Medical Benefits and Costs
PHP (HMO SNP) covers the medical services listed below at the specified cost sharing. 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 2022 Evidence of Coverage.
Your Cost Sharing
|Acupuncture||You pay $0 copay for up to two acupuncture visits per month. Referral required.|
|Acupuncture for Chronic Low Back Pain|
You pay $0 copay for up to 12 visits in 90 days under the following circumstances.
An additional eight sessions will be covered for those patients demonstrating an improvement. No more than 20 acupuncture treatments may be administered annually.
|Ambulance Services||You pay $150 copay for one-way or round trips.|
|Cardiac Rehabilitation Services||You pay $0 copay per service. Referral required.|
|Chiropractic Care||You pay $0 copay per visit for Medicare-covered chiropractic services to address an acute injury. We cover manual manipulation of the spine by a chiropractor or other qualified provider to correct a vertebral subluxation (when the spinal joints fail to move properly, but the contact between the joints remains intact). Referral required.|
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:
Comprehensive dental services such as the following: You pay $0 copay.
Comprehensive dental services are limited to $750 every year. No referral required.
|Diabetes Self-Management Training, Diabetic Services and Supplies||You pay $0 copay for diabetes self-management training and diabetic services and supplies. Referral required. Diabetic supplies require authorization.|
|Durable Medical Equipment and Related Supplies||You pay $0 copay per covered item. Authorization required.|
|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.|
You pay $0 copay for covered hearing services and hearing aids.
Hearing aids are limited to $1,000 every year. Hearing aids require authorization.
|Home Health Agency Care||You pay $0 copay for covered home health visits and services. Authorization required.|
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. No referral required.
|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. Authorization required.
|Inpatient Mental Health Care|
|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 post-inpatient discharge from an acute hospital or skilled nursing facility and members who have a chronic condition or other medical condition that prevents leaving the home to grocery shop. Meals may be provided in multiple increments through the year up to the 56-meal limit for the year. Authorization required.|
|Medicare Part B Prescription Drugs||You pay $0 copay per Medicare Part B prescription drug. Some drugs require authorization.|
|Outpatient Diagnostic Tests and Therapeutic Services and Supplies|
Referral required. If diagnostic, lab or imaging services are done at a hospital facility, you will be subject to an outpatient hospital services copay. See “Outpatient hospital services” below.
|Outpatient Hospital Services||You pay $100 copay per outpatient hospital service, i.e., outpatient surgery and surgery services and diagnostic radiology services, tests and procedures done at a hospital facility. Referral required. Outpatient surgery requires authorization.|
|Outpatient Mental Health Care||You pay $0 copay per visit. No referral required.|
|Outpatient Rehabilitation Services||You pay $0 copay per visit for occupational, physical and speech language therapies. Referral required.|
|Outpatient Substance Abuse Services||You pay $0 copay per visit. No referral required.|
|Outpatient Surgery||You pay $0 copay per visit. Authorization required.|
|Partial Hospitalization Services||You pay $0 copay per visit. Referral required.|
|Physician/Practitioner Services||You pay $0 copay per visit to primary care and specialist providers. Referral to specialist providers required.|
|Podiatry Services||You pay $0 copay per visit for Medicare-covered podiatry services. Referral required.|
You pay $0 copay for the following services:
Some services require referral.
|Prosthetic Devices and Related Supplies||You pay $0 copay for prosthetic devices and medical supplies. Authorization required.|
|Pulmonary Rehabilitation Services||You pay $0 copay per service. Referral required.|
|Services to Treat Kidney Disease and Conditions|
|Skilled Nursing Facility (SNF) Care|
|Transportation||You pay $0 copay for unlimited round trips to plan-approved locations. Plan will arrange and schedule transportation.|
|Urgently Needed Care||You pay $0 copay per visit.|
Eye wear is limited to $200 ever year. Referral required for Medicare-covered vision care. No referral required for routine annual eye exam.