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 2024 Evidence of Coverage.
Benefit | 2023 (this year) | 2024 (next year) |
Acupuncture | You pay nothing for up to | You pay nothing for up to |
Emergency Services | You pay $75 copay per emergency room visit. Cost sharing for necessary emergency services furnished out-of-network is the same as for such services furnished in-network. Emergency care is only covered within the United States. | You pay $25 copay per emergency room visit. Cost sharing for necessary emergency services furnished out-of-network is the same as for such services furnished in-network. Emergency care is only covered within the United States. |
Fitness Benefit | A gym membership is a benefit option of the Health and Wellness Benefit. You pay nothing for the Health and Wellness Benefit. You may choose either a gym membership at 24 Hour Fitness, LA Fitness/Esporta Fitness or AHF Fitness Center OR up to $200 worth of over-the-counter (OTC) pharmacy (non-prescription drug) items. | You pay nothing for a gym membership at either 24 Hour Fitness, LA Fitness/ (You do not have to make a choice between a gym membership benefit or the OTC pharmacy benefit — you receive both benefits.) |
Health and Wellness Benefit | You pay nothing for the Health and Wellness Benefit. You may choose either a gym membership at 24 Hour Fitness, LA Fitness/Esporta Fitness or AHF Fitness Center OR up to $200 worth of over-the-counter (OTC) pharmacy (non-prescription drug) items. | The Health and Wellness Benefit is not covered. The gym membership and over-the-counter (OTC) pharmacy benefits are decoupled so you receive both a gym membership and OTC pharmacy benefits. See Fitness Benefit (Gym Membership) above and Over-the-Counter (OTC) Pharmacy Items below. |
Over-the Counter (OTC) Pharmacy | OTC pharmacy items is a benefit option of the Health and Wellness Benefit. You pay nothing for the Health and Wellness Benefit. You may choose either a gym membership at 24 Hour Fitness, LA Fitness/Esporta Fitness or AHF Fitness Center OR up to $200 worth of over-the-counter (OTC) pharmacy (non-prescription drug) items. | You pay nothing for up to $550 per year in OTC pharmacy (non-prescription drug) items fulfilled by AHF Pharmacy. (You do not have to make a choice between a gym membership benefit or the OTC pharmacy benefit — you receive both benefits.) |
Skilled Nursing Facility (SNF) | You pay nothing per day for days 1 through 20. You pay $100 per day for days 21 through 100. Plan covers 100 days each benefit period. A “benefit period” starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. No prior inpatient hospital stay is required. Authorization required. | You pay nothing per day for days 1 through 100. Plan covers 100 days each benefit period. A “benefit period” starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended, a new benefit period begins. There is no limit to the number of benefit periods you can have. No prior inpatient hospital stay is required. Authorization required. |
H5852_4006 102323_2024