Changing the way you
receive healthcare

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.

    Benefit

    Your Cost Sharing

    AcupunctureYou 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 ServicesYou pay $150 copay for one-way or round trips.
    Cardiac Rehabilitation ServicesYou pay $0 copay per service.
    Chiropractic CareYou pay $0 copay per visit for Medicare-covered chiropractic services.
    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 $750 every year.

    Diabetes Self-Management Training, Diabetic Services and SuppliesYou pay $0 copay for diabetes self-management training and diabetic services and supplies.
    Durable Medical Equipment and Related SuppliesYou pay $0 copay per covered item.
    Emergency CareYou pay $75 copay per emergency room visit.
    Health and Wellness BenefitYou 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 $1,000 every year.

    Home Health Agency CareYou pay $0 copay for covered home health visits and 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 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.

    Medicare Part B Prescription DrugsYou pay $0 copay per Medicare Part B prescription drug.
    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.

    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 ServicesYou 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.
    Outpatient Mental Health CareYou pay $0 copay per visit.
    Outpatient Rehabilitation ServicesYou pay $0 copay per visit for occupational, physical and speech language therapies.
    Outpatient Substance Abuse ServicesYou pay $0 copay per visit.
    Outpatient SurgeryYou pay $0 copay per visit.
    Partial Hospitalization ServicesYou pay $0 copay per visit.
    Physician/Practitioner ServicesYou pay $0 copay per visit to primary care and specialist providers.
    Podiatry ServicesYou pay $0 copay per visit for Medicare-covered podiatry services.
    Preventive Care

    You pay $0 copay for the following services:

    • Abdominal aortic aneurysm screening
    • Alcohol misuse counseling
    • Bone mass measurement
    • Breast cancer screening (mammogram)
    • Cardiovascular disease (behavioral therapy)
    • Cardiovascular screenings
    • Cervical and vaginal cancer screening
    • Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy)
    • Depression screening
    • Diabetes screenings
    • HIV screening
    • Medical nutrition therapy services
    • Obesity screening and counseling
    • Prostate cancer screenings (PSA)
    • Sexually transmitted infections screening and counseling
    • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
    • Vaccines, including Flu shots, Hepatitis B shots, Pneumococcal shots
    • “Welcome to Medicare” preventive visit (one-time)
    • Yearly “Wellness” visit
    Prosthetic Devices and Related SuppliesYou pay $0 copay for prosthetic devices and medical supplies.
    Pulmonary Rehabilitation ServicesYou 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.
    TransportationYou pay $0 copay per round trip up to annual 12 round-trip limit.
    Transportation to Cancer Treatment VisitsYou pay $0 copay for unlimited transportation to cancer treatment visits at plan-approved locations.
    Transportation to Dialysis Treatment VisitsYou pay $0 copay for unlimited transportation to dialysis visits at plan-approved locations.
    Urgently Needed CareYou 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 $200 annual limit.

    Eye wear is limited to $200 ever year.

    You will need the Adobe Acrobat Reader program to view the above forms. To download this free program click here or use the link above – the link will open a new window and take you to the Adobe website.

     


    H5852_4006 101421_2022_A