2016 Orange County HICAP Medicare Advantage Special Needs Plans Comparison Chart

2016 Orange County HICAP Medicare Advantage Special Needs Plans Comparison Chart HICAP 714-560-0424 or 800-Medicare or medicare.gov Company Plan Name...
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2016 Orange County HICAP Medicare Advantage Special Needs Plans Comparison Chart HICAP 714-560-0424 or 800-Medicare or medicare.gov

Company Plan Name and Medicare Identifier Telephone Numbers and Website

Plan Type Chronic or Disabling Condition Total Monthly Premium & Annual Deductibles Size of Network Out of Pocket Limit Doctor/Specialist Visit

Inpatient Hospitalization

Skilled Nursing Facility

Ambulance Chemotherapy Drugs Chiropractic

Diabetes

Alignment Health Plan

Brand New Day

Brand New Day

Brand New Day

Heart & Diabetes H3815-010

Harmony Dual Access H0838-020

In Control Drug Savings H0838-026

In Control Dual Access H0838-027

New enrollment: 888-979-2247 Current members: 888-979-2247 alignmenthealthplan.com MA-PD (HMO)

Cardiovascular disorders, chronic heart failure, &/or diabetes

New enrollment: 866-255-4795 Current members: 866-255-4795 brandnewdayhmo.com

MA-PD (HMO) Medi-Medi option offered

New enrollment: 866-255-4795 Current members: 866-255-4795 brandnewdayhmo.com MA-PD (HMO)

New enrollment: 866-255-4795 Current members: 866-255-4795 brandnewdayhmo.com

MA-PD (HMO) Medi-Medi option offered

Mental health

Diabetes mellitus

Diabetes mellitus

$0 monthly premium $0 annual deductibles

$31.00 monthly premium $360 drug plan deductible

$0 monthly premium $0 annual deductibles

$31.00 monthly premium $360 drug plan deductible

$2,950 In-Network

$6,700 In-Network

$3,400 In-Network

$6,700 In-Network

3501-4000 providers

$0/$0 each visit

1001-1500 providers

$0-$15/0-20% of cost each visit

5001-5500 providers

$0/$0 each visit

5001-5500 providers

$0/$5-$25 each visit

$0 copay. Unlimited days each benefit period.

90 days each benefit period. 60 90 days each benefit period. 60 $0 copay. 90 days each benefit lifetime reserve days. Contact lifetime reserve days. Contact period. 60 lifetime reserve days. plan for more details. plan for more details.

Days 1-31: $0/day, Days 32100: $25/day. 100 days each benefit period.

100 days each benefit period. Contact plan for more details.

$0 copay. 100 days each benefit period.

100 days each benefit period. Contact plan for more details.

$100 each service

20% of cost each service

$65 each service

20% of cost each service

$0 for subluxation manipulation

20% of cost for subluxation manipulation

$0 for subluxation manipulation

20% of cost for subluxation manipulation

20% of cost for Part B chemotherapy drugs

20% of cost for Part B chemotherapy drugs

$0 for monitoring supplies. $0 for self-management training. $0 for therapeutic shoes or inserts.

20% of cost for monitoring supplies. 20% of cost for selfmanagement training. 20% of cost for therapeutic shoes or inserts.

$75 each visit, waived if admitted within 24 days.

$0 for Part B chemotherapy drugs

20% of cost for Part B chemotherapy drugs

$0 for monitoring supplies. $0 for self-management training. $0 for therapeutic shoes or inserts.

20% of cost for monitoring supplies. 20% of cost for selfmanagement training. 20% of cost for therapeutic shoes or inserts.

20% of cost each visit, waived if admitted within 3 days.

$65 each visit, waived if admitted within 3 days.

20% of cost each visit, waived if admitted within 3 days.

$0 each visit

20% of cost each visit

20% of cost each visit

$0 copay

$0 copay

$0 each occupational or cardiac visit. 20% of cost all other visits.

20% of cost for diagnostic 20% of cost for diagnostic $0 for diagnostic radiology $75 for diagnostic radiology radiology services. 20% of cost radiology services. 20% of cost services. $0 for diagnostic tests Diagnostic Tests, Lab & services. $0 for diagnostic tests for diagnostic tests and for diagnostic tests and and procedures. $0 for lab and procedures. $0 for lab procedures. $0 for lab services. procedures. $0 for lab services. Radiology Services, and services. $0 each x-ray. 20% of services. $0 each x-ray. $60 for 20% of cost each x-ray. 20% of 20% of cost each x-ray. 20% of X-Rays cost for therapeutic radiology therapeutic radiology services. cost for therapeutic radiology cost for therapeutic radiology services. services. services.

Emergency Room Visit Outpatient Hospital Services

Outpatient Rehabilitation Services Transportation

Dental Services

Hearing Services

Vision Services

Prescription Drugs www.coaoc.org 714-479-0107

$0 each visit

$0-$425 for limited dental. $0 for cleaning. $0-$30 for x-rays. $0-$20 for fluoride treatment. $0 for oral exam.

20% of cost each visit

$0 for limited dental. $0 for cleaning. $0 for x-rays. $0 for fluoride treatment. $0 for oral exam.

$0 each visit

$0 copay

0-20% of cost for limited dental. $15-$55 for cleaning. $0 for xrays. $0-$12 for fluoride treatment. $0 for oral exam.

20% of cost each visit

$0 copay

$0 for limited dental. $0 for cleaning. $0 for x-rays. $0 for fluoride treatment. $0 for oral exam.

$0 for diagnostic exam. $0 for routine exam. $0 for hearing aid 20% of cost for diagnostic exam 20% of cost for diagnostic exam 20% of cost for diagnostic exam fitting or evaluation. $0 for diagnostic exam. $0 for routine eye exam. $0 for contact 20% of cost for diagnostic exam. $0 for diagnostic exam. $0 for 20% of cost for diagnostic exam. routine eye exam. $0 for lenses. $0 for eyeglasses. $0 for $0 for routine eye exam. $0 for $0 for routine eye exam. $0 for eyeglass frames. $0 for eyeglass eyeglasses. $0 for eyewear after eyeglasses. $0 for eyewear after eyeglasses. $0 for eyewear after lenses. $0 for eyewear after cataract surgery. Plan pays up cataract surgery. Plan pays up cataract surgery. Plan pays up to $225 for eyeglasses. cataract surgery. Plan pays up to $150 for eyeglasses. to $200 for eyeglasses. to $200 each for eyewear. See separate Chart

See separate Chart

See separate Chart

Information is subject to change. Contact the plan to verify information. HICAP is not liable for missing or incorrect information.

See separate Chart

Rev. 10/26/2015 Page 1 of 6

2016 Orange County HICAP Medicare Advantage Special Needs Plans Comparison Chart HICAP 714-560-0424 or 800-Medicare or medicare.gov

Company

Brand New Day

Brand New Day

Brand New Day

Brand New Day

Plan Name and Medicare Identifier

Bridges Drug Savings H0838-028

Bridges Dual Access H0838-029

Healthy Heart Drug Savings H0838-030

Healthy Heart Dual Access H0838-031

Telephone Numbers and Website

Plan Type Chronic or Disabling Condition Total Monthly Premium & Annual Deductibles Size of Network Out of Pocket Limit Doctor/Specialist Visit

Inpatient Hospitalization

Skilled Nursing Facility

Ambulance Chemotherapy Drugs Chiropractic

Diabetes

New enrollment: 866-255-4795 Current members: 866-255-4795 brandnewdayhmo.com MA-PD (HMO)

New enrollment: 866-255-4795 Current members: 866-255-4795 brandnewdayhmo.com

MA-PD (HMO) Medi-Medi option offered

New enrollment: 866-255-4795 Current members: 866-255-4795 brandnewdayhmo.com MA-PD (HMO)

New enrollment: 866-255-4795 Current members: 866-255-4795 brandnewdayhmo.com

MA-PD (HMO) Medi-Medi option offered

Dementia

Dementia

Chronic heart failure

Chronic heart failure

$0 monthly premium $0 annual deductibles

$31.00 monthly premium $360 drug plan deductible

$0 monthly premium $0 annual deductibles

$31.00 monthly premium $360 drug plan deductible

$3,400 In-Network

$6,700 In-Network

$3,400 In-Network

$6,700 In-Network

5001-5500 providers

$0/$0 each visit

$0 copay. 90 days each benefit period. 60 lifetime reserve days.

5001-5500 providers

$0/$0 each visit

5001-5500 providers

$0/$0 each visit

5001-5500 providers

$0/$5-$15 each visit

90 days each benefit period. 60 90 days each benefit period. 60 $0 copay. 90 days each benefit lifetime reserve days. Contact lifetime reserve days. Contact period. 60 lifetime reserve days. plan for more details. plan for more details.

Days 1-20: $0/day. Days 21100: $148/day. 100 days each benefit period.

100 days each benefit period. Contact plan for more details.

$0 copay. 100 days each benefit period.

100 days each benefit period. Contact plan for more details.

20% of cost each service

20% of cost each service

$65 each service

20% of cost each service

$0 for subluxation manipulation

20% of cost for subluxation manipulation

$0 for subluxation manipulation

20% of cost for subluxation manipulation

$0 for Part B chemotherapy drugs

20% of cost for Part B chemotherapy drugs

$0 for monitoring supplies. $0 for self-management training. $0 for therapeutic shoes or inserts.

20% of cost for monitoring supplies. 20% of cost for selfmanagement training. 20% of cost for therapeutic shoes or inserts.

$65 each visit, waived if admitted within 3 days.

$0 each occupational or cardiac visit. 20% of cost all others visits.

$0 for Part B chemotherapy drugs

20% of cost for Part B chemotherapy drugs

$0 for monitoring supplies. $0 for self-management training. $0 for therapeutic shoes or inserts.

20% of cost for monitoring supplies. 20% of cost for selfmanagement training. 20% of cost for therapeutic shoes or inserts.

20% of cost each visit, waived if admitted within 3 days.

$65 each visit, waived if admitted within 3 days.

20% of cost each visit, waived if admitted within 3 days.

20% of cost each visit

$0 each occupational or cardiac visit. 20% of cost all other visits.

20% of cost each visit

0-20% of cost for limited dental. $15-$55 for cleaning. $0 for xrays. $0-$12 for fluoride treatment. $0 for oral exam.

$0 for limited dental. $0 for cleaning. $0 for x-rays. $0 for fluoride treatment. $0 for oral exam.

20% of cost for diagnostic 20% of cost for diagnostic $0 for diagnostic radiology $0 for diagnostic radiology radiology services. 20% of cost radiology services. 20% of cost services. $0 for diagnostic tests services. $0 for diagnostic tests Diagnostic Tests, Lab & for diagnostic tests and for diagnostic tests and and procedures. $0 for lab and procedures. $0 for lab procedures. $0 for lab services. procedures. $0 for lab services. Radiology Services, and services. $0 each x-ray. 20% of services. $0 each x-ray. 20% of 20% of cost each x-ray. 20% of 20% of cost each x-ray. 20% of X-Rays cost for therapeutic radiology cost for therapeutic radiology cost for therapeutic radiology cost for therapeutic radiology services. services. services. services.

Emergency Room Visit Outpatient Hospital Services

Outpatient Rehabilitation Services Transportation

Dental Services

Hearing Services

Vision Services

Prescription Drugs www.coaoc.org 714-479-0107

$65-$100 or 20% of cost each visit

$0 copay

0-20% of cost for limited dental. $15-$55 for cleaning. $0 for xrays. $0-$12 for fluoride treatment. $0 for oral exam.

20% of cost each visit

$0 copay

$0 for limited dental. $0 for cleaning. $0 for x-rays. $0 for fluoride treatment. $0 for oral exam.

$0 each visit

$0 copay

20% of cost each visit

$0 copay

$0 for diagnostic exam

20% of cost for diagnostic exam 20% of cost for diagnostic exam 20% of cost for diagnostic exam

$0 for diagnostic exam. $0 for routine eye exam. $0 for eyeglasses. $0 for eyewear after cataract surgery. Plan pays up to $150 for eyeglasses.

20% of cost for diagnostic exam. $0 for diagnostic exam. $0 for 20% of cost for diagnostic exam. routine eye exam. $0 for $0 for routine eye exam. $0 for $0 for routine eye exam. $0 for eyeglasses. $0 for eyewear after eyeglasses. $0 for eyewear after eyeglasses. $0 for eyewear after cataract surgery. Plan pays up cataract surgery. Plan pays up cataract surgery. Plan pays up to $225 for eyeglasses. to $225 for eyeglasses. to $200 for eyeglasses.

See separate Chart

See separate Chart

See separate Chart

Information is subject to change. Contact the plan to verify information. HICAP is not liable for missing or incorrect information.

See separate Chart

Rev. 10/26/2015 Page 2 of 6

2016 Orange County HICAP Medicare Advantage Special Needs Plans Comparison Chart HICAP 714-560-0424 or 800-Medicare or medicare.gov

Company

Brand New Day

CareMore Health Plan

CareMore Health Plan

CareMore Health Plan

Plan Name and Medicare Identifier

Hope Drug Savings H0838-032

CareMore Reliance H0544-004

CareMore Heart H0544-013

CareMore Breathe H0544-014

Telephone Numbers and Website

Plan Type Chronic or Disabling Condition Total Monthly Premium & Annual Deductibles Size of Network Out of Pocket Limit Doctor/Specialist Visit

Inpatient Hospitalization

Skilled Nursing Facility

Ambulance Chemotherapy Drugs Chiropractic

Diabetes

New enrollment: 866-255-4795 Current members: 866-255-4795 brandnewdayhmo.com MA-PD (HMO)

New enrollment: 888-291-1358 Current members: 800-499-2793 caremore.com MA-PD (HMO)

Mental health

Diabetes mellitus

$0 monthly premium $0 annual deductibles

$0 monthly premium $0 annual deductibles

$3,400 In-Network

$3,000 In-Network

1001-1500 providers

$0/$0 each visit

1001-1500 providers

$0/$0 each visit

New enrollment: 888-291-1358 Current members: 800-499-2793 caremore.com MA-PD (HMO)

Cardiovascular disorders and/or chronic heart failure

New enrollment: 888-291-1358 Current members: 800-499-2793 caremore.com MA-PD (HMO)

Lung disorders

$0 monthly premium $0 annual deductibles

$0 monthly premium $0 annual deductibles

$3,000 In-Network

$3,000 In-Network

1001-1500 providers

$0/$0 each visit

1001-1500 providers

$0/$0 each visit

$0 copay. 90 days each benefit $0 copay. 120 days each benefit $0 copay. 120 days each benefit period. 60 lifetime reserve days. period. 60 lifetime reserve days. period. 60 lifetime reserve days.

$0 copay. 120 days each benefit period. 60 lifetime reserve days.

$0 copay. 100 days each benefit period.

Days 1-31: $0/day, Days 32100: $25/day. 100 days each benefit period.

Days 1-31: $0/day, Days 32100: $25/day. 100 days each benefit period.

Days 1-31: $0/day, Days 32100: $25/day. 100 days each benefit period.

$90 each service

$100 each service

$100 each service

$100 each service

$0 for Part B chemotherapy drugs

20% of cost for Part B chemotherapy drugs

20% of cost for Part B chemotherapy drugs

20% of cost for Part B chemotherapy drugs

$0 for monitoring supplies. $0 for self-management training. $0 for therapeutic shoes or inserts.

$0 for monitoring supplies. $0 for self-management training. $0 for therapeutic shoes or inserts.

$0 for monitoring supplies. $0 for self-management training. $0 for therapeutic shoes or inserts.

$0 for monitoring supplies. $0 for self-management training. $0 for therapeutic shoes or inserts.

$0 for subluxation manipulation $0 for subluxation manipulation $0 for subluxation manipulation $0 for subluxation manipulation

$0 for diagnostic radiology $0-$75 for diagnostic radiology $0-$75 for diagnostic radiology $0-$75 for diagnostic radiology services. $0 for diagnostic tests Diagnostic Tests, Lab & services. $0 for diagnostic tests services. $0 for diagnostic tests services. $0 for diagnostic tests and procedures. $0 for lab and procedures. $0 for lab and procedures. $0 for lab and procedures. $0 for lab Radiology Services, and services. $0 each x-ray. 20% of services. $0 each x-ray. $60 for services. $0 each x-ray. $60 for services. $0 each x-ray. $60 for X-Rays cost for therapeutic radiology therapeutic radiology services. therapeutic radiology services. therapeutic radiology services. services.

Emergency Room Visit Outpatient Hospital Services Outpatient Rehabilitation Services Transportation

Dental Services

Hearing Services

Vision Services

Prescription Drugs www.coaoc.org 714-479-0107

$65 each visit, waived if admitted within 3 days.

$65 each visit, waived if admitted within 24 hours.

$65 each visit, waived if admitted within 24 hours.

$65 each visit, waived if admitted within 24 hours.

$0 each occupational or cardiac visit. 20% of cost all other visits.

$0 each visit

$0 each visit

$0 each visit

$0 copay

$0 copay

$0 copay

$0 each visit

$0 copay

$0 each visit

0-20% of cost for limited dental. $0 for limited dental. $35 for $15-$55 for cleaning. $0 for x- cleaning. $0-$10 for x-rays. $5 rays. $0-$12 for fluoride for fluoride treatment. $5-$15 treatment. $0 for oral exam. for oral exam.

$0 each visit

$0 for limited dental. $35 for cleaning. $0-$10 for x-rays. $5 for fluoride treatment. $5-$15 for oral exam.

$0 each visit

$0 for limited dental. $35 for cleaning. $0-$10 for x-rays. $5 for fluoride treatment. $5-$15 for oral exam.

$0 for diagnostic exam. $0 for $0 for diagnostic exam. $0 for $0 for diagnostic exam. $0 for routine hearing exam. $0 for routine hearing exam. $0 for routine hearing exam. $0 for 20% of cost for diagnostic exam hearing aid fitting or evaluation. hearing aid fitting or evaluation. hearing aid fitting or evaluation. $0 for hearing aid. Plan pays up $0 for hearing aid. Plan pays up $0 for hearing aid. Plan pays up to $250 for hearing aids. to $250 for hearing aids. to $250 for hearing aids.

$0 for diagnostic exam. $0 for $0 for diagnostic exam. $0 for $0 for diagnostic exam. $0 for routine eye exam. $0 for contact routine eye exam. $0 for contact routine eye exam. $0 for contact $0 for diagnostic exam. $0 for lenses. $0 for eyeglass frames. lenses. $0 for eyeglass frames. lenses. $0 for eyeglass frames. routine eye exam. $0 for $20 for eyeglass lenses. $0 for $20 for eyeglass lenses. $0 for $20 for eyeglass lenses. $0 for eyeglasses. $0 for eyewear after eyewear after cataract surgery. eyewear after cataract surgery. eyewear after cataract surgery. cataract surgery. Plan pays up Plan pays up to $100 each for Plan pays up to $100 each for Plan pays up to $100 each for to $150 for eyewear. contact lenses and eyeglass contact lenses and eyeglass contact lenses and eyeglass frames. frames. frames. See separate Chart

See separate Chart

See separate Chart

Information is subject to change. Contact the plan to verify information. HICAP is not liable for missing or incorrect information.

See separate Chart

Rev. 10/26/2015 Page 3 of 6

2016 Orange County HICAP Medicare Advantage Special Needs Plans Comparison Chart HICAP 714-560-0424 or 800-Medicare or medicare.gov

Company

CareMore Health Plan

Central Hlth. Medicare Pl.

Health Net of California

SCAN Health Plan

Plan Name and Medicare Identifier

CareMore ESRD H0544-015

Central Health Focus Plan H5649-006

Health Net Jade H0562-092

Heart First H5425-028

Telephone Numbers and Website

Plan Type Chronic or Disabling Condition Total Monthly Premium & Annual Deductibles Size of Network Out of Pocket Limit Doctor/Specialist Visit

Inpatient Hospitalization

Skilled Nursing Facility

Ambulance Chemotherapy Drugs Chiropractic

Diabetes

New enrollment: 888-291-1358 Current members: 800-499-2793 caremore.com

New enrollment: 866-314-2427 Current members: 866-314-2427 centralhealthplan.com MA-PD (HMO)

New enrollment: 800-977-6738 Current members: 800-275-4737 healthnet.com/medicare

New enrollment: 877-452-5898 Current members: 800-559-3500 scanhealthplan.com

End-stage renal disease requiring any mode of dialysis

Cardiovascular disorders, chronic heart failure and/or diabetes

Cardiovascular disorders, chronic heart failure and/or diabetes

Cardiovascular disorders and/or chronic heart failure

1001-1500 providers

4501-5000 providers

3001-3500 providers

9001-10000 providers

$0/$0 each visit

$0/$0 each visit

MA-PD (HMO)

$0 monthly premium $0 annual deductibles

$3,000 In-Network $0/$0 each visit

$0 monthly premium $0 annual deductibles

$3,400 In-Network $0/$0 each visit

MA-PD (HMO)

$0 monthly premium $0 annual deductibles

$3,400 In-Network

MA-PD (HMO)

$0 monthly premium $0 annual deductibles

$3,400 In-Network

Days 1-5: $75/day, Days 6-90: $0/day, $0/day after 90 days. 230 days each benefit period. 60 lifetime reserve days.

$0 copay. Unlimited days each benefit period.

$0 copay. Unlimited days each benefit period.

$0 copay. Unlimited days each benefit period.

Days 1-31: $0/day, Days 32100: $25/day. 100 days each benefit period.

Days 1-20: $0/day, Days 21-65: $75/day. Days 66-100: $0/day. 100 days each benefit period.

Days 1-31: $0/day, Days 32100: $25/day. 100 days each benefit period.

Days 1-20: $0/day, Days 21100: $50/day. 100 days each benefit period.

$0-$100 each service, waived if admitted.

$50 each service

20% of cost for Part B chemotherapy drugs

20% of cost for Part B chemotherapy drugs

$0 for monitoring supplies. $0 for self-management training. $0 for therapeutic shoes or inserts.

$0 for monitoring supplies. $0 for self-management training. $0 for therapeutic shoes or inserts.

$40 each service, waived if admitted.

$200 each service

20% of cost for Part B chemotherapy drugs

20% of cost for Part B chemotherapy drugs

$0 for monitoring supplies. $0 for self-management training. $0 for therapeutic shoes or inserts.

$0 for monitoring supplies. $0 for self-management training. $0 for therapeutic shoes or inserts.

$60 for diagnostic radiology

$100 for diagnostic radiology

therapeutic radiology services.

therapeutic radiology services.

$0 for subluxation manipulation $0 for subluxation manipulation $0 for subluxation manipulation $0 for subluxation manipulation

$0-$75 for diagnostic radiology

$0 for diagnostic radiology

Diagnostic Tests, Lab & services. $0 for diagnostic tests services. $0 for diagnostic tests services. $0 for diagnostic tests services. $0 for diagnostic tests and procedures. $0 for lab and procedures. $0 for lab and procedures. $0 for lab and procedures. $0 for lab Radiology Services, and services. $0 each x-ray. 20% of services. $0 each x-ray. $60 for services. $0 each x-ray. $60 for services. $0 each x-ray. $50 for X-Rays cost for therapeutic radiology therapeutic radiology services.

Emergency Room Visit Outpatient Hospital Services Outpatient Rehabilitation Services Transportation

Dental Services

Hearing Services

Vision Services

Prescription Drugs www.coaoc.org 714-479-0107

services.

$65 each visit, waived if admitted within 24 hours.

$50 each visit, waived if admitted within 24 hours.

$75 each visit, waived if immediately admitted.

$75 each visit, waived if immediately admitted.

$0 each visit

$0 each visit

$0 each visit

$0 copay

$0 copay

$0 copay

$0 each cardiac visit. $10 each all other visits.

$0 each visit

$0 for limited dental. $0-$45 for cleaning. $0 for x-rays. $0-$10 for fluoride treatment. $0 for oral exam.

$0 each visit

$0 for limited dental. $0 for cleaning. $0 for x-rays. $0 for fluoride treatment. $0 for oral exam.

$0 each visit

$0 for limited dental. $0 for cleaning. $0 for x-rays. $0 for fluoride treatment. $0 for oral exam.

$0-$100 each visit

$0 copay

$0 for limited dental

$0 for diagnostic exam. $0 for $0 for diagnostic exam. $0 for $0 for diagnostic exam. $0 for $0 for diagnostic exam. $0 for routine hearing exam. $0 for routine hearing exam. $0 for routine exam. $0 for hearing aid routine hearing exam. $0 for fitting or evaluation. $0 for hearing aid fitting or evaluation. hearing aid fitting or evaluation. hearing aid fitting or evaluation. hearing aid. Plan pays up to $0 for hearing aid. Plan pays up $0 for hearing aid. Plan pays up $0 for hearing aid. Plan pays up $250 for hearing aids. to $1000 for hearing aids. to $1000 for hearing aids. to $500 for hearing aids. $0 for diagnostic exam. $0 for $0 for diagnostic exam. $0 for $0 for diagnostic exam. $0 for $0 for diagnostic exam. $0 for routine eye exam. $35 for routine eye exam. $0 for contact contact lenses. $35 for routine eye exam. $0 for contact routine eye exam. $0 for contact lenses. $0 for eyeglass frames. lenses. $0 for eyeglasses. $0 for lenses. $0 for eyeglasses. $0 for eyeglasses. $0 for eyeglass $20 for eyeglass lenses. $0 for eyeglass frames. $0 for eyeglass eyeglass frames. $0 for eyeglass frames. $35 for eyeglass lenses. eyewear after cataract surgery. lenses. $0 for eyewear after $0 for eyewear after cataract lenses. $0 for eyewear after Plan pays up to $100 each for surgery. Plan pays up to $105 cataract surgery. Plan pays up cataract surgery. Plan pays up contact lenses and eyeglass to $150 for eyewear. to $250 for eyewear. for contact lenses or eyeglass frames. frames. See separate Chart

See separate Chart

See separate Chart

Information is subject to change. Contact the plan to verify information. HICAP is not liable for missing or incorrect information.

See separate Chart

Rev. 10/26/2015 Page 4 of 6

2016 Orange County HICAP Medicare Advantage Special Needs Plans Comparison Chart HICAP 714-560-0424 or 800-Medicare or medicare.gov

Company Plan Name and Medicare Identifier Telephone Numbers and Website

Plan Type Chronic or Disabling Condition Total Monthly Premium & Annual Deductibles Size of Network Out of Pocket Limit Doctor/Specialist Visit

Inpatient Hospitalization

Skilled Nursing Facility

Ambulance Chemotherapy Drugs Chiropractic

Diabetes

VillageHealth

SCAN Health Plan SCAN Balance H5425-034 New enrollment: 877-452-5898 Current members: 800-559-3500 scanhealthplan.com MA-PD (HMO)

Diabetes mellitus $0 monthly premium $0 annual deductibles

9001-10000 providers $3,400 In-Network $0/$0 each visit

$0 copay. Unlimited days each benefit period.

VillageHealth In-Network H5943-002 New enrollment: 877-916-1234 Current members: 800-399-7226 villagehealthca.com

MA-PD (HMO) Medi-Medi option offered

VillageHealth Out-of-Network H5943-002 New enrollment: 877-916-1234 Current members: 800-399-7226 villagehealthca.com MA-PD (HMO POS)

End-stage renal disease requiring any mode of dialysis

End-stage renal disease requiring any mode of dialysis

3001-3500 providers

3001-3500 providers

$31.00 monthly premium health plan deduct.: unavail. $360 drug plan deductible $6,700 In-Network $6,700 In & Out

$0/20% of cost each visit

$31.00 monthly premium health plan deduct.: unavail. $360 drug plan deductible $6,700 In-Network $6,700 In & Out

20%/20% of cost each visit

90 days each benefit period. 60 90 days each benefit period. 60 lifetime reserve days. Contact lifetime reserve days. Contact plan for more details. plan for more details.

Days 1-20: $0/day, Days 21100: $50/day. 100 days each benefit period.

100 days each benefit period. Contact plan for more details.

Not available out-of-network

$200 each service

20% of cost each service

20% of cost each service

20% of cost for Part B chemotherapy drugs

See Page 6 for Institutional Special Needs Plans

0-20% of cost for Part B chemotherapy drugs

$0 for subluxation manipulation $0 for subluxation manipulation

0-20% of cost for Part B chemotherapy drugs

20% of cost for subluxation manipulation

$0 for monitoring supplies. $0 for self-management training. $0 for therapeutic shoes or inserts.

$0 for monitoring supplies. $0 for self-management training. $0 for therapeutic shoes or inserts.

$0 for monitoring supplies. $0 for self-management training. $0 for therapeutic shoes or inserts.

$75 each visit, waived if immediately admitted.

$75 each visit, waived if immediately admitted.

$75 each visit, waived if immediately admitted.

$0 each cardiac visit. $10 each all other visits.

20% of cost each cardiac visit. $0 each all other visits.

20% of cost each visit

20% of cost for diagnostic $0 for diagnostic radiology $100 for diagnostic radiology radiology services. 20% of cost services. 20% of cost for Diagnostic Tests, Lab & services. $0 for diagnostic tests for diagnostic tests and diagnostic tests and procedures. and procedures. $0 for lab procedures. $0 for lab services. Radiology Services, and $0 for lab services. $0 each xservices. $0 each x-ray. $50 for 20% of cost each x-ray. 20% of X-Rays ray. 20% of cost for therapeutic therapeutic radiology services. cost for therapeutic radiology radiology services. services.

Emergency Room Visit Outpatient Hospital Services

Outpatient Rehabilitation Services Transportation

Dental Services

Hearing Services

Vision Services

Prescription Drugs www.coaoc.org 714-479-0107

$0-$100 each visit

$0 copay

$0 for limited dental

0-20% of cost each visit

$0 copay

20% of cost each visit

Not available out-of-network

20% of cost for limited dental. 20% of cost for limited dental. $0 for cleaning. $0 for x-rays. $0 Cleaning, x-rays, and oral exam not available out-of-network. for oral exam.

$0 for diagnostic exam. $0 for routine hearing exam. $0 for hearing aid fitting or evaluation. 20% of cost for diagnostic exam 20% of cost for diagnostic exam $0 for hearing aid. Plan pays up to $500 for hearing aids. $0 for diagnostic exam. $0 for 0-20% of cost for diagnostic 0-20% of cost for diagnostic routine eye exam. $35 for exam. $0 for routine eye exam. contact lenses. $35 for exam. Routine eye exam, $25 for contact lenses. $25 for eyeglasses. $0 for eyeglass contact lenses, eyeglasses, eyeglasses. $0 for eyeglass frames. $35 for eyeglass lenses. eyeglass frames, and eyeglass frames. $25 for eyeglass lenses. $0 for eyewear after cataract lenses not available out-of20% of cost for eyewear after surgery. Plan pays up to $105 network. 20% of cost for cataract surgery. Plan pays up each for contact lenses and eyewear after cataract surgery. to $175 for eyewear. eyeglass frames. See separate Chart

See separate Chart

See separate Chart

Information is subject to change. Contact the plan to verify information. HICAP is not liable for missing or incorrect information.

Rev. 10/26/2015 Page 5 of 6

2016 Orange County HICAP Medicare Advantage Special Needs Plans Comparison Chart HICAP 714-560-0424 or 800-Medicare or medicare.gov

Company

CareMore Health Plan

SCAN Health Plan

Plan Name and Medicare Identifier

CareMore Touch H0544-005

SCAN Healthy at Home H9104-006

Telephone Numbers and Website

Plan Type Chronic or Disabling Condition Total Monthly Premium & Annual Deductibles Size of Network Out of Pocket Limit Doctor/Specialist Visit

New enrollment: 800-589-3147 Current members: 866-646-3553 caremore.com MA-PD (HMO)

Long-term care residents $0 monthly premium $0 annual deductibles

New enrollment: 877-452-5898 Current members: 800-559-3500 scanhealthplan.com MA-PD (HMO)

Require nursing home level of care but live at home $0 monthly premium $0 annual deductibles

1001-1500 providers

15001-16000 providers

$0/$0 each visit

$10/$20 each visit

$3,000 In-Network

$6,700 In-Network

Days 1-10: $150/day. Days 11$0 copay. 190 days each benefit 90: $0/day. $0/day after 90 Inpatient Hospitalization period. 60 lifetime reserve days. days. Unlimited days each benefit period.

Skilled Nursing Facility

Ambulance Chemotherapy Drugs Chiropractic

Diabetes

$0 copay. 100 days each benefit period.

Days 1-20: $0/day, Days 21100: $100/day. 100 days each benefit period.

$100 each service

$110 each service

20% of cost for Part B chemotherapy drugs

20% of cost for Part B chemotherapy drugs

$0 for monitoring supplies. $0 for self-management training. $0 for therapeutic shoes or inserts.

$0 for monitoring supplies. $0 for self-management training. $0 for therapeutic shoes or inserts.

$0 for subluxation manipulation

$20 for subluxation manipulation

20% of cost for diagnostic $0-$75 for diagnostic radiology radiology services. $0 for Diagnostic Tests, Lab & services. $0 for diagnostic tests diagnostic tests and procedures. and procedures. $0 for lab Radiology Services, and $0 for lab services. $0 each xservices. $0 each x-ray. $60 for X-Rays ray. 20% of cost for therapeutic therapeutic radiology services. radiology services.

Emergency Room Visit Outpatient Hospital Services Outpatient Rehabilitation Services Transportation

Dental Services

Hearing Services

Vision Services

Prescription Drugs www.coaoc.org 714-479-0107

$65 each visit, waived if admitted within 24 hours.

$75 each visit, waived if immediately admitted.

$0 each visit

$20-$100 or 20% of cost each visit

$0 each visit

$20 each visit

$0 copay

Not covered

$0 for limited dental. $35 for cleaning. $0-$10 for x-rays. $5 for fluoride treatment. $5-$15 for oral exam.

$20 for limited dental

$0 for diagnostic exam. $0 for routine hearing exam. $0 for hearing aid fitting or evaluation. $0 for hearing aid. Plan pays up to $1500 for hearing aids.

$20 for diagnostic exam

See separate Chart

See separate Chart

Notes: Plans may limit the frequency of coverage of a benefit during the plan year. Please contact the plan for further details and to verify all information in the chart with the respective plan. Plans may limit coverage to select Orange County zip codes. Dental Coverage: Medicare does not cover most dental care, dental procedures, or supplies, like cleanings, fillings, tooth extractions, dentures, dental plates, or other dental devices.

Medicare Part A (Hospital Insurance) will pay for certain dental services that you get when you are in a hospital. Part A can pay for inpatient hospital care if you need to have emergency or complicated dental procedures, even though the dental care is not covered. The dental coverage benefit section of this chart details the standard dental coverage from each plan. Standard coverage does not require an additional premium.

Durable Medical Equipment: Copays for durable medical equipment (DME) are 20% of cost or less for Medicare-covered items. HMO POS: An HMO POS is a Medicare Advantage Plan that is a Health Maintenance Organization (HMO) with a more flexible network allowing Plan Members to seek care outside of the traditional HMO network under certain situations or for certain treatment.

Medi-Medi Option: Specified plans have an option for beneficiaries who have Medicare and Medi-Cal benefits. Benefits may inclue zero or reduced costs.

Medicare Advantage Plans: These plans are also called Medicare Health Plans and are offered by private companies that contract with Medicare to provide Part A and part B benefits to people with Medicare. There are several different types of Medicare Advantage Plans including HMO's and PPO's. In this chart you will find the type of plan offered by each company in the "Plan Type" row. Enrollees must utilize plan physicians, providers and hospitals.

Out-of-Pocket Maximum: All local MA plans must establish a mandatory maximum out-of-pocket (MOOP) amount for all Medicare Parts A and B services to mirror the same out-of-pocket costs an average beneficiary would have under Original Medicare's fee-for-service program.

After meeting the MOOP, a beneficiary's MA plan will cover his/her remaining Medicare-covered costs for the rest of the calendar year. The mandatory MOOP is $6,700, but plans can coluntarily set a lower MOOP in exchange for more flexibility in setting their cost-sharing amounts. Vision Coverage: "Eyewear" as used in this chart includes contact lenses and eyeglasses. "Eyeglasses" as used in this chart includes frames and lenses.

$0-$20 for diagnostic exam. $10 $0 for diagnostic exam. $0 for for routine eye exam. $0 for routine eye exam. $0 for contact contact lenses. $15 for lenses. $0 for eyeglass frames. eyeglasses. $0 for eyeglass $20 for eyeglass lenses. $0 for frames. $15 for eyeglass lenses. eyewear after cataract surgery. $10 for eyewear after cataract Plan pays up to $100 each for surgery. Plan pays up to $175 contact lenses and eyeglass each for contact lenses or frames. eyeglass frames. Information is subject to change. Contact the plan to verify information. HICAP is not liable for missing or incorrect information.

Rev. 10/26/2015 Page 6 of 6

2016 Medicare Part D Coverage Included in the Chroninc Illness and Institutional Special Needs Plans

Beneficiary must have both Medicare Parts A and B to enroll in a Medicare Advantage Plan with the drug benefits shown below. For assistance, call HICAP 714-560-0424 or 800-Medicare or medicare.gov

Prescription Drug Plans associated with Health Maintenance Organiazations (HMO's )

Organization Name

Non-Member Telephone No. Plan Internet Website

Annual Deductible for Part D

Plan Name

Copayments after deductible has been met and prior to reaching $3,310 in full drug cost Tier 1

Tier 2

Tier 3

Tier 4

Tier 5

Tier 6

Coverage in Gap*

Mail Order

Overall Quality Rating (Out of 5)

Drug Plan Rating (Out of 5)

Alignment Health Plan 888-979-2247

Heart & Diabetes

$0

$0

$5

$30

$75

33%

N/A

Tier 1

Yes

3.0

2.5

alignmenthealthplan.com Harmony Dual Access

$360

$0

$13

25%

25%

25%

$11

No

Yes

3.0

3.5

866-255-4795

In Control Drug Savings

$0

$0

$9

$45

$90

33%

$9

No

Yes

3.0

3.5

brandnewdayhmo.com

In Control Dual Access

$360

0%

0%

0%

25%

25%

0%

No

Yes

3.0

3.5

Bridges Drug Savings

$0

$0

$9

$45

$90

33%

$11

Tiers 1, 2, 6

Yes

3.0

3.5

Bridges Dual Access Healthy Heart Drug Savings

$360

0%

0%

0%

25%

25%

0%

No

Yes

3.0

3.5

$0

$0

$9

$45

$90

33%

$11

Tiers 1, 2, 6

Yes

3.0

3.5

Healthy Heart Dual Access Hope Drug Savings

$360

0%

0%

0%

25%

25%

0%

No

Yes

3.0

3.5

$0

$0 $0

33% 33%

$11 $0

Yes Yes

3.5

$0 $0

$90 $85

3.0

CareMore Reliance

$45 $37.50

No

CareMore Health Plan 888-291-1358

$9 $7.50

4.0

5.0

$7.50

$37.50

$85

33%

$0

Yes

4.0

5.0

caremore.com

CareMore Heart CareMore Breathe

$0

$7.50

$37.50

$85

33%

$0

Yes

4.0

5.0

$0

$0

$7.50

$37.50

$85

33%

$0

Tiers 1, 2, 6

Yes

4.0

5.0

CareMore ESRD

$0

$0

$7.50

$37.50

$85

33%

$0

Tiers 1, 2, 6

Yes

4.0

5.0

Central Health Focus Plan

$0

$0

$5

$35

$75

33%

$0

Tiers 1, 2, 6

Yes

3.5

4

Health Net of California 800-977-6738

Health Net Jade

$0

$5

$15

$47

$100

33%

$0

Tiers 1, 2, 6

Yes

4.0

4.5

healthnet.com/medicare SCAN Health Plan 877-452-5898

Heart First

$0

$3

$7

$47

$100

33%

$0

Tiers 1, 2, 6

Yes

4.5

4.5

SCAN Balance

$0

$3

$7

$47

$100

33%

$0

Tiers 1, 2, 6

Yes

4.5

4.5

SCAN Healthy at Home

$0

$3

$10

$47

$100

33%

$11

Tier 1

Yes

4.0

3.5

VillageHealth

$360

25%

25%

25%

25%

25%

25%

No

Yes

3.5

3.5

Brand New Day

Central Health Medicare Plan 866-314-2427

CareMore Touch

$0 $0

Tiers 1, 2, 6 Tiers 1, 2, 6 Tiers 1, 2, 6

centralhealthplan.com

scanhealthplan.com VillageHealth 877-916-1234 villagehealthca.com

*During the coverage gap, plans may cover all or only some drugs within the tiers listed. Total premium cost is shown on the Medicare Advantage Special Needs Plans Comparison Chart.

Information subject to change. Contact plans to verify information.

Generally, Tier 1 = Generics Tier 2 = Generics and Preferred Brands Tier 3 = Non-Preferred Brands Tiers 4 and 5 = Specialties and Injectables

Rev. 10/23/15 Page 1

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