 711).

Spanish ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 505-923-5420, 1-855-592-7737 (TTY: 711).

Navajo   

D77 baa ak0 n7n7zin: D77 saad bee y1n7[ti’go Diné Bizaad, saad bee 1k1’1n7da’1wo’d66’, t’11 jiik’eh, 47 n1 h0l=, koj8’ h0d77lnih 505‐923‐5420, 1‐855‐592‐7737 (TTY: 711). 

Vietnamese CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 505-923-5420, 1-855-592-7737 (TTY: 711).

German ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 505‐923‐5420, 1‐855‐592‐7737 (TTY: 711). 

Chinese 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 505-923-5420, 1-855-592-7737 (TTY: 711)。 

Arabic (, 7737-592-855-1, 5420-923-505)مقرTTY:711( مقرب لصتا .ناجمالب كل رفاوتت ةيوغلال ةدعاسمال تامدخ نإف ،ةغلال ركذا ثدحتت تنك اذإ :ةظوحلم .مكبالو مصال فتاھ

Korean 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 505-923-5420, 1-855-592-7737 (TTY: 711)번으로 전화해 주십시오. 

Tagalog-Filipino

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 505-923-5420, 1-855-592-7737 (TTY: 711). 

Japanese 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。

505-923-5420, 1-855-592-7737 (TTY: 711) まで、お電話にてご連絡ください。 

French ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 505-923-5420, 1-855-592-7737 (ATS : 711). 

Italian ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero  505-923-5420, 1-855-592-7737 (TTY: 711). 

Russian ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните  505-923-5420, 1-855-592-7737 (телетайп: 711). 

Hindi �या� द: यद आप हदी बोलत ेह तो आपके ि◌लए मु�त म भाषा सहायता सेवाएं �पल�� ह। 505-923-5420, 1-855-592-7737 (TTY: 711) पर कॉल कर। 

Farsi 7737-592-855-1, 5420-923-505-1فراھم می باشد. با (TTY:711) تماس بگيريد.توجه: اگر به زبان فارسی گفتگو می کنيد، تسھيالت زبانی بصورت رايگان برای شما

Thai เรียน: ถ้าคณุพดูภาษาไทยคณุสามารถใช้บริการช่วยเหลือทางภาษาได้ฟรี โทร 505-923-5420, 1-855-592-7737 (TTY: 711). 

 

505-923-5420, 1-855-592-7737 (TTY: 711)

505-923-5420, 1-855-592-7737

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505-923-5420, 1-855-592-7737

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MEDICARE ADVANTAGE PLANS

Discrimination is Against the Law

Presbyterian Healthcare Services complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Presbyterian Healthcare Services does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Presbyterian Healthcare Services:

• Provides free aids and services to people with disabilities to communicate effectively with us, such as:

– Qualified sign language interpreters

– Written information in other formats (large print, audio, accessible electronic formats, other formats)

• Provides free language services to people whose primary language is not English, such as:

– Qualified interpreters

– Information written in other languages

If you need these services, contact the Presbyterian Customer Service Center at (505) 923-5420, 1-855-592-7737, TTY 711.

If you believe that Presbyterian Healthcare Services 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 the Presbyterian Privacy Officer and Civil Rights Coordinator, P.O. Box 27489, Albuquerque, NM 87125, or call 1-866-977-3021, TTY 711, fax (505) 923-5124, or info@phs.org. You can file a grievance in person, or by mail, fax, or email. If you need help filing a grievance, the Privacy Officer and Civil Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue SW, Room 509F HHH Building Washington, D.C. 20201 1-800-868-1019, 1-800-537-7697 (TDD)

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

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NOTICE OF NONDISCRIMINATION AND ACCESSIBILITY