PHP, California

Rachel Sakai
AHF Provider

Medical Benefits and Costs

PHP (HMO SNP) covers the medical services listed below at the specified cost sharing.  For more details about the coverage, costs and prior authorization requirements for these services, see Chapter 4, Medical Benefits Chart (what is covered and what you pay), in the 2021 Evidence of Coverage.

Benefit

Your Cost Sharing
Acupuncture You pay $0 copay for up to two acupuncture visits per month.
Acupuncture for Chronic Low Back Pain You pay $0 copay for up to 12 visits in 90 days under the following circumstances.
For the purpose of this benefit, chronic low back pain is defined as:

  • Lasting 12 weeks or longer;
  • nonspecific, in that it has no identifiable systematic cause (i.e., not associated with metastatic, inflammatory, infectious, etc. disease;
  • not associated with surgery; and
  • not associated with pregnancy.

An additional eight sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually.

Treatment must be discontinued if the patient is not improving or is regressing.
Ambulance Services You pay $150 copay for one-way or round trips.
Cardiac Rehabilitation Services You pay $0 copay per service.
Chiropractic Care You pay $0 copay per visit for Medicare-covered chiropractic services.  The plan covers only manual manipulation of the spine to correct subluxation.
Dental Services Limited dental services (this does not include services in connection with care, treatment, filling removal or replacement of teeth): You pay $0 copay.

Preventive dental services:

  • Cleaning (for up to 2 every year): You pay $0 copay.
  • Dental x-ray(s) (for up to 1 every year): You pay $0 copay.
  • Fluoride treatment (for up to 2 every year): You pay $0 copay.
  • Oral exam: You pay $0 copay.

Comprehensive dental services such as the following: You pay $0 copay.

  • 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.
Diabetes Self-Management Training, Diabetic Services and Supplies You pay $0 copay for diabetes self-management training and diabetic services and supplies.
Durable Medical Equipment and Related Supplies You pay $0 copay per covered item.
Emergency Care You pay $75 copay per emergency room visit.
Health and Wellness Benefit You pay $0 copay for either a gym membership OR over-the-counter (OTC) pharmacy items up to the $200 annual limit.
Hearing Services You pay $0 copay for covered hearing services and hearing aids.

Hearing aids are limited to $400 every year.
Home Health Agency Care You pay $0 copay for covered home health visits and services.
Home Infusion Therapy You pay $0 copay for covered home infusion therapy services.
Hospice Care

When enrolled in a Medicare-certified hospice program, your hospice and Part A and B services related to your terminal prognosis are paid for by Original Medicare.

You pay $0 copay for hospice consultation services.
In-Home Support Services (IHSS)

You pay $0 copay for up to 16 hours a week of IHSS for up to two (2) weeks. IHSS is available to members after inpatient discharge from an acute hospital or skilled nursing facility.
Inpatient Care
  • You pay $100 copay per day for days 1 through 6.
  • You pay $0 copay per day for days 7 through 90.
  • You pay $0 copay per day for “lifetime reserve days” 91 through 150.
Inpatient Mental Health Care
  • You pay $100 copay per day for days 1 through 6.
  • You pay $0 copay per day for days 7 through 90.
  • You pay $0 copay per day for “lifetime reserve” days 91 through 150.
Meal Benefit You pay $0 copay for up to two (2) meals per day for up to 28 days (56 meal limit per year). Meal benefit is available to members after inpatient discharge from an acute hospital or skilled nursing facility.
Medicare Part B Prescription Drugs You pay $0 copay per Medicare Part B prescription drug.
Opioid Treatment Program Services You pay $0 copay for covered opioid treatment program services.
Outpatient Diagnostic Tests and Therapeutic Services and Supplies
  • You pay $0 copay for medical supplies.
  • You pay $0 copay per laboratory test.
  • You pay $0 copay per diagnostic test or procedure.
  • You pay $0 copay per therapeutic radiology service.
  • You pay $0 copay per X-ray service.
  • You pay $0 copay per unit (pint) of blood.
  • You pay $0 copay per diagnostic radiological service, i.e., CT, MRI, etc.
Outpatient Hospital Observation You pay $0 copay for outpatient hospital observation.
Outpatient Hospital Services You pay $0 copay per visit/service.
Outpatient Mental Health Care You pay $0 copay per visit.
Outpatient Rehabilitation Services You pay $0 copay per visit for occupational, physical and speech language therapies.
Outpatient Substance Abuse Services You pay $0 copay per visit.
Outpatient Surgery You pay $0 copay per visit.
Partial Hospitalization Services You pay $0 copay per visit.
Physician/Practitioner Services You pay $0 copay per visit to primary care and specialist providers.
Podiatry Services You pay $0 copay per visit for Medicare-covered podiatry services.
Preventive Services You pay $0 copay for the following services:

  • Abdominal aortic aneurysm screening
  • Alcohol misuse counseling
  • Annual wellness visit
  • Bone mass measurements
  • Breast cancer screening (mammograms)
  • Cardiovascular disease risk reduction visit
  • Cardiovascular disease screening
  • Cervical and vaginal cancer screening
  • Colorectal cancer screening
  • Depression screening
  • Diabetes screening
  • HIV screening
  • Immunizations, including Flu shots, Hepatitis B shots, Pneumococcal shots
  • Lung cancer screening with low dose computed tomography
  • Medical nutrition therapy
  • Medicare Diabetes Prevention Program
  • Obesity screening and therapy to promote sustained weight loss
  • Prostate cancer screening exams
  • Sexually transmitted infections screening and counseling
  • Smoking and tobacco use cessation (counseling to stop smoking or tobacco use)
  • “Welcome to Medicare” preventive visit (one-time)
Prosthetic Devices and Related Supplies You pay $0 copay for prosthetic devices and medical supplies.
Pulmonary Rehabilitation Services You pay $0 copay per service.
Services to Treat Kidney Disease and Conditions
  • You pay $0 copay for kidney disease education services.
  • You pay $0 copay per outpatient renal dialysis session.
Skilled Nursing Facility (SNF) Care
  • You pay $0 copay per day for days 1 through 20.
  • You pay $100 copay per day for days 21 through 100.
Supervised Exercise Therapy (SET) SET if covered for members who have symptomatic peripheral artery disease (PAD) and a referral for PAD from the physician responsible for PAD treatment. You pay $0 copay for up to 36 sessions over a 12-week period if the SET program requirements are met.
Therapeutic Massage You pay $0 copay for up to 2 therapeutic massages per month for members diagnosed with AIDS-related neuropathy.
Transportation You pay $0 copay for unlimited round trips to plan-approved locations.
Urgently Needed Services You pay $0 copay per visit.
Vision Care
  • You pay $0 copay per Medicare-covered vision care service.
  • You pay $0 copay for routine annual eye exam.
  • You pay $0 copay for glasses or contact lenses up to the $150 annual limit.

Eye wear is limited to $150 ever year.

 


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