California PHP

Benefit

Your Cost Sharing

Acupuncture

You pay $0 copay for up to two acupuncture visits per month.

Acupuncture for Chronic Low Back Pain

$0 copay for Medicare-covered acupuncture services for chronic low back pain.

Up to 12 visits in 90 days are covered for Medicare beneficiaries 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 systemic cause (i.e., not associated with metastatic, inflammatory or infectious disease, etc.);
•  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 $1,200 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

Your cost sharing for Medicare oxygen equipment coverage is $0.

If prior to enrolling in PHP you had made 36 months of rental payment for oxygen equipment coverage, your cost sharing in PHP is $0

Emergency Care

You pay $25 copay per emergency room visit.

Fitness Benefit

$0 copay for one gym membership

Members receive a gym membership at one of the following gyms:

•  24 Hour Fitness (multiple locations)

•  LA Fitness/Esporta Fitness (multiple locations)

•  AHF Fitness Center (one location at 4905 Hollywood Blvd., Los Angeles, CA 90027)

Hearing Services

$0 copay for a routine hearing exam every year.

$2,500 plan coverage limit for up to 2 hearing aids 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)

$0 copay for up to 16 hours a week of IHSS for up to 2 weeks per year. IHSS include personal care and domestic services. IHSS are available to members after 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 Services in a Psychiatric Hospital

•  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

$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 Drugs

You pay $0 copay per Medicare Part B prescription drug.

Insulin cost sharing is limited to $35 for one-month’s supply.

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.

Over-the-Counter (OTC) Pharmacy Items

$0 copay for over-the-counter pharmacy items.

The OTC benefit is limited to $550 every year.

Non-Emergency Transportation

$0 copay for unlimited round trips to plan-approved locations every year.

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 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

$0 copay for up to 2 therapeutic massages per month for members diagnosed with AIDS-related neuropathy.

Urgently Needed Services

You pay $0 copay per visit.

Vision Services

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 $250 annual limit.

Eye wear is limited to $250 ever year.