2019 FeelWell (HMO SNP) Covered Services Requirements

Services Requires Prior Authorization

Limitations

MUST MAINTAIN FULL MEDICAID ELEGIBILITYAbdominal aortic aneurysm screening No One-Time Screening ultrasound for people at risk. Must have family history of AAA or

male 65-75yrs who smoked at least 100 cigarettes in his lifetime

Acupuncture No We cover 6 acupuncture treatments/year when provided by certified network providersAir Ambulance Services No

(Prior Authorization is required for non-emergency air ambulance services)

Covered emergency ambulance services include air ambulance and ground ambulance services, to the nearest appropriate facility that can provide care if they are furnished to a member whose medical condition is such that other means of transportation could endanger the person’s health or if authorized by the plan

Non-emergency transportation by air ambulance or ground ambulance is appropriate if it is documented that the member’s condition is such that other means of transportation could endanger the person’s health and that transportation by air ambulance is medically required

Ground Ambulance Services No

(Prior Authorization is required for non-emergency ground ambulance services)

Annual Routine Physical Exam No Annual Routine Physical Exam is limited to one each year.Annual Routine Physical Exam includes comprehensive physical examination and evaluation of status of chronic diseases. Doesn’t include lab tests, radiological diagnostic tests or non-radiological diagnostic tests or diagnostic tests. Additional cost share may apply to any lab or diagnostic testing performed during your visit.

Annual wellness visit No Once every 12 monthsBone mass measurement No Once every 24 months or more frequently if medically necessary

Breast cancer screening Screening mammogram

No One baseline mammogram between ages 35-39One screening mammogram every 12 months for women 40 and olderClinical breast exams once every 24 months

Page | 1Effective 01/01/2019 MUST MAINTAIN FULL MEDICAID ELIGIBILITY

2019 FeelWell (HMO SNP) Covered Services Requirements

Services Requires Prior Authorization

Limitations

MUST MAINTAIN FULL MEDICAID ELEGIBILITYBreast cancer

Diagnostic mammogramYes Once a year or as many times as medically necessary

Cardiac rehabilitation services(Includes exercise, education, counselling)- Initial course treatment

Yes Limited to a maximum of 2, 1-hour sessions per day for up to 36 sessions with the option for an additional 36 sessions or an extended period of time if approved based on medical necessity./ Intensive cardiac rehab limited to 72, 1-hour sessions, up to 6 sessions per day, over a period of up to 18 weeks

Cardiovascular disease risk reduction visit (therapy for cardiovascular disease)

No One visit per year

Cardiovascular disease testing No Blood tests (Lipid Panel) for the detection of cardiovascular disease (or abnormalities associated with an elevated risk of cardiovascular disease) once every 5 years (60 months)

Cervical and vaginal cancer screening Pelvic Exam Pap Test

No For all women: Pap tests and pelvic exams once every 24 monthsAt high risk or have had an abnormal pap test and are of childbearing age: one Pap test every 12 months

Chiropractic services No Manual manipulation of the spine to correct subluxation (one or more of the bones of your spine move out of position)

Colorectal cancer screening Colonoscopy

(screening/preventive)

Yes For people 50 and older: Flexible sigmoidoscopy (or screening barium enema as an alternative) every 48 months; One of the following every 12 months: Guaiac-based fecal occult blood test or Fecal immunochemical test; DNA based colorectal screening every 3 years;For people at high risk: Screening colonoscopy (or screening barium enema as an alternative) every 24 months;For people not at high risk: Screening colonoscopy every 10 years (120 months), but not within 48 months of a screening sigmoidoscopy

Colorectal cancer Colonoscopy (surgical)

Yes

Dental services Comprehensive services

Contact HealthPlex 1-800-468-9868 for coverage and

Comprehensive dental: Non-routine 1 every year; diagnostic services 1 every 6 months; restorative services 1 every year; Endodontics/periodontics/extractions 1 every

Page | 2Effective 01/01/2019 MUST MAINTAIN FULL MEDICAID ELIGIBILITY

2019 FeelWell (HMO SNP) Covered Services Requirements

Services Requires Prior Authorization

Limitations

MUST MAINTAIN FULL MEDICAID ELEGIBILITYauthorization year; prosthodontics, other oral/maxillofacial surgery 1 every year

Depression screening No One screening for depression per yearDiabetes screening No Based on test results, we cover up to 2 diabetes screenings every 12 months, if there is a

history of HTN, High cholesterol/triglyceride level, obesity or hyperglycemia; or if 2 or more apply: 65 years or older, obesity, family history, or gestational diabetes

Diabetes self-management training No You qualify for initial training and up to 2 hours of follow-up training each yearDiabetic services and supplies No Supplies to monitor your blood glucose. At high risk of diabetes, a family history of

glaucoma, are African-American and 50 or older or are Hispanic American 65 or olderDiabetic therapeutic shoes and inserts Yes One pair per calendar year of therapeutic custom molded shoes (including inserts

provided with such shoe).Two additional pairs of inserts, or one pair of depth shoes, and three pairs of inserts (not including the non-customized removable inserts provided with such shoes)

Durable medical equipment and related supplies

Yes Covered items include, but are not limited to: wheelchairs, crutches, hospital bed, IV infusion pump, oxygen equipment, nebulizer, and walker. Please refer to Medicare limitations

Emergency care (US + Territories Only)

No Medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting Worse.If you are admitted to the hospital within 24 hours for the same condition, you do not pay the cost share.

Fitness Program Registration is required contact Silver Sneakers 1-888-423-4632

Hearing services by a physician, audiologist, or other qualified provider

No (Contact EPIC Hearing 1-877-606-3742 for coverage)

Diagnostic hearing and balance evaluations performed by your provider to determine if you need medical treatment are covered as outpatient care when furnished by a physician, audiologist, or other qualified provider1 Routine Hearing Exam per year

Hearing aids Yes (Contact EPIC Hearing 1-877-606-3742 for

We cover $1,000 towards the purchase of hearing aids once every 2 yearsIncludes fitting and evaluation for hearing aids.

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2019 FeelWell (HMO SNP) Covered Services Requirements

Services Requires Prior Authorization

Limitations

MUST MAINTAIN FULL MEDICAID ELEGIBILITYcoverage)

HIV screening No Increased risk: one screening exam every 12 monthsWomen who are pregnant: 3 screening exams during pregnancy

Home health agency care Yes Must total fewer than 8 hours per day and 35 hours per weekHospice care Not Covered Original Medicare benefitImmunizations

Influenza Pneumococcal Hepatitis B

No Flu shots once a year in the fall or winterPneumonia vaccines, Hepatitis B and other vaccines if you are at risk and they meet Medicare Part B coverage rules

Inpatient hospital care Yes Benefit period begins the day you are admitted as an inpatient in the hospital and ends when you haven’t received any inpatient care for 60 consecutive days

Inpatient mental health care Yes Up to 90 days of medically necessary hospitalization and 40 additional days in a Psychiatric hospital

Medical nutrition therapy No This benefit is for people with diabetes, renal (kidney) disease (but not on dialysis), or after a kidney transplant when ordered by your doctor. 3 hours of one-on-one counseling services during your first year, 2 hours each year after that

Medicare Diabetes Prevention Program (MDPP)

No MDPP services will be covered for eligible Medicare beneficiaries

Medicare Part B prescription drugs Yes Step Therapy may apply to certain drugs.Medicare Part D prescription Drugs Yes Consult Formulary for PA requirements on certain drugs EnvisionRx 1-800-361-4542

Depending on your level of Medicaid/LIS

Page | 4Effective 01/01/2019 MUST MAINTAIN FULL MEDICAID ELIGIBILITY

2019 FeelWell (HMO SNP) Covered Services Requirements

Services Requires Prior Authorization

Limitations

MUST MAINTAIN FULL MEDICAID ELEGIBILITYObesity screening and therapy to promote sustained weight loss

No If you have body mass index 30 or more

Outpatient diagnostic tests and therapeutic services and supplies (Part 1)

Preventive Diagnostic procedures and tests

X-Rays Lab services Diagnostic procedures and tests

such as:-Echocardiogram-EKG-Sonogram-Ultrasound

No

(Prior Authorization is needed for tests that require contrasts or Anesthesia)

Outpatient diagnostic tests and therapeutic services and supplies (Part 2)

Surgical and medical supplies Blood Services Therapeutic radiological

services Diagnostic radiological services

(CT, MRI, PET scan, MRA, etc)

Yes

Page | 5Effective 01/01/2019 MUST MAINTAIN FULL MEDICAID ELIGIBILITY

2019 FeelWell (HMO SNP) Covered Services Requirements

Services Requires Prior Authorization

Limitations

MUST MAINTAIN FULL MEDICAID ELEGIBILITYOutpatient hospital services Yes - for tests that require

Anesthesia

(Prior Authorization is not required for tests such as Sonogram/Ultrasound, Electrocardiogram, X-Ray and Lab)

We cover medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injuryCovered services include, but are not limited to:

Services in an emergency department or outpatient clinic, such as observation services or outpatient surgery

Laboratory and diagnostic tests billed by the hospital Mental health care, including care in a partial-hospitalization program, if a

doctor certifies that inpatient treatment would be required without it X-rays and other radiology services billed by the hospital Medical supplies such

as splints and casts Certain screenings and preventive services

Certain drugs and biologicals that you can’t give yourselfOutpatient mental health care Yes Cover individual or group outpatient mental health care

Outpatient rehabilitation services Occupational therapy Physical therapy Speech-language pathology

(Speech therapy)

Yes In 2018 Therapy Cap Limits for PT and SLP combined is $2,010 and for OT is $2,010

Outpatient substance abuse services Yes Cover individual and group outpatient substance abuse servicesOutpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers

Yes

Over-The-Counter benefit No $80 per month for OTC

Partial hospitalization services Yes

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2019 FeelWell (HMO SNP) Covered Services Requirements

Services Requires Prior Authorization

Limitations

MUST MAINTAIN FULL MEDICAID ELEGIBILITYPhysician/Practitioner services, including doctor’s office

PCP Specialist

No

(Prior Authorization is needed for tests that require Contrasts or Anesthesia)

Annual Routine Physical Exam includes comprehensive physical examination and evaluation of status of chronic diseases. Doesn’t include lab tests, radiological diagnostic tests or non-radiological diagnostic tests or diagnostic tests. Additional cost share may apply to any lab or diagnostic testing performed during your visit.

Podiatry services Nail debridement and clipping

No Nail debridement and clippingMust meet Medicare criteria for Podiatry services

Prostate cancer screening exams No For men age 50 and older once every 12 months: digital rectal exam or prostate specific antigen test

Prosthetic devices and related supplies YesPulmonary rehabilitation services Yes Limited to up to 36 sessions, no more than two sessions per dayScreening and counseling to reduce alcohol misuse

No One alcohol misuse screening for adults who misuse alcohol but aren’t alcohol dependentIf you screen positive for alcohol misuse, you get up to 4 face-to-face counseling sessions per year

Screening for lung cancer with low dose computed tomography

No Covered once every 12 months for people 55-77 years who have a history of tobacco smoking

Screening for sexually transmitted infections (STIs) and counseling to prevent STIs

No Cover tests once every 12 months or at certain times during pregnancyCover up to 2 individual 20 to 30 minutes face-to-face counseling sessions each year

Services to treat Kidney disease and conditions

Kidney disease education Dialysis

Yes

Skilled nursing facility (SNF) care Yes Covered for 100 days in a SNF during each benefit period.

Smoking and tobacco use cessation (counseling to stop smoking or tobacco use)

No If you use tobacco but do not have signs of tobacco related disease we cover two counseling sessions within a 12 month period If you use tobacco and have been diagnosed with a tobacco related disease we cover

Page | 7Effective 01/01/2019 MUST MAINTAIN FULL MEDICAID ELIGIBILITY

2019 FeelWell (HMO SNP) Covered Services Requirements

Services Requires Prior Authorization

Limitations

MUST MAINTAIN FULL MEDICAID ELEGIBILITYtwo counseling sessions with 12 month period, however, there is a cost share(Each counseling attempt includes up to 4 face-to-face visits)

Supervised Exercise Therapy (SET) Yes Up to 36 sessions over a 12-week period are covered if the SET program requirements are met. SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider.

Telemonitoring Services Yes (referral may also be required)

Model of care intended to reduce avoidable hospital admissions for members living with chronic conditions and transitioning from home health services to community with no formal support. Telemonitoring is provided through structured electronic contact between members and health care providers (with or without home visits) and includes reporting of symptoms and physiological data to physicians. The tele monitoring benefit does not include blood glucose monitors.

If a member calls for this benefit:

“This benefit is offered to qualified members based on certain criteria; if you wish to know if you qualify, let me put you in contact with one of our Wellness Coaches to determine if the service is appropriate for you” (number will be posted on intranet). You can also call the Navigator line 718.696.0203 to be transferred. Thank you for your call”.

Transportation Not coveredUrgently needed services (US + Territories Only)

No

Vision Care Glaucoma screening

No (Contact National Vision Associates 1-844-344-1250 for coverage and authorization)

High risk of Glaucoma 1 screening per yearFor people with diabetes one screening for diabetic retinopathy per yearOne pair of eyeglasses with standard frames (or one set of contact lenses) after cataract surgery that implants an intraocular lens.

Eye Wear Yes (Contact National Vision Associates 1-844-

One pair of eyeglasses or one set of contact lenses after cataract surgery with an intraocular lens

Page | 8Effective 01/01/2019 MUST MAINTAIN FULL MEDICAID ELIGIBILITY

2019 FeelWell (HMO SNP) Covered Services Requirements

Services Requires Prior Authorization

Limitations

MUST MAINTAIN FULL MEDICAID ELEGIBILITY344-1250 for coverage and authorization)

“Welcome to Medicare” Preventive visit No One time visit only within the first 12 months you have Medicare Part BMedicare-covered EKG following Welcome Visit Preventive Services at no additional cost.

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