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Special Needs Plans are either HMO or PPO plans that limit membership to people with special needs as defined by the health plan. See Page 2 for specific plan requirements. Chronic care HMOs have a network of doctors, hospitals, and other health care providers who hav contracted with the plan to provide care to Medicare beneficiaries in that plan. In an HMO, you must generally get your medical care and services from providers and hospitals in the plan’s network (except emergency or urgent care). You generally must see a primary care doctor before getting care from a specialist. If you get health care outside the plan’s network, you may have to pay the full cost of care for that visit. In addition, special needs plans (SNP) are often designed to provide special care management and services including care focused management based on the identified disease or setting. The attached comparison sheets should be used as a guideline in selecting the type of health plan that meets your individual needs. BENEFITS ASSISTANCE PROGRAM A State Health Insurance Assistance Program (SHIP) A program of the Area Agency on Aging, Region One 1366 East Thomas, Suite 108, Phoenix, AZ 85014 602-280-1059 This project was supported in part by grant number 15AAAZMSHI, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy. 2019 Medicare Advantage Chronic Conditions & Institutional Care Special Needs Plans (SNP) Maricopa County Most current revision 10/16/2018

2019 Medicare Advantage Special Needs Plans (SNP) · Allwell CHF/Diabetes Medicare (HMO SNP) Page 3 Plan Number H0351-038 800-333-3930 STAR Rating 4.0 out of 5 Must have diabetes

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Special Needs Plans are either HMO or PPO plans that limit membership to people

with special needs as defined by the health plan. See Page 2 for specific plan

requirements.

Chronic care HMOs have a network of doctors, hospitals, and other health care providers who have

contracted with the plan to provide care to Medicare beneficiaries in that plan. In an HMO, you

must generally get your medical care and services from providers and hospitals in the plan’s

network (except emergency or urgent care). You generally must see a primary care doctor before

getting care from a specialist. If you get health care outside the plan’s network, you may

have to pay the full cost of care for that visit.

In addition, special needs plans (SNP) are often designed to provide special care management

and services including care focused management based on the identified disease or setting.

The attached comparison sheets should be used as a guideline in selecting the type of

health plan that meets your individual needs.

BENEFITS ASSISTANCE PROGRAMA State Health Insurance Assistance Program (SHIP)

A program of the Area Agency on Aging, Region One

1366 East Thomas, Suite 108, Phoenix, AZ 85014

602-280-1059

This project was supported in part by grant number 15AAAZMSHI, from the U.S. Administration for

Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees

undertaking projects under government sponsorship are encouraged to express freely their findings and

conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration

for Community Living policy.

2019Medicare Advantage

Chronic Conditions & Institutional CareSpecial Needs Plans (SNP)

Maricopa County

Most current revision 10/16/2018

See plan page to determine the specific "Special Need" required to select this plan.

Chronic Condition Plans - Income not an issue Page

Allwell CHF/Diabetes Medicare (HMO SNP) 3CIGNA-HealthSpring Achieve Plus (HMO SNP) 5Fresenius Total Health (PPO SNP)

Resides in Long-Term Care FaciityAmerivantage Caremore Care to You (HMO SNP) 7United Healthcare Nursing Home Plan (PPO SNP) 9

Special Needs Plans SNPs

Allwell CHF/Diabetes Medicare (HMO SNP) Page 3

Plan Number H0351-038 800-333-3930

STAR Rating 4.0 out of 5 www.allwellmedicare.com

Must have diabetes or chronic heart failure to enroll into this plan

Monthy Premium $0

Maximum-out-of-Pocket Limit (MOOP) $3,400

Out-of-Network Services not covered

Physician/Provider Services Copayments

Primary Care $0

Specialist $15

Mental Health $25

PT, OT, Speech Therapy $35

Chiropractic (limited services) $0, Optional plan available

Podiatry (limited visits) $0 - $25

Hospital (Inpatient) Care - Copayments

Hospital inpatient Per Days 1 - 10 $205

Hospital inpatient Per Days 11 - beyond $0

Skilled Nursing Facility (SNF) Per Days 1 - 20 $0

Skilled Nursing Facility (SNF) Per Days 21 - 100 $170

Oupatient Care - Copayments

Hospital Surgery Center $200

Ambulatory Surgery Center

Emergency/Urgent Care Services - Copayments

Emergency Room $120

Urgent Care $15

Ambulance per Trip $350

Diagnostic Testing

Radiology Tests and Imaging $0 - $200

Lab Tests $0 - $25

Durable Medical Equipment (DME)

Diabetes Supplies $0

Equipment 20%

Prosthetic Device 20%

Prescription Drugs

Part D drugs - Deductible $0

Call Plan or consult Medicare.gov Plan Finder to determine your estimated drug cost

Part B Immunizations - Flu, pheumonia, and hepititis B vacinnations 0%

Transplant drug and facility based infusions such as chemotherapy 20%

Allwell CHF/Diabetes Medicare (HMO SNP) Page 4

Physician Network, Additional Benefits, Preferred Pharmacies and Hospital Networks

Physician Network

To determine if your physician is in this specific plan, check with the plan and/or call your physician.

Additional Benefits

Vision (Exams, lenses & glasses) Optional plan available

Hearing (Routine) Exams Not Covered

Hearing Aid Appliance Not Covered

Home Health Care Not Covered

Transportation $0, Up to (10) 1 way trips

Dental Optional plan available

Over-the-Counter allowance $75 / quarter

24 hour Nurse Line $0

Gym Membership $0

Meals after Hosital Stay Up to 28 meals @ $0 copay

Preferred pharmacies:

If your plan has preferred pharmacies, using those pharmacies may save you money.

Albertsons Costco CVS

Frys Safeway Walmart

Hospital Networks

Abrazo St Lukes Banner

West Campus (Goodyear) Tempe Baywood

Central Campus Phoenix Boswell

Maryvale Del Webb

Phoenix (PV-Bell) Maricopa Medical Center Desert

Arrowhead Estrella

Gateway

Honor Health Goldfield (Apache Junction)

Scottsdale Healthcare Osborn University Medical Center

Scottsdale Healthcare Shea Ironwood

Scottsdale Heallthcare Thompson Peak Thunderbird

John C Lincoln Deer Valley

John C Lincoln Phoenix

CIGNA-HealthSpring Achieve Plus (HMO SNP) Page 5

Plan Number H0354-027 855-561-3811

STAR Rating 4.5 out of 5 www.cignahealthspring.com

Must have diabetes to enroll into this plan

Monthy Premium $0

Maximum-out-of-Pocket Limit (MOOP) $3,800

Out-of-Network Services not covered

Physician/Provider Services Copayments

Primary Care $0

Specialist $25

Mental Health $25

PT, OT, Speech Therapy $25

Chiropractic (limited services) $15

Podiatrist $0

Hospital (Inpatient) Care - Copayments

Hospital inpatient Per Days 1 - 7 $200

Hospital inpatient Per Days 8 - beyond $0

Skilled Nursing Facility (SNF) Per Days 1 - 20 $0

Skilled Nursing Facility (SNF) Per Days 21 - 100 $172

Oupatient Care - Copayments

Hospital Surgery Center $325

Ambulatory Surgery Center $125

Emergency/Urgent Care Services - Copayments

Emergency Room $90

Urgent Care $0

Ambulance per Trip $200

Diagnostic Testing

Radiology Tests and Imaging $0 - $150 or 20%

Lab Tests $0

Durable Medical Equipment (DME)

Diabetes Supplies $0

Equipment 20%

Prosthetic Device 20%

Prescription Drugs

Part D drugs - Deductible (Tier 5) $200

Call Plan or consult Medicare.gov Plan Finder to determine your estimated drug cost

Part B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0

Transplant drug and facility based infusions such as chemotherapy 20%

CIGNA-HealthSpring Achiecve Plus (HMO SNP) Page 6Physician Network, Additional Benefits, Preferred Pharmacies and Hospital Networks

Physician Network

To determine if your physician is in this specific plan, check with the plan and/or call your physician.

Additional Benefits

Vision (Exams, lenses & glasses) $25; $0 - $100 annual allowance

Hearing (Medicare Covered & Routine) Exams $10

Hearing Aid Appliance Not Covered

Home Health Care $0

Transportation $0 Unlimited

Dental Separate Plan Available

Over-the-Counter allowance Not Covered

24 hour Nurse Line $0

Gym Membership $0

Preferred pharmacies:

If your plan has preferred pharmacies, using those pharmacies may save you money.

Osco Cigna Center Pharmacy Fry's

Walmart Safeway Walgreens

Hospital Networks

Abrazo Dignity Health BannerWest Campus (Goodyear) Arizona General Baywood

Central Campus Chandler Regional Boswell

Maryvale Mercy Gilbert Del Webb

Phoenix (PV-Bell) St Joseph’s Desert

Arrowhead St Joseph’s Westgate Estrella

Gateway

Honor Health St Luke’s Goldfield (Apache Junction)

Scottsdale Healthcare Osborn Tempe University Medical Center

Scottsdale Healthcare Shea Phoenix Ironwood

Scottsdale Heallthcare Thompson Peak Thunderbird

John C Lincoln Deer Valley Maricopa Medical Center

John C Lincoln Phoenix

Amerivantage CareMore Care to You (HMO SNP) Page 7

Plan Number 2593-019-0 877 211-6614

STAR Rating 4.0 out of 5 NOTE: Dialysis co-pay is $0 www.amerigroup.com/medicare

Must live in an assisted living facility

Monthy Premium $0

Maximum-out-of-Pocket Limit (MOOP) $3,000

Out-of-Network Services Not Covered

Physician/Provider Services Copayments

Primary Care $0

Specialist $0

Mental Health $0

PT, OT, Speech Therapy $0

Chiropractic (limited services) $0

Podiatrist $0 / 4 visits yr

Hospital (Inpatient) Care - Copayments

Hospital inpatient Per Days 1 - 5 $175

Hospital inpatient Per Days 6 - 255 $0

Skilled Nursing Facility (SNF) Per Days 1 - 20 $0

Skilled Nursing Facility (SNF) Per Days 21 - 100 $0

Oupatient Care - Copayments

Hospital Surgery Center $175

Ambulatory Surgery Center $100

Emergency/Urgent Care Services - Copayments

Emergency Room $100

Urgent Care $0

Ambulance per Trip $195

Diagnostic Testing

Radiology Tests and Imaging $0 - $150, 20%

Lab Tests $0

Durable Medical Equipment (DME)

Diabetes Supplies $0

Equipment 0% - 20%

Prosthetic Device 0% - 20%

Prescription Drugs

Part D drugs - Deductible $0

Call Plan or consult Medicare.gov Plan Finder to determine your estimated drug cost

Part B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0

Transplant drug and facility based infusions such as chemotherapy 20%

Amerivantage CareMore Care to You (HMOfSNP) Page 8

Physician Network, Additional Benefits, Preferred Pharmacies and Hospital Networks

Physician Network

To determine if your physician is in this specific plan, check with the plan and/or call your physician.

Additional Benefits

Vision (Exams, lenses & glasses) $0, $100 (every 2 years)

Hearing (Routine) Exams $0

Hearing Aid Appliance $0, $1500

Home Health Care $0

Transportation $0 (6) one-way trips

Dental Preventive only

Over-the-Counter allowance $50 per quarter

24 hour Nurse Line $0

Gym Membership $0

Preferred pharmacies:

If your plan has preferred pharmacies, using those pharmacies may save you money.

The pharmacy network for this plan is NOT restricted.

Hospital Networks

Abrazo St Luke’sWest Campus (Goodyear) Tempe

Central Campus Phoenix

Maryvale

Phoenix (PV-Bell)

Arrowhead

UnitedHealthcare Nursing Home Plan (PPO SNP) Page 9

Plan Number 0710-005 888-834-3721

STAR Rating 4.0 out of 5 Renal Dialysis $0 / 20% www.uhcmedicaresolutions.com

Must live in a nursing home available through the plan

Monthy Premium $32.60

Maximum-out-of-Pocket Limit (MOOP) In- / Out-of-Network $1,500 / $5,100

Physician/Provider Services Copayments

Primary Care $0 / 30%

Specialist $0 / 30%

Mental Health $0-20% / 30%

PT, OT, Speech Therapy $0-20% / 30%

Chiropractic (limited services) $0 - 20% / 30%

Podiatry $0 - 20% / 30%

Hospital (Inpatient) Care - Copayments

Hospital inpatient Days 1 - 90 $1,300 / $1,300

Skilled Nursing Facility (SNF) Days 1 - 100 $0 / 30%

Oupatient Care - Copayments

Hospital Surgery Center $0 / 30%

Ambulatory Surgery Center $0 / 30%

Emergency/Urgent Care Services - Copayments

Emergency Room $0

Urgent Care $65

Ambulance per Trip 20%

Diagnostic Testing

Radiology Tests and Imaging $0-20% / 30%

Lab Tests $0 / $0

Durable Medical Equipment (DME)

Diabetes Supplies 20% / 30%

Equipment 20% / 30%

Prosthetic Device $0 - 20% / 30%

Prescription Drugs

Part D drugs - Deductible $415

Call Plan or consult Medicare.gov Plan Finder to determine your estimated drug cost

Part B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0 / $0

Transplant drug and facility based infusions such as chemotherapy 20% / 30%

In-Network charges noted below reflect services performed in the Nursing Home.

UnitedHealthcare Nursing Home Plan (PPO SNP) Page 10

Physician Network, Additional Benefits, Preferred Pharmacies and Hospital Networks

Physician Network

To determine if your physician is in this specific plan, check with the plan and/or call your physician.

Additional Benefits

Vision (Exams, lenses & glasses) $0 / 30, $300

Hearing (Medicare Covered & Routine) Exams $0-20% / 30%

Hearing Aid Appliance $0 / $0

Home Health Care Not Covered

Transportation $0 (60) 1-way trips / 75%

Dental $0, $5000 / $0, $5000

Over-the-Counter allowance $365 per quarter

24 hour Nurse Line Not Covered

Gym Membership Not Covered

Preferred pharmacies:

If your plan has preferred pharmacies, using those pharmacies may save you money.

The pharmacy network for this plan is NOT restricted.

Or list pharmacies

Hospital Networks delete hospitals not in network

Abrazo Dignity Health BannerWest Campus (Goodyear) Arizona General Baywood

Central Campus Chandler Regional Boswell

Maryvale Mercy Gilbert Del Webb

Phoenix (PV-Bell) St Joseph’s Desert

Arrowhead St Joseph’s Westgate Estrella

Gateway

Honor Health St Luke’s Goldfield (Apache Junction)

Scottsdale Healthcare Osborn Tempe University Medical Center

Scottsdale Healthcare Shea Phoenix Ironwood

Scottsdale Heallthcare Thompson Peak Thunderbird

John C Lincoln Deer Valley

John C Lincoln Phoenix