Information for Dual-Eligible Members with Secondary Coverage through Florida Medicaid (Fee-for-Service) January 1, 2014 – December 31, 2014

Broward and Miami-Dade Counties This publication is a supplement to the 2014 PHP (HMO SNP) Evidence of Coverage and is for dual-eligible members who are enrolled in PHP and have Florida Medicaid (feefor-service). This publication explains which benefits are covered through PHP as primary Medicare payer, and which benefits are covered through Florida Medicaid (feefor-service) as secondary payer and how these benefits are coordinated. This information is available for free in other languages. Please contact our Member Services number at (888) 456-4715 for additional information. (TTY users should call 711). Hours are 8:00 a.m. to 8:00 p.m., seven days a week. Member Services also has free language interpreter services available for non-English speakers. Esta información está disponible gratis en otros idiomas. Por favor, póngase en contacto con el número de nuestro Departamento de servicios para miembros (888) 456-4715 para obtener información adicional. (Los usuarios de TTY deben llamar al 711). El horario es de 8:00 a.m. a 8:00 p.m., siete días a la semana. El Departamento de servicios para miembros también tiene servicios de intérprete gratis para personas que no hablan inglés. PHP is an HMO plan with a Medicare contract. Enrollment in PHP depends on contract renewal. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium, deductible and/or copyaments/coinsurance may change on January 1, 2015.

H3132_2082 2014 081913 Approved

Introduction You have received this publication because you are “dual-eligible.” This means that you are eligible for health care coverage through Medicare and Florida Medicaid. You are enrolled in PHP (HMO SNP) for your Medicare medical (Part C) and prescription drug (Part D) coverage and have Florida Medicaid (fee-for-service) that covers certain health care services that Medicare does not. Florida Medicaid also covers some of the costs of your Medicare coverage such as Medicare Part B premium and deductible. You and/or Florida Medicaid must continue to pay your Medicare Part B premium to be eligible for PHP. Generally, PHP is the primary, or first, payer for your health care and prescription drugs. Florida Medicaid (fee-for-service) is the secondary, or second, payer. If PHP does not cover a service or has limitations on a service you need that you have exhausted, Florida Medicaid (fee-for-service) will usually cover that service. For example, PHP does not cover long-term care, however, Florida Medicaid (fee-for-service) does. Please refer to the table on the following pages for all Florida Medicaid-covered services. If you have any questions about covered services through PHP or Florida Medicaid, please call Member Services at (888) 456-4715, 8:00 a.m. to 8:00 p.m., seven days a week. TTY users call 711.

Covered Services by Payer The table on the following pages describes which services are covered by PHP and which are covered by Florida Medicaid (fee-for-service). For more information about benefits covered through PHP and their cost sharing and limitations, if any, see Chapter 4 in the 2014 Evidence of Coverage. Limitations shown in the Florida Medicaid (Fee-for-Service) column do not apply to children and pregnant women.

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Benefit Inpatient Care Inpatient Hospital Care

PHP (HMO SNP) In network. $0 copay. Plan covers 90 days each benefit period. If more than 90 days are required, plan covers up to 60 additional days lifetime reserve days. Lifetime reserve days can only be used once. Includes substance abuse and rehabilitation services.

Florida Medicaid (Fee-for-Service) If inpatient stay is greater than 90 days and lifetime reserve days are exhausted, Florida Medicaid covers additional medically necessary inpatient care up to 45 days per year (up to 365 days per year for emergency inpatient); $0 copay; requires prior authorization.

Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital. Inpatient Mental Health Care

In network. $0 copay. 190-day lifetime limit in a psychiatric hospital. Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.

Skilled Nursing Facility (SNF)

In network in a Medicarecertified SNF. $0 copay. Plan covers up to 100 days each benefit period. Authorization rules may apply. No prior hospital stay is required.

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If lifetime limit of 190 days is exhausted, Florida Medicaid covers additional medically necessary inpatient care up to 45 days per year (up to 365 days per year for emergency inpatient); $0 copay; requires prior authorization. If SNF stay is longer than 100 days, Florida Medicaid covers additional days; limits apply depending on type of SNF facility; $0 copay; requires prior authorization.

Benefit

PHP (HMO SNP)

Florida Medicaid (Fee-for-Service) Covered; no limits; $0 copay; requires prior authorization.

Long-Term Care

Not covered.

Home Health Care (includes medically necessary intermittent skilled nursing care, home health aide services, rehabilitation services, etc.)

In network. $0 copay for Medicare-covered home health visits. Authorization rules may apply.

Covered through PHP network providers. 

Hospice

Covered by Original Medicare at Medicarecertified hospice. Hospice consultation services covered by plan.

Covered through PHP network providers. 

In network. $0 copay for each primary care doctor and specialist visit and urgent care visit for Medicare-covered benefits. Authorization rules may apply.

Covered through PHP network providers. 

In network. $0 copay for Medicare-covered chiropractic visits. Authorization rules may apply.

Covered through PHP network providers. 

Outpatient Care Doctor Office Visits

Chiropractic Services

Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part).

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Benefit Podiatry Services

PHP (HMO SNP) In network. $0 copay for Medicare-covered podiatry benefits. Authorization rules may apply.

Florida Medicaid (Fee-for-Service) Covered through PHP network providers. 

Medicare-covered podiatry visits are for medically necessary foot care.

Outpatient Mental Health Care

In network. $0 copay for Medicare-covered mental health visits and partial hospitalization program services. Authorization rules may apply.

Covered through PHP network providers. 

Outpatient Substance Abuse Care

In network. $0 copay for Medicare-covered visits.

Covered through PHP network providers. 

Outpatient Services

In network. $0 copay for each Medicare-covered ambulatory surgical center and outpatient hospital facility visit. Authorization rules may apply.

Covered through PHP network providers. 

Ambulance Services (medically necessary ambulance services)

In network. $0 copay for Medicare-covered ambulance benefits. Authorization rules may apply.

Covered through PHP network providers. 

Emergency Care (You may go to any emergency room if you reasonably believe you need emergency care.)

$0 copay for each Medicare-covered emergency room visit.

Covered through PHP network providers. 

Not covered outside the US except under limited circumstances.

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Benefit

PHP (HMO SNP)

Urgently Needed Care (This is not emergency care, and in most cases, is out of the service area.)

$0 copay for each Medicare-covered urgentcare visit.

Outpatient Rehabilitation Services (Occupational Therapy, Physical Therapy, Speech and Language Therapy)

In network. $0 copay for Medicare-covered occupational therapy, physical therapy, and speech and language therapy visits. Authorization rules may apply.

Outpatient Medical Services and Supplies Durable Medical In network. $0 copay for Equipment Medicare-covered items. (includes wheelchairs, Authorization rules may oxygen, etc.) apply.

Florida Medicaid (Fee-for-Service) Covered through PHP network providers. 

Covered through PHP network providers. 

Covered through PHP network providers. 

Prosthetic Devices (includes braces, artificial limbs and eyes, etc.)

In network. $0 copay for Medicare-covered prosthetic devices and medical supplies related prosthetics, splints and other devices. Authorization rules may apply.

Covered through PHP network providers. 

Diabetes Programs and Supplies

In network. $0 copay for Medicare-covered diabetes self-management training, diabetes monitoring supplies and therapeutic shoes or inserts. Authorization rules may apply.

Covered through PHP network providers. 

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Benefit

PHP (HMO SNP)

Florida Medicaid (Fee-for-Service) Covered through PHP network providers. 

Diagnostic Tests, X-Rays, Lab Services, and Radiology Services

In network. $0 copay for Medicare-covered lab services, diagnostic procedures and tests, Xrays, diagnostic radiology services and therapeutic radiology services. Authorization rules may apply.

Cardiac and Pulmonary Rehabilitation Services

In network. $0 copay for Medicare-covered cardiac rehabilitation services, intensive cardiac rehabilitation services and pulmonary rehabilitation services. Authorization rules may apply.

Covered through PHP network providers. 

$0 copay for case management and disease management services provided by plan’s nurses.

Not covered.

In network. $0 copay for all Medicare-covered preventive services. Medicare-covered preventive services are those covered under Original Medicare. $0 copay for annual physical exam. Authorization rules may apply for certain preventive services.

Covered through PHP network providers. 

Preventive Services Case Management and Disease Management Services

Preventive Services

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Benefit

PHP (HMO SNP)

Florida Medicaid (Fee-for-Service) Covered through PHP network providers. 

Kidney Disease and Conditions

In network. $0 copay for Medicare-covered renal dialysis and kidney disease education services. Authorization rules may apply.

Outpatient Prescription Drugs

$0 copay for Part Bcovered drugs.

Covers some drugs not on PHP formulary. 

Part D drugs are covered, but there may be cost sharing.

Help for copays may be available. 

See Chapter 6 of the 2014 Evidence of Coverage for a complete description of Part D coverage and your “Evidence of Coverage Rider for People Who Get Extra Help Paying for Prescription Drugs” (also called Low Income Subsidy Rider or LIS Rider) for cost sharing information that applies to you. In most cases, your prescriptions are covered only if they are filled at the plan’s network pharmacies Quantity limits and restrictions may apply. Authorization rules may apply.

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Benefit Dental Services

PHP (HMO SNP) In network. $0 copay for Medicare-covered dental benefits.

Florida Medicaid (Fee-for-Service) Covered through PHP network providers. 

$0 copay for preventive dental benefits such as oral exams, cleanings, fluoride treatments and dental Xrays. Plan offers additional supplemental comprehensive dental benefits. $650 limit for supplemental dental benefits every year.

Hearing Services

If cost of hearing aid(s) exceeds $400 in a year, Florida Medicaid will cover the difference up to the current yearly Medicaid $0 copay for one (1) limit for the type of supplemental routine hearing aid required. hearing exam every year and fitting-evaluation for a Annual limit computation hearing aid. $0 copay each includes $400 coverage through PHP; $0 copay; for up to two (2) supplemental hearing aids requires prior authorization. every year. $400 plan coverage limit for supplemental hearing aids every year.

In network. $0 copay for Medicare-covered diagnostic hearing exams.

Authorization rules may apply.

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Benefit Vision Services

PHP (HMO SNP) In network. $0 copay for Medicare-covered diagnosis and treatment for diseases and conditions of the eye, including an annual glaucoma screening for people at risk. $0 copay for one (1) pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery. $0 copay for one (1) pair of eyeglasses (lenses and frames), contact lenses, eyeglass lenses, and/or eyeglass frame every year. $100 plan coverage limit for supplemental eye wear every year.

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Florida Medicaid (Fee-for-Service) Covered through PHP network providers. 

Benefit

PHP (HMO SNP)

Health/Wellness Education and Other Supplemental Benefits & Services

$0 copay for 24-hour nurse advice line, health education information and additional smoking and tobacco use cessation visits.

Florida Medicaid (Fee-for-Service) Not covered.

Members may choose either a gym membership or up to $200 worth of over-the-counter items, such as vitamins, fiber supplements, first aid supplies, sunscreen, tooth brushes and pastes, cold medication, antacids, etc.,

every year for $0 copay. Transportation

In network. $0 copay for up to 12 round trip(s) to plan-approved location every year. Authorization rules may apply.

If number of medically necessary round trips exceeds 12, Florida Medicaid will cover additional non-emergency medical transport when no other means of transportation to and from Medicaid-compensable services is available. No limits; $0 copay.

Acupuncture and Other Alternative Therapies

Not covered.

Not covered.

 Benefit covered by both PHP and Florida Medicaid (fee-for-service); however, PHP is primary payer and services will be provided through PHP network providers. There is no copay for covered services through PHP and Florida Medicaid (fee-for-service).  Most prescription drugs are covered through PHP for dual-eligible members. Some prescription drugs are not on PHP’s list of drugs (formulary). Florida Medicaid (fee- 10 -

for-service) will generally cover those drugs that are not on our formulary with no copay.  Help to pay copays for certain drugs may be available through Florida’s AIDS Drug Assistance Program (ADAP), but you must apply for it. Call Member Services for more information at (888) 456-4715, Monday through Friday, 8:00 a.m. to 8:00 p.m. TTY users call 711.  PHP covers preventive dental care and other medically necessary dental services up to $650 per year. If the following medically necessary dental services exceed $650 in a year, Florid Medicaid will cover them. • Comprehensive oral exam • Denture-related procedures • Full dentures and removable partial dentures (partial dentures require prior authorization) • Incision and drainage of abscess • Necessary radiographs to make a diagnosis • Problem-focused oral evaluation Medicaid-covered dental services must be provided by a participating Medicaid dentist.

Coordination of Covered Services PHP coordinates the covered services provided to you by PHP. If you require services covered by Florida Medicaid (fee-for-service), your primary care provider or specialist will refer you to the appropriate participating Florida Medicaid provider and get authorization from Florida Medicaid for that service, if required.

Getting Covered Services from Network Providers PHP has its own provider networks. Florida Medicaid (fee-for-service) has participating providers who contract with Medicaid to provide services to Medicaid recipients. Most of the PHP providers accept Florida Medicaid (fee-for-service), but not all. If you need a referral for a service that is covered by Florida Medicaid (fee-for-service), your primary care provider will refer you to a participating Medicaid provider. For services you receive through PHP, you must generally receive your care from a network provider. In most cases, care you receive from a non-network provider (a provider who is not part of the PHP network) will not be covered. See Chapter 3 of your 2014 PHP Evidence of Coverage for more information.

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Which Member Identification Card to Use As a dual eligible member enrolled in PHP and eligible for Florida Medicaid (fee-forservice) you receive a PHP member identification (ID) card. When you get covered services or fill prescriptions, show your PHP member identification (ID) card and your gold Medicaid card. Do not use your red, white and blue Medicare ID card. Put it away for safe keeping in case you need to use it later if you change Medicare coverage to Original Medicare. If you lose your PHP member ID card, please call Member Services at (888) 456-4715, 8:00 a.m. to 8:00 p.m., seven days a week. TTY users call 711.

For More Information If you have questions about your covered services or their coordination, please call Member Services at (888) 456-4715, 8:00 a.m. to 8:00 p.m., seven days a week. TTY users call 711.

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