Medical Benefits and Costs

Changing the way you
receive healthcare

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
Acupuncture	You pay $0 copay for up to two acupuncture visits per month. Referral required.
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. Referral required.
Ambulance Services	You pay $150 copay for one-way or round trips.
Cardiac Rehabilitation Services	You pay $0 copay per service. Referral required.
Chiropractic Care	You pay $0 copay per visit for Medicare-covered chiropractic services to address an acute injury. We cover manual manipulation of the spine by a chiropractor or other qualified provider to correct a vertebral subluxation (when the spinal joints fail to move properly, but the contact between the joints remains intact). Referral required.
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 $850 every year. No referral required.
Diabetes Self-Management Training, Diabetic Services and Supplies	You pay $0 copay for diabetes self-management training and diabetic services and supplies. Referral required. Diabetic supplies require authorization.
Durable Medical Equipment and Related Supplies	You pay $0 copay per covered item. Authorization required.
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.
Hearing Services	You pay $0 copay for covered hearing services and hearing aids. Hearing aids are limited to $1,000 every year. Hearing aids require authorization.
Home Health Agency Care	You pay $0 copay for covered home health visits and services. Authorization required.
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. No referral required.
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. Authorization required.
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. Authorization required.
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. Authorization required.
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. Authorization required.
Medicare Part B Prescription Drugs	You pay $0 copay per Medicare Part B prescription drug. Some drugs require authorization.
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. Referral required. 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 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. Referral required. Outpatient surgery requires authorization.
Outpatient Mental Health Care	You pay $0 copay per visit. No referral required.
Outpatient Rehabilitation Services	You pay $0 copay per visit for occupational, physical and speech language therapies. Referral required.
Outpatient Substance Abuse Services	You pay $0 copay per visit. No referral required.
Outpatient Surgery	You pay $0 copay per visit. Authorization required.
Partial Hospitalization Services	You pay $0 copay per visit. Referral required.
Physician/Practitioner Services	You pay $0 copay per visit to primary care and specialist providers. Referral to specialist providers required.
Podiatry Services	You pay $0 copay per visit for Medicare-covered podiatry services. Referral required.
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 Some services require referral.
Prosthetic Devices and Related Supplies	You pay $0 copay for prosthetic devices and medical supplies. Authorization required.
Pulmonary Rehabilitation Services	You pay $0 copay per service. Referral required.
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. Referral required.
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. Authorization required.
Transportation	You pay $0 copay for unlimited round trips to plan-approved locations. Plan will arrange and schedule transportation.
Urgently Needed Care	You 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. Referral required for Medicare-covered vision care. No referral required for routine annual eye exam.

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H3132_4006 101421_2022_A

Changing the way you
receive healthcare