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.|
|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.
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.|
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 $850 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.|
|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.
|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.|
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 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.|
|Medicare Part B Prescription Drugs||You pay $0 copay per Medicare Part B prescription drug.|
|Opioid Treatment Program Services||You pay $0 copay for covered opioid treatment program services.|
|Outpatient Diagnostic Tests and Therapeutic Services and Supplies|
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 Observation||You pay $0 copay for outpatient hospital observation.|
|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.|
|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.|
|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.|
You pay $0 copay for the following services:
|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|
|Skilled Nursing Facility (SNF) Care|
|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||You pay $0 copay for up to 2 therapeutic massages per month for members diagnosed with AIDS-related neuropathy.|
|Transportation||You pay $0 copay for unlimited round trips to plan-approved locations.|
|Urgently Needed Services||You pay $0 copay per visit.|
Eye wear is limited to $200 ever year.