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 2022 Evidence of Coverage.

Benefit

2021 (this year)

2022 (next year)

Ambulatory Surgery Center

You pay nothing for outpatient surgery and ambulatory surgery center services.

Referral and authorization required.

You pay nothing for outpatient surgery and ambulatory surgery center services done at an ambulatory surgery center.

Referral and authorization required.  If outpatient surgery and/or surgery services are done at a hospital facility, you will be subject to an outpatient hospital copay.  See “Outpatient Hospital” below.

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.

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 $750 every year.

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

Diagnostic Services/Labs/
Imaging

You pay nothing for the following services:

  • Diagnostic radiology services, e.g., MRI, CT, PET scans
  • Lab services
  • Diagnostic tests and procedures
  • Outpatient x-rays

Referral required.  Some tests and services require authorization.

You pay nothing for the following services:

  • Diagnostic radiology services, e.g., MRI, CT, PET scans
  • Lab services
  • Diagnostic tests and procedures
  • Outpatient x-rays
  • Colonoscopy, sigmoidoscopy, endoscopy

Referral required.  Some tests and services require authorization.  If diagnostic, lab or imaging services are done at a hospital facility, you will be subject to an outpatient hospital copay.  See “Outpatient Hospital” below.

Hearing Services

You pay nothing for the following services every year:

  • One routine hearing exam
  • One fitting-evaluation for a hearing aid
  • Up to two hearing aids

$400 plan coverage limit for up to 2 hearing aids every year.

Authorization required.

You pay nothing for the following services every year:

  • One routine hearing exam
  • One fitting-evaluation for a hearing aid
  • Up to two hearing aids

$1,000 plan coverage limit for up to 2 hearing aids every year.

Authorization required.

Meal Benefit

You pay nothing 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 discharge from an acute hospital or skilled nursing facility. Authorization required.

You pay nothing 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.

Outpatient Hospital

You pay nothing for outpatient hospital services.

Some services require referral and authorization.

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.

Some services require referral and authorization.

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

$150 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

$200 plan coverage limit for eye wear every year.


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