PHP, California

Rachel Sakai
AHF Provider

Medical Benefits and Costs

Next year, PHP (HMO SNP) is changing coverage for the medical services listed below. The information below describes these changes. For more details about the coverage and costs for these services, see Chapter 4, Medical Benefits Chart (what is covered and what you pay), in your 2021 Evidence of Coverage.

Benefit

2020 (this year)

2021 (next year)

Dental Services You pay nothing for limited Medicare-covered dental services (this does not include services in connection with care, treatment, filling, removal or replacement of teeth). Referral and authorization required.

You pay nothing for preventive dental services:

  • Cleaning (for up to 2 every year)
  • Dental x-ray(s) (for up to 1 every year)
  • Fluoride treatment (for up to 2 every year)
  • Oral exams (unlimited)

You pay nothing for comprehensive dental services such as the following:

  • Non-routine services
  • Diagnostic services
  • Restorative services
  • Endodontics/
    periodontics/
    extractions
  • Prosthodontics, other oral/maxillofacial surgery, other services

Comprehensive dental services are limited to $800 every year.

No referral or authorization required for preventive or comprehensive dental services.

You pay nothing for limited Medicare-covered dental services (this does not include services in connection with care, treatment, filling, removal or replacement of teeth). Referral and authorization required.

You pay nothing for preventive dental services:

  • Cleaning (for up to 2 every year)
  • Dental x-ray(s) (for up to 1 every year)
  • Fluoride treatment (for up to 2 every year)
  • Oral exams (unlimited)

You pay nothing for comprehensive dental services such as the following:

  • Non-routine services
  • Diagnostic services
  • Restorative services
  • Endodontics/
    periodontics/
    extractions
  • Prosthodontics, other oral/maxillofacial surgery, other services

Comprehensive dental services are limited to $700 every year.

No referral or authorization required for preventive or comprehensive dental services.

Therapeutic Massage Therapeutic massage is not covered. You pay nothing for up to two (2) one (1)-hour therapeutic massages per month to increase blood circulation. Therapeutic massage benefit is available to members who have been diagnosed with AIDS-related neuropathy.

Referral and authorization required.

Transportation You pay nothing for up to 12 round trips to plan-approved locations.

Plan must authorize and book transportation and will verify that transportation requested is to and from provider offices or facilities.

You pay nothing for unlimited round trips to plan-approved locations.

Plan must authorize and book transportation and will verify that transportation requested is to and from provider offices or facilities.

Transportation to Cancer Treatment Visits You pay nothing for unlimited transportation to cancer treatment visits at plan-approved locations.

Plan must authorize and book transportation and will verify that transportation requested is to and from provider offices or facilities.

Unlimited transportation for cancer treatment visits is not covered.
Transportation to Dialysis Visits You pay nothing for unlimited transportation to dialysis visits at plan-approved locations.

Plan must authorize and book transportation and will verify that transportation requested is to and from provider offices or facilities.

Unlimited transportation for dialysis visits is not covered.
Vision Care You pay nothing for Medicare-covered vision care services. Referral and authorization required for the following:

  • Diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration
  • For members who at high risk for glaucoma, one glaucoma screening each year
  • For members with diabetes, one diabetic retinopathy screening each year
  • One (1) pair of eyeglasses or contact lenses after cataract surgery that includes insertion of an intraocular lens

You pay nothing for supplemental vision care benefits. No referral or authorization required for the following:

  • One (1) routine eye exam ever year
  • One (1) pair of eyeglasses (lenses and frames or lenses) or contact lenses every year

$100 plan coverage limit for eye wear every year.

You pay nothing for Medicare-covered vision care services. Referral and authorization required for the following:

  • Diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration
  • For members who at high risk for glaucoma, one glaucoma screening each year
  • For members with diabetes, one diabetic retinopathy screening each year
  • One (1) pair of eyeglasses or contact lenses after cataract surgery that includes insertion of an intraocular lens

You pay nothing for supplemental vision care benefits. No referral or authorization required for the following:

  • One (1) routine eye exam ever year
  • One (1) pair of eyeglasses (lenses and frames or lenses) or contact lenses every year

$150 plan coverage limit for eye wear every year.


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