2018 Summary of Benefits - AgeWell New York · 2017. 11. 9. · 2018 Summary of Benefits Bronx, Kings (Brooklyn), Queens, Nassau, New York (Manhattan), Suffolk and Westchester Counties

2018 Summary of Benefits Bronx, Kings (Brooklyn), Queens, Nassau, New York (Manhattan), Suffolk and Westchester Counties

StayWell(HMO)

If you remember these special moments, you’re ready for AgeWell New York

H4922_SWSB1099 Accepted 08292017

IMPORTANT NUMBERS

a g e w e l l n e w y o r k . c o m 1 |

AgeWell New York StayWell (HMO) 2018 Summary of Benefits

Proposed Effective Date _____/_____/______

Name

Address

____________________________________________________

__________________________________________________

Phone Number

Name of Licensed Sales Representative

(_____) ______________________________________

_________________________

Important Numbers

StayWell (HMO) Navigator Number: 718-696-0203

AWNY (Member Services) 1-866-586-8044 (TTY) 1-800-662-1220

7 days a week 8:00 am – 8:00 pm.

Note: From February 15 to September 30, we

may use alternative technologies on weekends

and Federal holidays

EnvisionRX (Pharmacy Services) 1-844-782-7670

7 days a week 24 hours a day

VSP (Vision Services) 1-800-877-7195

Monday-Friday 8:00 am – 8:00 pm

Saturday 10:00 am – 11:00 pm

Sunday 10:00 am – 10:00 pm

HealthPlex (Dental Services) 1-800-468-9868

Monday-Friday 8:00 am – 8:00 pm

Navigating Medicare optionsTurning 65, means choosing health care coverage that promotes healthy living and

independence, and maintains your overall well-being. There are various health care coverage

options to explore, from Original Medicare to a Medicare Advantage Plan.

Receive your Medicare benefits by joining a Medicare Advantage plan such as StayWell(HMO).

Receive your Medicare benefits through Original Medicare (Fee-for Service Medicare).

Compare health plans through the Medicare Plan Finder at www.medicare.gov. To learn moreabout Original Medicare costs and coverage view the current “Medicare & You” handbook at

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) 1-877-486- 2048.

http://agewellnewyork.com

http://www.medicare.gov

http://www.medicare.gov

2 | a g e w e l l n e w y o r k . c o m

Supporting your health care coverage needs

!geWell New York StayWell (HMO) 2018 Summary of Benefits

SUMMARY OF BENEFITS FOR MEDICAL, HOSPITAL AND DRUG BENEFITS COVERED BY:

StayWell (HMO) from January 1, 2018 to December 31, 2018

StayWell (HMO)

Eligibility You must be entitled to Medicare Part A, be enrolled in Medicare Part B, and

live in our service area

Provider Network You can see our plan’s provider and pharmacy directory at

www.agewellnewyork.com or call us and we will send you a copy of the

provider and pharmacy directories

Covered Drugs You can see our plan’s Formulary (List of Covered Drugs) at

www.agewellnewyork.com

Our service area includes: Bronx, Kings (Brooklyn), Nassau, New York, Queens, Suffolk and Westchester.

AgeWell New York, LLC is a Health Maintenance Organization (HMO) plan with a Medicare contract and a

Coordination of Benefits Agreement with New York State Department of Health. Enrollment in AgeWell New York,

LLC depends on contract renewal.

This information is not a complete description of benefits. 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. The Formulary, pharmacy network, and/or

provider network may change at any time. You will receive a notice when necessary. This document may be available in

an alternate format such as Braille, larger print, or audio. ATTENTION: If you speak Spanish, language assistance

services, free of charge, are available to you. Call 1-866-586-8044 (TTY: 1-800-662-1220). ATENCIÓN: si habla

español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1- 866-586-8044 (TTY: 1-800-662

1220). Assistance services for other languages are also available free of charge at the number above.

Hours of Operations: 7 days a week 8:00 am –– 8:00 pm. Note: From February 15 to September 30, we may use alternative technologies on weekends and Federal holidays 1-866-586-8044 │ │TTY 1-800-662-1220 www.agewellnewyork.com


http://www.agewellnewyork.com





StayW ell (HMO) Helps you pay for your Healthcare Costs

This plan may be right for you if you qualify for “Extra Help” also known as Low Income Subsidy (LIS) and/or a

Medicare Savings Program (MSP). AgeWell New York wants to support your healthcare needs. This is why we offer

AgeWell New York StayWell (HMO) plan with the assistance of service to help you connect with local state programs.

If you have Medicare and your income is under a certain amount, you may qualify for the following financial assistance

programs:

Extra Help or Low Income

Subsidy (LIS) !dministered by

Social Security !dministration

Medicare Savings Programs

(Four Levels) !dministered by

New York State

Medicaid !dministered by

New York State

The Low Income Subsidy (LIS)

helps with Medicare Part D

(prescription drug) monthly

premiums

All levels of Extra Help provides

reduced Part D copays

If you have Extra Help you may also

have Medicaid and/or a Medicare

Savings Program- but it is not

necessarily the case, since the Extra

Help income eligibility levels are

higher

Medicare Savings Programs provides

help paying Medicare costs, including

Medicare premiums, copays, and

coinsurance

Will not pay for costs of services

Medicare does not cover

Everyone with a Medicare Savings

Program will also have Extra Help

Some people with Medicare Savings

Programs will also have incomes that

qualify them for Medicaid

Medicaid provides help paying

Medicare copays, and coinsurances

Pays for some services that

Medicare may not cover

Does not pay for Part B premium

Everyone with Medicare and

Medicaid will also have Extra Help

Some people with Medicare and

Medicaid will also have incomes

that qualify for Medicare Savings

Programs

For More Information Call the

Social Security Administration at

1-800-772-1213 (TTY 1-800-325

0778)

For More Information Call the New

York State Medicaid Program in New

York City: Medicaid Help Line at 1

888-692-6116

For More Information Call the New

York State Medicaid Program in

New York City: Medicaid Help Line at 1-888-692-6116

For More information contact Member Services at 1-866-586-1220 (TTY 1-800-662-1220)

You may be eligible for these programs, depending on your income and your necessities. Each program has different

income eligibility levels and may also have additional requirements. Call 1-866-586-8044 (TTY 1-800-662-1220) to find

out if you may be eligible for these programs.

If you have any of these programs, you may also qualify for EPIC, New York’s State Pharmaceutical Assistance Program. EPIC also helps with plan premiums and Part D copays and coinsurances. You can have both EPIC and Extra

Help together. You may be eligible for EPIC even if you don’t qualify for the Extra Help, Medicare Savings Program, or

Medicaid. Call 1-866-586-8044 (TTY 1-800-662-1220) for more information.


List of Covered Benefits


The benefits information provided is a summary of covered benefits and costs. It does not list every covered service, exclusion or limitation. For a complete listing of services, please refer to the Evidence of Coverage, you can access it online at www.agewellnewyork.com, or you can call 1-866-586-8044 (TTY 1-800-662-1220), 7 days a week from 8:00 am to 8:00 pm to request a hard copy.

StayWell (HMO)

Monthly Plan Premium

You must continue to pay your

Medicare Part B Premium.

$0 or up to $39 per month

Plan Premium may vary depending if you qualify for Extra Help/Medicare

Savings Program/Medicaid

Deductible $0 or $83 up to $405 Part D deductible depending on your eligibility for Extra

Help/Medicare Savings Program/Medicaid

Maximum Out of Pocket (MOOP) (does not include

prescription drugs)

$6,700 for services you receive from in-network providers

If you reach the limit on the out-of-pocket costs, you will continue to be covered

for hospital and medical services




Original Medicar e vs StayWell (HMO) !geWell New York StayWell (HMO) 2018 Summary of Benefits

Original Medicare is health coverage m anaged by the federal government and includes just Part A (hospital insurance)

and Part B (medical insurance). StayWell (HMO) is a Medicare Advantage plan that offers the same benefits as Original

Medicare, PLUS other benefits like dental, vision, and more. Here’s how they compare:

Original Medicare Benefits (Amounts may change for 2018)

vs StayWell (HMO)

Inpatient Hospital

$1,316 deductible for each benefit period

$0 copay for days 1–60 of each benefit

period

$329 copay per day for days 61–90 of

each benefit period

vs

$295 copay for days 1-6 $0 copay for days 7-90

Our plan covers 60 “lifetime reserve days”.

Prior authorization is required

Outpatient Hospital

20% of the cost after the $183 deductible

is met vs

Diagnostic tests and procedures: $20 copay X-ray: $15 copay Lab: $0 copay

Prior authorization is not required

Surgery: $225 copay Diagnostic radiology services (such as MRIs,

CT scans): $150 copay Therapeutic radiology services (such as

radiation treatment for cancer): 20% of the cost Renal Dialysis: 20% of the cost


Doctor Visits


is met vs Primary Care Physician: $0 copay

Specialist: $25 copay


https://www.medicare.gov/coverage/hospital-care-inpatient.html#1306





vs StayWell (HMO)

Preventive Care $0 for most preventive services

20% of the cost after the $183

deductible is met for Diabetes

Self -Management Training

and Glaucoma Screening

$0 copay for all preventive services listed

Covered services include:

Abdominal aortic aneurysm screening

Alcohol misuse screening and counseling

Bone mass measurement (bone density)

Breast cancer screening (mammograms)

Cardiovascular disease screenings and risk reduction visit (therapy for

cardiovascular disease)

Cervical and vaginal cancer screenings

Colorectal cancer screenings

Depression screening

Diabetes screenings and self-management training

Glaucoma tests

Hepatitis C screening test

HIV screening

Immunizations

Lung cancer screening

Medicare Diabetes Prevention Program (MDPP)

Medical nutrition therapy services

Obesity screening and counseling

Pneumococcal shot

Prostate cancer screenings

Sexually transmitted infection (STI) screening and counseling

Smoking and tobacco-use cessation (counseling to stop smoking or using

tobacco products)

“Welcome to Medicare” preventive visit

Yearly “Wellness” visit

Any additional preventive services approved by Medicare during the contract year will be

covered.

Emergency Care

20% of the cost after the $183 deductible vs $80 copay

If admitted within 24 hours, you do not have

to pay your share of the cost for emergency

care





vs StayWell (HMO)

Urgently Needed Services


If admitted within 24 hours, you do not have

to pay your share of the cost for urgent

services

Diagnostic Services/

Labs/Imaging Diagnostic radiology services, X-Rays,

and Therapeutic radiology services: 20%

of the cost after the $183 deductible

Diagnostic lab tests: $0 copay

vs

Diagnostic tests and procedures: $20 copay Lab: $0 copay X-Ray: $15 copay

Authorization is not required

Diagnostic radiology services (such as CT,

MRI, scans): $150 copay Therapeutic radiological services (such as

radiation treatment for cancer): 20% of the cost


Hearing

Original Medicare does not cover any

routine hearing services or hearing aids vs

Routine Hearing Exams: $0 copay

We cover up to $1,000 every two years for hearing aids

Authorization is required for Hearing Aids

Dental

Original Medicare does not cover any

routine dentistry, preventive care, or

dentures

vs

Preventive Dental: $0 copay Oral exams: 1 every 6 months

Cleaning: 1 every 6 months

Fluoride treatment: 1 every 6 months

X-rays: 1 every 6 months

Comprehensive Dental:

Diagnostic Services: $30 copay Restorative Services: $30 copay Endodontic Services: $30 copay Periodontics Services: $30 copay Extraction Services: $30 copay Other Oral/Maxillofacial Surgery: $30 copay

Prior authorization and limitations may apply for certain Comprehensive Dental services.





vs StayWell (HMO)

Vision Original Medicare does not cover routine

vision services

20% of the cost for one pair of eye

glasses or one set of contact lenses after

each cataract surgery with an intraocular

lens

vs

Routine eye exams: $0 copay (1 per year)

Consecutive and Medicare covered eye

exams: $25 copay

We cover up to $150 every year for eyeglasses

Authorization is required for eyeglasses

Mental Health (including Inpatient)

Inpatient:

$1,316 deductible for each benefit period


period

$329 copay per day for days 61–90 of

each benefit period

Outpatient:


vs

Inpatient Visit:

$267 copay for days 1-6 $0 copay for days 7-90 Outpatient Visit:

Individual and group sessions: $40 copay

Authorization is required inpatient stays

Skilled Nursing Facility (SNF)


period

$164.50 copay per day for days 21–100

of each benefit period in 2017

3 day prior hospital stay is required

vs $0 copay for days 1-20 $167.50 copay for days 21-100

3 day prior hospital stay is not required


Physical Therapy



Ambulance

20% of the cost after the $183 deductible vs

$225 copay

If you are admitted to the hospital, you do not

have to pay for ambulance services

Prior authorization is required for non-emergency ambulance




https://www.medicare.gov/coverage/skilled-nursing-facility-care.html#1288

https://www.medicare.gov/coverage/skilled-nursing-facility-care.html#1288




vs StayWell (HMO)

Transportation Original Medicare does not cover non-

ambulance transportation vs Not Covered

Medicare Part B Drugs


Part B drugs ( such as Chemotherapy drugs):

20% of the cost Other Part B Drugs: 20% of the cost


Over-the-Counter (OTC)

Original Medicare does not offer OTC vs

StayWell (HMO) offers $10 per month for

approved over-the-counter items

Unused balances expire each month

Acupuncture Original Medicare does not cover

Acupuncture vs $10 copay

We cover 10 treatments per year

Ambulatory Surgical Center



Chiropractic Services

20% of the cost after the $183 deductible vs Medicare-Covered Chiropractic Services: $20 copay

Rehabilitation Services


Occupational and Speech therapy visits: $40 copay

Cardiac rehab services: 20% of the cost Pulmonary rehab services: 20% of the cost






vs StayWell (HMO)

Podiatry Services (Foot

Care) 20% of the cost after the $183 deductible vs

$25 copay

Routine foot care for members with certain

medical conditions affecting the lower limbs

Medical Equipment /Supplies


Diabetic supplies: $0 copay Diabetic therapeutic shoes and inserts: $10 copay Durable medical equipment (DME) and

Supplies: 20% of the cost Prosthetic devices and supplies: 20% of the cost Prior authorization is required for DME and Prosthetics

Wellness Program (Silver

Sneakers) Original Medicare does not cover gym

memberships or fitness programs. vs

$0 copay

Registration is required Silver Sneakers offers programming, social

activities, health education seminars, and

more all specifically designed for older adults.

Each beneficiary receives a basic fitness

membership at a participating location,

including access to fitness equipment and

Silver Sneaker classes lead by certified

instructors



Prescription Drug Coverage


Cost sharing may change when entering another phase of the Part D benefits

Deductible Stage $0 or $83 or $405 per year for Part D drugs

Amounts vary depending if you qualify for Extra Help/Medicare Savings program/Medicaid

Initial Coverage Stage

Cost Sharing for covered drugs Standard retail cost-sharing (1 month supply)

Mail Order cost-sharing (3 month Supply)

Depends on your Level of LIS, MSP, Medicaid

0% or up to 25% of the cost 0% or up to 25% of the cost

Generic Drugs $0 copay; or

$1.25 copay; or

$3.35 copay

$0 copay; or

$1.25 copay; or

$3.35 copay

All Other Drugs $0 copay; or

$3.70 copay; or

$8.35 copay

$0 copay; or

$3.70 copay; or

$8.35 copay

Mail Order Receive a 90-day supply of select drugs mailed directly to your front door. There are no shipping and handling fees. Get a larger supply for lower copay. Using this program may reduce or eliminate your pharmacy visits. If you

have drugs that you take on a regular basis, for a long term medical condition try our mail order program. Note: Requires

a 90 day Prescription from your doctor.

Enroll Today Register ONLINE 1)

Go to envisionpharmacies.com

2) Click register now

3) Create a Member Profile

Once you register you can: Select your shipping preference, Add a credit card to your account, Change your personal

information, Order and track refills in your account, and View your order history

Register by PHONE Enroll via telephone at 1-866-909-5170 or TTY 711 (Monday – Friday 8:00 am – 10:00 pm and Saturday 8:30 am –

4:30 pm)

Register by MAIL Complete by enrollment form and mail to EnvisionMail at: 7835 Freedom Ave NW, North Canton, OH 44720

E-Prescriptions Have your physician electronically prescribe (e-prescribe) your refills via the internet. Call or fax your next 90 day

prescription: Call Center 1-866-909-5170 │ TTY 711 │ Fax 1-866-909-5171


http://envisionpharmacies.com


Coverage Gap Stage After you spend up to $3,750 for your drugs

o

o


For all other drugs on the coverage gap stage you pay no more than 44% of the costs of generic drugs and the 56% for

generic drugs is paid by the plan. Only the amount you pay counts and moves you through the coverage gap.

Medicare has rules about what counts and what does not count as your out-of-pocket costs. When you reach an out-of

pocket limit of $5,000, you leave the Coverage Gap Stage and move on to the Catastrophic Coverage Stage.

Catastrophic Coverage Stage After your out-of-pocket cost reaches $5,000 for the year

Once you are in the Catastrophic Coverage Stage, you will stay in this payment stage until the end of the calendar year.

During this stage, the plan will pay most of the cost for your drugs.

Your share of the cost for a covered drug will be either coinsurance or a copayment, whichever is the larger

amount:

– either – coinsurance of 5% of the cost of the drug

–or – $3.35 for a generic drug or a drug that is treated like a generic and $8.35 for all other drugs.

Our plan pays the rest of the cost.



Notice of Nondis crimination


AgeWell New York complies with applicable Federal civil rights laws and does not discriminate on the basis of race,

color, national origin, age, disability, or sex. AgeWell New York does not exclude people or treat them differently

because of race, color, national origin, age, disability, or sex. AgeWell New York 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)

Free language services to people whose primary language is not English, such as qualified interpreters and

information written in other languages

If you need these services, contact AgeWell New York Member Services at 1-866-586-8044. If you believe that AgeWell New York 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:

AgeWell New York

Civil Rights Coordination Unit 1991 Marcus Avenue Suite M201

Lake Success, New York 11042-2057 1-866-586-8044

TTY/TDD: 1-800-662-1220 Fax: 855-895-0778

Email: [email protected]

You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Civil Rights

Coordination Unit 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, DC 20201, 1-800-368-1019, TDD: 1-800-537

7697

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


mailto:[email protected]

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html



Multi -Language Insert English: ATTENTION: If you do not speak English, language assistance services, free of charge, are available to you. Call

1-866-586-8044 (TTY: 1-800-662-1220).

Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al

1- 866-586-8044 (TTY: 1-800-662-1220).

Chínese: 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 1-866-586-8044

(TTY：1-800-662-1220)。

Russian: ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните

1- 866-586-8044 (телетайп: 1-800-662-1220).

French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1- 866-586-8044

(TTY: 1-800-662-1220).

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다 . 1-866-586-8044

(TTY: 1-1-800-662-1220)번으로 전화해 주십시오 .

Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti.

Chiamare il numero 1-866-586-8044 (TTY: 1-800-662-1220).

Yiddish: אויפמערקזאם: אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל.

.(TTY: 1-800-662-1220) 1-866-586-8044 רופ

Bengali:

Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer

1- 866-586-8044 (TTY: 1-800-662-1220).




Arabic:

French: ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le

1- 866-586-8044 (ATS : 1-800-662-1220).

Urdu :

Tagolog: PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang

bayad. Tumawag sa 1-866-586-8044 (TTY: 1-800-662-1220).

Greek: ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες

παρέφονται δωρεάν. Καλέστε 1- 866-586-8044 (TTY: 1-800-662-1220).

Albanian: KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në

1- 866-586-8044 (TTY: 1-800-662-1220).



We’re herefor your call.

agewe l lnewyork .com

866-586-8044 TTY/TDD 800-662-1220


Documents

2018 Summary of Benefits - AgeWell New York · 2017. 11. 9. · 2018 Summary of Benefits Bronx, Kings (Brooklyn), Queens, Nassau, New York (Manhattan), Suffolk and Westchester Counties