January 1, 2015 December 31, 2015

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You have choices about how to get your Medicare benefits

• One choice is to get your Medicare benefits through Original Medicare (fee-for-service Medicare). Original Medicare is run directly by the Federal government.

• Another choice is to get your Medicare benefits by joining a Medicare health plan (such as

AlohaCare Advantage Plus (HMO SNP)).

Tips for comparing your Medicare choices

This Summary of Benefits booklet gives you a summary of what AlohaCare Advantage Plus (HMO SNP) covers and what you pay.

• If you want to compare our plan with other Medicare health plans, ask the other plans for their

Summary of Benefits booklets. Or, use the Medicare Plan Finder on http://www.medicare.gov.

• If you want to know more about the coverage and costs of Original Medicare, look in your

current “Medicare & You” handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY/TDD users should call 1-877-486-2048.

Sections in this booklet

• Things to Know About AlohaCare Advantage Plus (HMO SNP)

• Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services • Covered Medical and Hospital Benefits

• Prescription Drug Benefits

This document is available in other formats such as Braille and large print.

This document may be available in a non-English language. For additional information, call us at 973-6395 or toll free at 1-866-973-6395. TTY/TDD users should call at 1-877-447-5990.

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Hours of Operation

• From October 1 to February 14, you can

call us 7 days a week from 8:00 a.m. to 8:00 p.m. Hawaii time.

• From February 15 to September 30, you

can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Hawaii time.

AlohaCare Advantage Plus (HMO SNP)

Phone Numbers and Website

• If you are a member of this plan, call

toll-free 1-866-973-6395.

• If you are not a member of this plan,

call toll-free 1-866-973-6395.

• Our website: AlohaCare.org

Who can join?

To join AlohaCare Advantage Plus (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and QUEST Integration Program (Medicaid), and live in our service area.

Our service area includes the following counties in Hawaii: Hawaii, Honolulu, Kalawao, Kauai, and Maui.

Which doctors, hospitals, and

pharmacies can I use?

AlohaCare Advantage Plus (HMO SNP) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services.

You must generally use network pharmacies to fill your prescriptions for covered Part D drugs.

You can see our plan’s pharmacy directory at our website (www.AlohaCare.org/

providersearch).

Or, call us and we will send you a copy of the provider and pharmacy directories.

What do we cover?

Like all Medicare health plans, we cover

everything that Original Medicare covers – and more.

• Our plan members get all of the

benefits covered by Original Medicare. For some of these benefits, you may pay more in our plan than you would in Original Medicare. For others, you may pay less.

• Our plan members also get more than

what is covered by Original Medicare. Some of the extra benefits are outlined in this booklet.

We cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider.

• You can see the complete plan formulary

(list of Part D prescription drugs) and any restrictions on our website, AlohaCare.org.

• Or, call us and we will send you a copy of

the formulary.

How will I determine my drug costs?

The amount you pay for drugs depends on the drug you are taking and what stage of the benefit you have reached. Later in this document we discuss the benefit stages that occur after you meet your deductible: Initial

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January 1, 2015 – December 31, 2015

Monthly Premium, Deductible, and

Limits on how much you pay for Covered Services

How much is the

monthly premium? $0 per month How much is the

deductible? This plan does not have a deductible.

This plan does not have a deductible for chemotherapy and other drugs administered in your doctor’s office (Part B drugs).

This plan does not have a deductible for Part D prescription drugs.

Is there any limit on how much I will pay for my covered services?

Yes. Like all Medicare health plans, our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. In this plan, you may pay nothing for Medicare-covered services, depending on your level of QUEST Integration eligibility.

Refer to the “Medicare & You” handbook for Medicare-covered services. For QUEST Integration-covered services, refer to the Medicaid Coverage section in this document.

Your yearly limit(s) in this plan:

• $6,700 for services you receive from in-network providers.

If you reach the limit on out-of-pocket costs, you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.

Is there a limit on how

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NOTE:

• Services with a

1

_{may require prior authorization.}

• Services with a

2

_{may require a referral from your doctor.}

Outpatient Care and Services

Acupuncture and Other Alternative Therapies1

For up to 15 visit(s) every year; there is a limit to how much our plan will pay:

• $1000 plan coverage limit for

acupuncture and other alternative therapies every year.

You pay nothing.

Ambulance1 _{You pay nothing.}

Chiropractic

Care1 Manipulation of the spine to correct a _{subluxation (when 1 or more of the bones of}

your spine move out of position):

You pay nothing.

Dental Services Limited dental services (this does not include services in connection with care, treatment, filling, removal, or replacement of teeth): Preventive dental services:

You pay nothing.

• Cleaning (for up to 2 every year): • Dental x-ray(s) (for up to 2 every year): • Oral exam (for up to 2 every year):

Diabetes Supplies and Services1

Diabetes monitoring supplies: You pay nothing. Diabetes self-management training:

Therapeutic shoes or inserts:

Diagnostic Tests, Lab and Radiology Services, and X-Rays1

Diagnostic radiology services (such as MRIs,

CT scans): You pay nothing.

Diagnostic tests and procedures: Lab services:

Outpatient x-rays:

Therapeutic radiology services (such as radiation treatment for cancer):

Doctor’s Office

Visits2 Primary care physician visit: _{Specialist visit:} You pay nothing.

Durable Medical Equipment

(wheelchairs,

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Outside the U.S., plan annual maximum covered benefit limit of $1000. You pay a $0 copay and any amounts over $1000. You will have to pay the facility or provider for services. Receipts must be in English with billed charges in U.S. dollars. AlohaCare Advantage Plus will reimburse you up to your benefit limit.

Foot Care

(podiatry services)1, 2

Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:

You pay nothing. Routine food care (for up to 8 visit(s) every

year):

Hearing Services

1, 2 Exam to diagnose and treat hearing and _{balance issues:} You pay nothing.

Home Health

Care1 You pay nothing.

Mental Health

Care1 Inpatient visit:

Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.

The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you’re admitted as an inpatient and ends when you haven’t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.

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sessions up to 36 weeks): Occupational therapy visit:

Physical therapy and speech and language therapy visit:

Outpatient Substance Abuse1

Group therapy visit: You pay nothing.

Individual therapy visit:

Outpatient

Surgery1 Ambulatory surgical center: _{Outpatient hospital:} You pay nothing.

Over-the-Counter

Items Please visit our website to see our list of covered over-the-counter items.

Prosthetic Devices (braces, artificial limbs, etc.)1

Prosthetic devices: You pay nothing.

Related medical supplies:

Renal Dialysis1, 2 _{You pay nothing.}

Transportation Not covered.

Urgent Care You pay nothing.

Vision Services Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):

You pay nothing.

Eyeglasses or contact lenses after cataract surgery:

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Our plan covers many preventive services, including:

• 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 • Colonoscopy

• Colorectal cancer screenings • Depression screenings • Diabetes screenings • Fecal occult blood test • Flexible sigmoidoscopy • 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

Any additional preventive services approved by Medicare during the contract year will be covered.

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Inpatient Hospital

Care1 The copays for hospital and skilled nursing _{facility (SNF) benefits are based on benefit}

periods. A benefit period begins the day you’re admitted as an inpatient and ends when you haven’t received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There’s no limit to the number of benefit periods.

Our plan covers 90 days for an inpatient hospital stay.

Our plan also covers 60 “lifetime reserve days.” These are “extra” days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.

You pay nothing.

Inpatient Mental

Health Care For inpatient mental health care, see the “Mental Health Care” section of this booklet.

Skilled Nursing

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How much do I

pay? For Part B drugs such as chemotherapy drugs

1_{: You pay nothing.}

Other Part B drugs1_:

Initial Coverage Our plan does not have a deductible for Part D prescription drugs.

Depending on your income and institutional status, you pay the following:

For generic drugs (including brand drugs

treated as generic), either: • $0 copay; or

• $1.20 copay; or • $2.65 copay

For all other drugs, either: _• _{$0 copay; or}

• $3.60 copay; or • $6.60 copay

You may get your drugs at network retail pharmacies.

If you reside in a long-term care facility, you pay the same as at a retail pharmacy.

You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.

Catastrophic

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AlohaCare Advantage Plus (HMO SNP), H5969, Plan 002

The following section will describe benefits that you are entitled to as a recipient of Medicaid benefits, in the State of Hawaii.

Medicare members, who also qualify for Medicaid, are eligible for additional benefits, including assistance with paying for their Medicare premiums, deductibles and cost sharing, such as copays and coinsurance. The Medicaid benefits available to you are managed under the QUEST Integration Program. This document does not describe all of the details of your Medicaid benefits.

Please contact your QUEST Integration plan for a complete listing.

As a QUEST Integration beneficiary, you can access these benefits through one of five health plans handbooks; AlohaCare, HMSA, Kaiser Foundation Health Plan, ‘Ohana Health Plan, or United Healthcare Community Plan. You can also get more information from Med-QUEST:

Med-QUEST Enrollment Services Section Oahu: 524-3370

Neighbor Islands: 1-800-316-8005

The benefits described below are covered by Medicaid. The benefits described in the Covered

Medical and Hospital Benefits section of the Summary of Benefits are covered by Medicare. For each benefit listed below, you can see what QUEST Integration covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility.

Benefit Category Medicaid AlohaCare Advantage Plus _{(HMO SNP)} IMPORTANT INFORMATION

Premium and Other

Important Information There are no copays and no coinsurance for this plan General

$0 monthly plan premium.* In-Network

$0 annual deductible.*

$6,700 out-of-pocket limit for Medicare-covered services. However, in this plan you will have no cost sharing responsibility for Medicare-covered services, based on your

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Doctor and Hospital Choice

(For more information, see Emergency Care and Urgently Needed Care.)

$0 copay for

Medicaid-covered services. In-NetworkYou must go to network doctors, specialists, and hospitals.

Referral required for network specialists (for certain benefits).

SUMMARY OF BENEFITS INPATIENT CARE Inpatient Hospital Care

(Includes Substance Abuse and

Rehabilitation Services)

$0 copay for Medicaid-covered services. No limit on number of days of service.

Includes the cost of room and board for Inpatient stays for: • Nursing care • Medical supplies • Equipment • Drugs • Diagnostic services • Physical and occupational therapy • Audiology • Speech-language pathology services In-Network

Plan covers 90 days each benefit period. You will not be charged additional cost sharing for professional services.

$0 annual service category deductible.* $0 copay.*

Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.

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Inpatient Mental Health

Care $0 copay for Medicaid-covered services. No limit on number of days of service.

Covered services include all medically necessary behavioral health services. These services include:

• Ambulatory services,

including 24-hours-a-day, 7-days-a-week crisis services

• 24-hour-a-day care

for acute psychiatric illnesses, including: - Room and board - Nursing care

- Medical supplies and equipment - Diagnostic services - Physician services - Other practitioner services, as needed - Other medically necessary services In-Network

You get up to 190 days of inpatient psychiatric hospital care in a lifetime.

Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. $0 annual service category deductible. $0 copay.*

Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.

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Skilled Nursing Facility (SNF)

(In a Medicare-certified skilled nursing facility)

$0 copay for Medicaid-covered services. No limit on number of days of service.

Covered for members who need 24-hour-a-day help with activities of daily living (ADLs) and instrumental activities of daily living (IADLs.) These members need regular,

long-term care from licensed nurses and para-medical personnel.

The care that is provided in a nursing facility includes:

• Independent and group

activities

• Meals and snacks • Housekeeping and

laundry services

• Nursing and social work

services • Nutritional monitoring and counseling • Pharmaceutical services and rehabilitative services General

Authorization rules may apply. In-Network

Plan covers up to 100 days each benefit period.

No prior hospital stay is required.

$0 annual service category deductible.* $0 copay for SNF services.*

You will not be charged additional cost sharing for professional services.

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Home Health Care

(Includes medically necessary intermittent skilled nursing

care, home health aide services, and rehabilitation services, etc.)

$0 copay for Medicaid-covered services.

Some home health services included are:

• Skilled nursing • Home health aides • Medical supplies • Physical and

occupational Therapy

• Audiology and

speech-language pathology

General

$0 copay for Medicare-covered home health visits.*

Hospice $0 copay for Medicaid-covered services.

Provides care to terminally ill patients who have 6 months or less to live.

General

You must get care from a Medicare-certified hospice.

You must consult with your plan before you select hospice.

OUTPATIENT CARE Doctor Office Visits $0 copay for

Medicaid-covered services. Services include:

• Initial and interval

histories • Comprehensive physical examinations (including developmental services) • Immunizations • Diagnostic and screening laboratory • X-ray services

(including screening for tuberculosis)

In-Network

$0 copay for each Medicare-covered primary care doctor visit.*

$0 copay for each Medicare-covered specialist visit.*

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Cornea Transplants and Bone

Graft Services

$0 copay for Medicaid-covered services. Cornea transplants

(keraplasty) and Bone graft.

Chiropractic Services Not Covered. General

$0 copay for Medicare-covered chiropractic visits.*

Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part).

Podiatry Services $0 copay for Medicaid-covered services.

Medically necessary foot care.

General

$0 copay for Medicare-covered podiatry visits.*

You pay nothing for up to 8 supplemental routine podiatry visit(s) every year.

Medicare-covered podiatry visits are for medically necessary foot care.

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Outpatient Mental

Health Care $0 copay for Medicaid-covered services. Covered services include all medically necessary behavioral health services. These services include:

• Ambulatory services,

including 24-hours-a-day, 7-days-a-week crisis services

• Acute day hospital/

partial hospitalization, including: • Medication management psychiatrist* • Prescribed drugs • Medical supplies • Diagnostic tests • Therapeutic services, including individual, and group therapy and aftercare

• Other medically

necessary services

In-Network $0 copay for:

• each Medicare-covered individual

therapy visit.*

• each Medicare-covered group therapy

visit.* $0 copay for:

therapy visit with a psychiatrist.*

• each Medicare-covered group therapy

visit with a psychiatrist.*

$0 copay for Medicare-covered partial hospitalization program services.*

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Outpatient Substance

Abuse Care $0 copay for Medicaid-covered services. Covered services include all medically necessary behavioral health services. These services include:

• Methadone treatment

services, which include the provision of

methadone or a suitable alternative (e.g. LAAM), as well as outpatient counseling services • Prescribed drugs including medication management and patient counseling • Diagnostic/laboratory services, including: - Psychological testing - Screening for drug and alcohol problems - Other medically necessary diagnostic services • Psychiatric or psychological evaluation • Physician services General

$0 copay for:

substance abuse outpatient treatment visit.*

• each Medicare-covered group

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Outpatient Services $0 copay per visit for Medicaid-covered services. This service includes 24-hour-a-day, 7-days-per-week care for:

• Emergency services • Ambulatory center

services

• Urgent care services • Medical supplies • Equipment and drugs • Diagnostic services • Therapeutic services

(including chemotherapy and radiation therapy)

General

$0 copay for each Medicare-covered ambulatory surgical center visit.* $0 copay for each Medicare-covered outpatient hospital facility visit.*

Ambulance Services

(medically necessary ambulance services)

$0 copay per trip for

Medicaid-covered services. GeneralAuthorization rules may apply. In-Network

$0 copay for Medicare-covered ambulance benefits.*

Emergency Care

(You may go to any emergency room if you reasonably believe you need emergency care.)

$0 copay per visit for Medicaid-covered services. Covered for medically necessary services. No prior authorization is required.

General

$0 annual service category deductible.* $0 copay for Medicare-covered emergency room visits.*

$1,000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year.

If you are admitted to the hospital within 3-day(s) for the same condition, you pay $0

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Urgently Needed Care $0 copay for Medicaid-covered services. Covered as medically necessary. No prior authorization is required. General

$0 copay for Medicare-covered urgently-needed-care visits.*

Outpatient

Rehabilitation Services

(Occupational Therapy, Physical Therapy, Speech and Language Therapy, Audiology)

Covered services include:

• Physical and

occupational therapy

• Audiology and

speech-language pathology

General

Authorization rules may apply.

Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered. In-Network

$0 copay for Medicare-covered Occupational Therapy visits.*

$0 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits.*

Durable Medical Equipment

(Includes wheelchairs, oxygen, etc.)

Covered services include but are not limited to the following:

• Oxygen tanks and

concentrators

• Ventilators • Wheelchairs

• Crutches and canes • Eyeglasses

• Orthotic devices • Prosthetic devices

General

$0 annual service category deductible.* Authorization rules may apply.

In-Network

$0 copay for Medicare-covered durable medical equipment.*

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Prosthetic Devices

(Includes braces,

artificial limbs and eyes, etc.)

$0 copay for Medicaid-covered services. Covered as medically necessary.

General

Authorization rules may apply. $0 copay for Medicare-covered:

• prosthetic devices*

• medical supplies related to prosthetics,

splints, and other device*

Diabetes Programs

and Supplies $0 copay for Medicaid-covered services. Covered services include:

• Coverage for glucose

monitors • Test strips • Lancets • Screening tests • Management Training General

$0 copay for Medicare-covered Diabetes self-management training.*

$0 copay for Medicare-covered:

• Diabetes monitoring supplies.* • Therapeutic shoes or inserts.*

Diagnostic Tests, X-Rays, Lab Services, and Radiology Services

$0 copay per visit for Medicaid-covered services. Covered services include:

• Diagnostic • Therapeutic radiology and imaging • Screening and diagnostic laboratory tests

Laboratory and diagnostic exclusions: • Experimental • Investigational or generally unproven • Chromosomal General

$0 copay for Medicare-covered:

• lab services*

• diagnostic procedures and tests* • X-rays*

• diagnostic radiology services (not

including X-rays)*

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Cardiac Pulmonary Rehabilitation Services

$0 copay for Medicaid-covered services. Covered as medically necessary.

General

$0 copay for:

• Medicare-covered Cardiac Rehabilitation

Services*

• Medicare-covered Intensive Cardiac

Rehabilitation Services*

• Medicare-covered Pulmonary

Rehabilitation Services*

PREVENTIVE SERVICES Preventive Services $0 copay for

Medicaid-covered services. Health Education and Counseling

Substance use (including Alcohol)

Diet and exercise Injury prevention Sexual behavior

General

$0 copay for all preventive services covered under Original Medicare at zero cost

sharing.

Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare.

Plan covers a physical exam annually.

Bone Mass Measurement

(for people with Medicare who are at risk)

$0 copay for

Medicaid-covered services. You pay nothing.

Colorectal Screening Exams

(for people with

$0 copay for Medicaid-covered services. Annually – One

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Immunizations

(Flu vaccine, Hepatitis B vaccine - for people with Medicare who are at risk, Pneumonia vaccine)

$0 copay for Medicare-covered services. Tetanus-diphtheria (td) booster, Rubella, Hepatitis B in high risk - household and contacts of HBsAg positive person

Mammograms (Annual Screening)

(for women with Medicare age 40 and older)

Mammography and clinical breast exam every year. A woman of any age with a history of breast cancer, or whose mother or sister has a history of breast cancer, is eligible for a screening mammography when authorized by a physician.

Pap Smears and Pelvic Exams

(for women with Medicare)

Annually – One Pap Test and pelvic exam

Prostate Cancer Screening Exams

(for men with Medicare age 50 and older)

Kidney Disease and

Conditions $0 copay per visit for Medicaid-covered services. Dialysis Services and Epogen Injections.

Acute hospital admissions

$0 copay for Medicare-covered renal dialysis.*

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PRESCRIPTION DRUG BENEFITS Outpatient

Prescription Drugs Covers drugs listed on the Drugs covered under Medicare Part B Plan’s Preferred Drug List (PDL). This list will also have drugs that may have limits such as prior authorization, quantity limits, step therapy, age limits or gender limits. Alternate Drugs may be covered with prior authorization.

OTC drugs may be covered by the Plan when physician prescribed and medically necessary at $0 copay.

Drugs covered under Medicare Part B General

$0 yearly deductible for Medicare Part B drugs.*

$0 copay for Part B chemotherapy drugs and other Part-B drugs.*

Drugs covered under Medicare Part D General

This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://AlohaCare.org on the web.

Different out-of-pocket costs may apply for people who:

- have limited incomes,

- live in long term care facilities, or

- have access to Indian/Tribal/Urban (Indian Health Service) providers.

Your in-network prescription coverage may be limited to the plan’s service area. This means that if you travel outside the service area, you may have to pay the full cost of your prescription. In certain emergencies, your drugs will be covered if you get them at an out-of-network-pharmacy, although you may have to pay additional charges. Contact the plan for details.

Total yearly drug costs are the total drug costs paid by you, the plan, and Medicare.

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Your provider must get prior authorization from AlohaCare Advantage Plus (HMO SNP) for certain drugs.

The plan will pay for certain over-the-counter drugs as part of its utilization management program. Some over-the-counter drugs are less expensive than prescription drugs and work just as well. Contact the plan for details.

You must go to certain pharmacies for a very limited number of drugs, due to special handling, provider coordination, or patient education requirements that cannot be met by most pharmacies in your network.

These drugs are listed on the plan’s website, formulary, printed materials, as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.

If the actual cost of a drug is less than the normal cost-sharing amount for that drug, you will pay the actual cost, not the higher cost-sharing amount.

In-Network

You pay a $0 annual deductible. Initial Coverage

Depending on your income and institutional status, you pay the following:

For generic drugs (including brand drugs treated as generic), either:

- A $0 copay; or - A $1.20 copay; or - A $2.65 copay Outpatient Prescription Drugs (continued)

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For all other drugs, either: - A $0 copay; or

- A $3.60 copay; or - A $6.60 copay. Retail Pharmacy

Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

You can get drugs the following way(s): - one-month (30-day) supply

- three-month (90-day) supply Long Term Care Pharmacy

Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time.

They may also dispense less than a month’s supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.

You can get drugs the following way(s): - one-month (31-day) supply of drugs Mail Order

Contact your plan if you have questions about cost-sharing or billing when less than a one-month `supply is dispensed.

You can get drugs the following way(s): - one-month (30-day) supply

- three-month (90-day) supply

Outpatient

Prescription Drugs

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Out-of-Network

Plan drugs may be covered in special circumstances, for instance, illness while traveling outside of the plan’s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition, you will likely have to pay the pharmacy’s full charge for the drug and submit

documentation to receive reimbursement from AlohaCare Advantage Plus (HMO SNP).

You can get out-of-network drugs the following way:

- one-month (30-day) supply Out-of-Network Initial Coverage

Depending on your income and institutional status, you will be reimbursed by

AlohaCare Advantage Plus (HMO SNP) up to the plan’s cost of the drug minus the following:

For generic drugs purchased out-of-network (including brand drugs treated as generic), either:

- A $0 copay; or - A $1.20 copay; or - A $2.65 copay

For all other drugs purchased out-of-network, either:

- A $0 copay; or - A $3.60 copay; or - A $6.60 copay.

Out-of-Network Catastrophic Coverage You will be reimbursed in full for drugs purchased out-of-network.

Outpatient

Prescription Drugs

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OUTPATIENT MEDICAL SERVICES AND SUPPLIES Dental Services $0 copay for medically

related Medicaid-covered services.

For adults, emergency-only dental services are also covered under the FFS dental Plan.

Dental services are coordinated through Community Case Management Corporation (CCMC). CCMC will help members: • Find a dentist • Make an appointment • Coordinate transportation and translation services. Call from Oahu 1-808-792-1070 or toll-free

1-888-792-1070.

In-Network

$0 annual service category deductible for Medicare- covered dental benefits.* $0 copay for Medicare-covered dental benefits.*

$0 copay for the following preventive dental benefits:

• up to 2 oral exam(s) every year • up to 2 cleaning(s) every year • up to 2 dental x-ray(s) every year

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Hearing Services Hearing/Audiology Services - $0 copay per visit for Medicaid-covered services.

• Hearing Evaluation -

1 Per year (Hearing Aid Suppliers will not be paid for a hearing evaluation)

• Hearing Services -

Ear Plugs (Custom-made earplugs can be prescribed only by ENT specialists for individuals with recurrent middle ear infections)

• Hearing Aids - $0 per

item prescribed by an ENT specialist

• Hearing aid examination

and selection, monaural - 1 per 3 yrs

• Hearing aid examination

and selection, binaural - 1 per 3 yrs

• Fitting/orientation/

checking of hearing aid (to follow initial hearing aid exam and selection) - 1 per 3 yrs

General

$0 annual service category deductible for Medicare covered diagnostic hearing exams.*

In general, supplemental routine hearing exams and hearing aids not covered. $0 copay for:

Medicare-covered diagnostic hearing exams.*

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Vision Services The Plan provides eye and vision services:

• once every 2 years

More visits may be allowed, depending on the symptoms or medical condition.

Covered services include:

• Vision examinations • Prescription lenses • Cataract removal • Prosthetic eyes • Ophthalmologic exam with refraction

• Visual aids (eyeglasses) • Contact lenses and

miscellaneous vision supplies (if medically necessary).

This includes the costs for the lens, frames, or other parts of the glasses. Fittings and adjustments are also covered.

In-Network

This plan offers only Medicare-covered eye care and eyewear.

$0 copay for:

Medicare-covered diagnosis and treatment for diseases and conditions of the eye, including an annual glaucoma screening for people at risk.*

$0 copay for

• one pair of Medicare-covered

eyeglasses (lenses and frames) or contact lenses after cataract surgery. *

(32)

Over-the-Counter

Items Not Covered. GeneralThe plan provides $125 credit every three months.

Please visit our website to see our list of covered over-the-counter items.

Transportation

(Routine) $0 copay for Medicaid-covered services. The Plan provides both emergency and non-emergency ground and air services to and from medically necessary medical appointments for members who:

• Have no means of

transportation

• Reside in areas not

served by public transportation

• Cannot access public

transportation due to their medical condition

In-Network

This plan does not cover supplemental routine transportation.

Acupuncture and Other Alternative Therapies

Not covered Authorization rules may apply. In-Network

$0 copay for up to 15 visit(s) for

acupuncture and other alternative therapies every year.

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Methadone maintenance

Treatment Program (MMTP)

Medication management, prescribed drugs, medical supplies, diagnostic tests, therapeutic services, (individual, family, group and after care), and other medically necessary services. Includes the provision of methadone or a suitable alternatives as well as outpatient counseling services.

This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit. Long-Term Care Services (Institutional) - Nursing Facility services

Cost sharing amounts from members who have cost sharing requirements may apply.

This service is covered under your QUEST Integration health plan. Please contact your QUEST Integration health plan for details on this benefit.

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At-Risk Services

At-risk services are certain Home and Community-based Services (HCBS) which are listed below and that are provided to you if your assessment indicates that you are “at-risk” for worsening and going into a nursing home or other type of care outside of your home.

Adult Day Care $0 copay for Medicaid-covered services. Services include: • Observation and supervision by center staff • Coordination of behavioral, medical and social plans and implementation of the instructions as listed in the participant’s care plan

• Therapeutic, social,

educational, recreational activities

• Adult day care staff may

not perform healthcare related services

such as medication administration

(35)

Adult Day Health $0 copay for Medicaid-covered services.

Adult day health services are organized day

programs for therapeutic, social and health services for individuals that requires nursing oversight or care). This also includes:

• Emergency care • Dietetic services • Occupational therapy • Physical therapy • Physician services • Pharmaceutical services • Psychiatric or psychological services

• Recreational and social

activities

• Social services • Speech-language

pathology

• Transportation services

Home-Delivered Meals $0 copay for Medicaid-covered services.

Includes nutritious meals delivered to a location

(36)

Personal Assistance

Services—Level 1 $0 copay for Medicaid-covered services. Services may include:

• Routine housekeeping • Meal preparation • Laundry

• Shopping • Errands

(37)

Services—Level 2 $0 copay for Medicaid-covered services. Covered for those that require assistance with their activities of daily living (ADL).

This level of service is to be provided by a Home Health Aide (HHA), Personal Care Aide (PCA), Certified Nurse Aide (CNA) or Nurse Aide (NA) with applicable skills. Some activities include:

• Personal hygiene and

grooming, including bathing, skin care, oral hygiene, hair care and dressing

• Help with bowel and

bladder care

• Help with mobility • Help with transfers • Help with medications • Help with routine or

maintenance health care services by a personal care provider

• Help with feeding,

nutrition, meal

preparation and other dietary activities

(38)

Personal Emergency Response

Services (PERS)

PERS services are limited to those individuals:

• Who live alone • Who are alone for

significant parts of the day

• Who have no regular

caregiver for extended periods

• Who would otherwise

need extensive routine supervision

PERS services will only be offered to a member living in a non-licensed setting

Skilled Nursing

Services $0 copay for Medicaid-covered services. Covered for those who need on-going nursing care. The service is provided by licensed nurses within the scope of state law.

(39)

Home and Community-Based Services

You must meet certain level of care requirements and have an assessment performed with your QUEST Integration Service Coordinator. Your Service Coordinator will determine what services you need based on your assessment. Please contact your QUEST Integration health plan for details on this benefit.

Adult Day Care $0 copay for Medicaid-covered services. Services include: • Observation and supervision by center staff • Coordination of behavioral, medical and social plans and implementation of the instructions as listed in the participant’s care plan

• Therapeutic, social,

educational, recreational activities

• Adult day care staff may

not perform healthcare related services

such as medication administration

(40)

Adult Day Health $0 copay for Medicaid-covered services.

Adult day health services are organized day

programs for therapeutic, social and health services for individuals that requires nursing oversight or care). This also includes:

• Emergency care • Dietetic services • Occupational therapy • Physical therapy • Physician services • Pharmaceutical services • Psychiatric or psychological services

• Recreational and social

activities

• Social services • Speech-language

pathology

• Transportation services

(41)

Assisted Living

Services $0 copay for Medicaid-covered services. Assisted living services include:

• Personal care

• Supportive care services

(homemaker, chore, attendant services and meal preparation) The QUEST Integration health plan is not

responsible for payment for room and board.

Community Care Management Agency (CCMA)

Covered for members living in Community Care Foster Family Homes and other community settings, as required.

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Community Care Foster Family Home (CCFFH) Services

• Personal care • Supportive services • Homemaker services • Attendant care • Companion services • Local transportation • Day programming • Medication oversight

(to the extent permitted under state law)

All services must be provided in a certified private home by a principal care provider who lives in the home.

The QUEST Integration health plan is not

Counseling and

Training $0 copay for Medicaid-covered services. Counseling and training activities include the following:

• Member care training

for members, family and caregivers regarding the nature of the

(43)

Counseling and Training

(continued)

• Methods of transmission

and infection control measures

• Biological, psychological

care and special treatment needs/ regimens

• Use of equipment

specified in the service plan employer

• Skills updates as

necessary to safely maintain the individual at home • Crisis intervention • Supportive counseling • Family therapy • Suicide risk assessments and intervention

• Death and dying

counseling

• Substance abuse

counseling

• Nutritional assessment

and counseling

Counseling and training is a service provided to:

• Members

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Environmental Accessibility Adaptations

• The installation of ramps

and grab-bars • Widening of doorways • Modification of bathroom facilities • Installation of specialized electric and plumbing systems (must be necessary to accommodate the medical equipment and supplies that are necessary for the

welfare of the individual) All services shall comply with state or local building codes.

Home-Delivered Meals $0 copay for Medicaid-covered services.

Includes nutritious meals delivered to a location where an individual resides (excluding residential or institutional settings). The meals will not replace or substitute for a full day’s nutrition (i.e., no more than 2 meals per day).

(45)

Home Maintenance $0 copay for Medicaid-covered services. Home maintenance

services are those services not included as a part of personal assistance and include:

• Heavy-duty cleaning

to bring a home up to acceptable standards of cleanliness at the start of service to a member

• Minor repairs to

essential appliances, limited to stoves, refrigerators and water heaters

• Fumigation or

extermination services This benefit is provided to individuals who cannot perform these services without assistance and are determined, through assessment, to require the service to prevent institutionalization.

(46)

Moving Assistance

This benefit is provided in the rare instances when it is determined, through assessment that an individual needs to move to a new home. This benefit is not utilized when the individual has family members, a landlord, and other community members who can provide this service.

This includes:

• Unsafe home due to

deterioration

• The individual is

wheelchair bound, living in a building with no elevator, multistory building with no elevator or where the client lives above the first floor

• Member is evicted from

his or her current home

• Member can no longer

afford the home due to a rent increase

Moving expenses include packing and moving of belongings.

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Non-Medical

Transportation $0 copay for Medicaid-covered services. This service helps members travel as specified by the member care plan. It helps members get to community services, activities and resources. Whenever possible, those who can offer this service without cost will be used. They include family, neighbors, friends or community agencies.

Exclusion:

Members living in a

residential care setting or a CCFFH are not eligible for this service.

Services—Level 1 $0 copay for Medicaid-covered services. Services may include:

• Routine housekeeping • Meal preparation • Laundry

• Shopping • Errands

(48)

Services—Level 2 $0 copay for Medicaid-covered services. Covered for those that require assistance with their activities of daily living (ADL).

This level of service is to be provided by a Home Health Aide (HHA), Personal Care Aide (PCA), Certified Nurse Aide (CNA) or Nurse Aide (NA) with applicable skills. Some activities include:

• Personal hygiene and

grooming, including bathing, skin care, oral hygiene, hair care and dressing

• Help with bowel and

bladder care

• Help with mobility • Help with transfers • Help with medications • Help with routine or

maintenance health care services by a personal care provider

• Help with feeding,

nutrition, meal

preparation and other dietary activities

• Help with exercise,

positioning and range of motion

• Taking and recording

vital signs, including blood pressure

(49)

Personal Emergency Response

Services (PERS)

PERS services are limited to those individuals:

• Who live alone • Who are alone for

significant parts of the day

• Who have no regular

caregiver for extended periods

• Who would otherwise

need extensive routine supervision

PERS services will only be offered to a member living in a non-licensed setting

Skilled or Private-Duty

Nursing $0 copay for Medicaid-covered services. Covered for those who need on-going nursing care. The service is provided by licensed nurses within the scope of state law.

(50)

Licensed Residential

Care $0 copay for Medicaid-covered services. Residential care is provided in a licensed private home by a principle care provider who lives in the home. He or she gives the following services to members:

• Personal care services • Homemaker, chore,

attendant care and companion services

• Medication oversight (to

the extent allowed by law)

• Transportation to

medical appointments The QUEST Integration health plan is not

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Respite Care $0 copay for Medicaid-covered services.

Respite care is short-term basis for individuals who are unable to care for themselves. It provides relief to caregivers. It may be provided hourly, daily and overnight. Respite care may be provided in the following locations:

• Member’s home or

place of residence

• Foster home or

expanded-care adult residential care home

• Medicaid-certified

nursing facility

• Licensed respite day

care facility

• Other community care

residential facility approved by the Plan Respite care services are authorized by the member’s PCP as part of the member’s care plan.

(52)

Specialized Medical Equipment

Warranty and Supplies

$0 copay for Medicaid-covered services. Refers to the purchase, rental, lease, costs, installation, repairs and removal of devices, controls or appliances specified in the care plan. This also includes:

• Items necessary for life

support

• Supplies and equipment

needed for the proper functioning of such items

• Durable and

non-durable medical

equipment not available under the Medicaid state plan

Examples include:

• Shower seat

• Portable humidifiers • Electric bills specific to

electrical life support devices (ventilator, oxygen concentrator)

• Medical supplies

(53)

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