Medicare Advantage Special Needs Plan

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Friends for Health. Friends for Life.

2016

i

Care

Medicare Advantage

Special Needs Plan

SUMMARY OF BENEFITS

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H2237_IC828 CMS Accepted

Multi-language Interpreter Services

English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-800-777-4376. Someone who speaks English/Language can help you. This is a free service.

Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-800-777-4376. Alguien que hable español le podrá ayudar. Este es un servicio gratuito. Chinese Mandarin: 我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑 问。如果您需要此翻译服务，请致电 1-800-777-4376。我们的中文工作人员很乐意帮助您。这是一项免费服务。 Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯服務。如需翻譯服務，請致電 1-800-777-4376。我們講中文的人員將樂意為您提供幫助。這是一項免費服務。

Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang

makakuha ng tagasaling-wika, tawagan lamang kami sa 1-800-777-4376. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo.

French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au 1-800-777-4376. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit.

Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-800-777-4376 sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí .

German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-800-777-4376. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos.

Korean: 당사는의료보험또는약품보험에관한질문에답해드리고자무료통역

서비스를제공하고있습니다. 통역서비스를이용하려면전화 1-800-777-4376번으로

문의해주십시오. 한국어를하는담당자가도와드릴것입니다. 이서비스는무료로

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H2237_IC828 CMS Accepted Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону 1-800-777-4376. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная. Arabic:

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Hindi: हमारेस्वास््ययादवाकीयोजनाकेबारेमें आपकेककसी भीप्रश्नकेजवाब देनेकेलिएहमारे पासमुफ्तदुभाषिया सेवाएँउपिब्धहैं. _एक_{दुभाषिया}_{प्राप्त} _करने_के_लिए, बसहमें 1-800-777-4376 परफोनकरें. _कोई_{व्यक्तत}_जो_{हहन्दी}_{बोिता}_है _आपकी _मदद_कर_सकता_है. _यह_एक_{मुफ्त}_सेवा_है. Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-800-777-4376. Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito.

Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer

questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número 1-800-777-4376. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito.

French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-800-777-4376. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.

Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-800-777-4376. Ta usługa jest bezpłatna.

Japanese: 当社の健康健康保険と薬品処方薬プランに関するご質問にお答えするために

、無料の通訳サービスがありますございます。通訳をご用命になるには、1-800-777

4376にお電話ください。日本語を話す人者が支援いたします。これは無料のサービス

です。

Hmong: Peb muaj tib neeg los pab ntxhais lus dawb rau koj yog koj muaj kev nug txog ntawm peb cov ntaub ntawv ua yog kev los pab kho mob los yog kev muab tshuaj noj. Yog xav tau kev pab txhais lus, hu tau rau peb tus xov tooj 1-800-777-4376. Muaj ib tus neeg ua paub hais lus Hmoob yuav los pab koj. Qhov no yog kev pab dawb xwb.

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2016 Summary of Benefits for

i

Care Medicare Plan

(HMO SNP)

i

CARE MEDICARE PLAN (HMO SNP)

(a Medicare Advantage Health Maintenance Organization (HMO) offered by INDEPENDENT CARE HEALTH PLAN, INC. with a Medicare contract)

Summary of Benefits

January 1, 2016 - December 31, 2016

This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the "Evidence of Coverage."

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

iCare Medicare Plan (HMO SNP).

Tips for comparing your Medicare choices

This Summary of Benefits booklet gives you a summary of what iCare Medicare Plan (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 users should call 1-877-486-2048.

Sections in this booklet

 Things to Know About iCare Medicare Plan (HMO SNP)

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

 Prescription Drug Benefits

 Additional Information About iCare Medicare Plan  Medicaid Benefit Comparison

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2016 Summary of Benefits for

i

Care Medicare Plan

(HMO SNP)

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 1-800-777-4376.

THINGS TO KNOW ABOUT

i

CARE MEDICARE PLAN

(HMO SNP)

Hours of Operation

You can call us 24 hours-a-day, 7 days-a-week (office hours: Monday-Friday, 8:30 a.m. to 5:00 p.m), or visit www.icare-wi.org

iCare Medicare Plan (HMO SNP) Phone Numbers and Website

 If you are a member of this plan, call toll-free 1-800-777-4376.  If you are not a member of this plan, call toll-free 1-855-689-7690.  Our website:http://www.icare-wi.org

Who can join?

To join iCare Medicare Plan (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and Wisconsin Medicaid, and live in our service area. Our service area includes the following counties in Wisconsin: Brown, Calumet, Dane, Kenosha, Kewaunee, Manitowoc,

Marinette, Menominee, Milwaukee, Oconto, Outagamie, Ozaukee, Racine, Rock, Sauk, Shawano, Sheboygan, Walworth, Washington, Waukesha, Waupaca, and Winnebago.

Which doctors, hospitals, and pharmacies can I use?

iCare Medicare Plan (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 provider and pharmacy directory at our website (http://www.icare-wi.org).

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 allof the benefits covered by Original Medicare. Our plan

members also get more than what iscovered by Original Medicare. Some of the extra

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2016 Summary of Benefits for

i

Care Medicare Plan

(HMO SNP)

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, http://www.icare-wi.org.

 Or, call us and we will send you a copy of the formulary.

How will I determine my drug costs?

Our plan groups each medication into one of three "tiers." You will need to use your formulary to locate what tier your drug is on to determine how much it will cost you. The amount you pay depends on the drug's tier 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 Coverage, Coverage Gap, and Catastrophic Coverage.

MONTHLY PREMIUM, DEDUCTIBLE, AND LIMITS ON HOW

MUCH YOU PAY FOR COVERED SERVICES

How much is the monthly premium?

$0 per month. In addition, you must keep paying your Medicare Part B premium.

How much is the deductible? This plan has deductibles for some hospital and medical services.

$0 or $147 per year for in-network services, depending on your level of Medicaid eligibility. This amount may change for 2016.

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 Wisconsin Medicaid eligibility.

Your yearly limit(s) in this plan:

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

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2016 Summary of Benefits for

i

Care Medicare Plan

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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.

Refer to the "Medicare & You" handbook for Medicare covered services. For Wisconsin Medicaid-covered services, refer to the Medicaid Coverage section in this document.

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 much the plan will pay?

Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.

The iCare Medicare Plan HMO SNP is a Coordinated Care plan with a Medicare contract and a contract with the Wisconsin Medicaid program. Enrollment in the iCare Medicare Plan depends on contract renewal. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

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2016 Summary of Benefits for

i

Care Medicare Plan

(HMO SNP)

COVERED MEDICAL AND HOSPITAL BENEFITS

NOTE:

 Services with a 1may require prior authorization.

 Services with a 2may require a referral from your doctor.

OUTPATIENT CARE AND SERVICES

Acupuncture Not covered

Ambulance 0% or 20% of the cost

Chiropractic Care Manipulation of the spine to correct a subluxation (when 1 or

more of the bones of your spine move out of position): 0% or 20% of the cost

Dental Services Limited dental services (this does not include services in

connection with care, treatment, filling, removal, or replacement of teeth): 0% or 20% of the cost

Diabetes Supplies and Services1 Diabetes monitoring supplies: You pay nothing

Diabetes self-management training: 0% or 20% of the cost

Therapeutic shoes or inserts: 0% or 20% of the cost

Diagnostic Tests, Lab and Radiology Services, and X-Rays (Costs for these services may be different if received in an outpatient surgery setting)1

Diagnostic radiology services (such as MRIs, CT scans): 0% or 20% of the cost

Diagnostic tests and procedures: 0% or 20% of the cost

Lab services: 0% or 20% of the cost

Outpatient x-rays: 0% or 20% of the cost

Therapeutic radiology services (such as radiation treatment for cancer): 0% or 20% of the cost

Doctor's Office Visits Primary care physician visit: 0% or 20% of the cost

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2016 Summary of Benefits for

i

Care Medicare Plan

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Durable Medical Equipment (wheelchairs, oxygen, etc.)1

0% or 20% of the cost

Emergency Care $0 or $75 copay

If you are admitted to the hospital within 3 days, you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section of this booklet for other costs.

Foot Care (podiatry services) Foot exams and treatment if you have diabetes-related nerve

damage and/or meet certain conditions: 0% or 20% of the cost

HearingServices Exam to diagnose and treat hearing and balance issues:

0% or 20% of the cost

Home Health Care1,2 You pay nothing

Mental Health Care1,2 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 applies to inpatient mental services provided in a general hospital.

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.

In 2015 the amounts for each benefit period were $0 or: 

 $1,260 deductible for days 1 through 60  $315 copay per day for days 61 through 90

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2016 Summary of Benefits for

i

Care Medicare Plan

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 $630 copay per day for 60 lifetime reserve days These amounts may change for 2016.

Outpatient group therapy visit: 0% or 20% of the cost

Outpatient individual therapy visit: 0% or 20% of the cost

Outpatient Rehabilitation1,2 Cardiac (heart) rehab services (for a maximum of 2 one-hour

sessions per day for up to 36 sessions up to 36 weeks): 0% or 20% of the cost

Occupational therapy visit: 0% or 20% of the cost

Physical therapy and speech and language therapy visit: 0% or 20% of the cost

Outpatient Substance Abuse Group therapy visit: 0% or 20% of the cost

Individual therapy visit: 0% or 20% of the cost

Outpatient Surgery Ambulatory surgical center: 0% or 20% of the cost

Outpatient hospital: 0% or 20% of the cost

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: 0% or 20% of the cost

Related medical supplies: 0% or 20% of the cost

Renal Dialysis 0% or 20% of the cost

Transportation Not covered

Urgently Needed Services 0% or 20% of the cost (up to $65)

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2016 Summary of Benefits for

i

Care Medicare Plan

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(including yearly glaucoma screening): 0% or 20% of the cost

Eyeglasses or contact lenses after cataract surgery: 0% or 20% of the cost

PREVENTIVE CARE You pay nothing

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 (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

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

Annual physical exam: You pay nothing

HOSPICE You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and

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2016 Summary of Benefits for

i

Care Medicare Plan

(HMO SNP)

respite care. Hospice is covered outside of our plan. Please contact us for more details.

INPATIENT CARE

Inpatient Hospital Care1

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.

In 2015 the amounts for each benefit period were $0 or:

 $1,260 deductible for days 1 through 60  $315 copay per day for days 61 through 90  $630 copay per day for 60 lifetime reserve days These amounts may change for 2016.

Inpatient Mental Health Care For inpatient mental health care, see the "Mental Health Care"

section of this booklet.

Skilled Nursing Facility (SNF) 1,2 Our plan covers up to 100 days in a SNF.

In 2015 the amounts for each benefit period were $0 or:

 You pay nothing for days 1 through 20

 $157.50 copay per day for days 21 through 100 These amounts may change for 2016.

PRESCRIPTION DRUG BENEFITS

How much do I pay? For Part B drugs such as chemotherapy drugs1: 0% or 20% of

the cost

Other Part B drugs1: 0% or 20% of the cost

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

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2016 Summary of Benefits for

i

Care Medicare Plan

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You pay the following:

You may get your drugs at network retail pharmacies and mail order pharmacies.

Standard Retail and Mail Order Cost-Sharing

Tier One-Month Supply Two-month supply Three-month supply Tier 1 (generic), Tier 2 (brand) For generic drugs (including brand drugs treated as generic), either:  $0 copay; or  1.20 copay; or  $2.95 copay For all other drugs, either:  $0 copay; or  $3.60 copay; or  $7.40 copay For generic drugs (including brand drugs treated as generic), either:  $0 copay; or  1.20 copay; or  $2.95 copay For all other drugs, either:  $0 copay; or  $3.60 copay; or  $7.40 copay For generic drugs (including brand drugs treated as generic), either:  $0 copay; or  1.20 copay; or  $2.95 copay For all other drugs, either:  $0 copay; or  $3.60 copay; or  $7.40 copay Tier 3 (specialty) For generic drugs (including brand drugs treated as generic), either:  $0 copay; or  1.20 copay; or  $2.95 copay For all other drugs, either:  $0 copay; or  $3.60 copay;

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2016 Summary of Benefits for

i

Care Medicare Plan

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or

 $7.40 copay

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 Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,850, you pay nothing for all drugs.

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2016 Summary of Benefits for

i

Care Medicare Plan

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ADDITIONAL INFORMATION ABOUT

i

CARE MEDICARE PLAN

Fitness Center Membership Up to $35.00 per month reimbursement for a single fitness center membership fee. Reimbursement is limited to one membership per month. Contact iCare for more details.

Over-the-Counter Drug Program

Up to $17 per month for Over-the-Counter drugs and supplies.

The iCare OTC program allows members to purchase

over-the-counter “Drug Store” type items using an account that is replenished with funds on a monthly basis. The following product categories are offered:

 Medicines, ointments and sprays with active medical ingredients

 First aid supplies  Incontinence supplies  Vitamins and minerals  Diagnostic equipment  Weight loss items

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Medicaid Benefit Comparison

2016 Summary of Benefits for

i

Care Medicare Plan (HMO SNP)

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 Wisconsin Medicaid covers and what our plan covers. What you pay for covered services may depend on your level of Medicaid eligibility.

Benefit Category

Medicaid Fee-for-Service

i

Care Medicaid SSI Plan

Alcohol and Other Drug Abuse (AODA) Day Treatment

Full coverage - $.50-$3 copay per service

Prior Authorization is required.

In-Network

$0 copay for Medicaid-covered services.

Alcohol and Other Drug Abuse (AODA) Services

In-Network

Ambulatory Prenatal Services

Full coverage. No copay. In-Network

Ambulatory Surgical Centers

Coverage of certain surgical

procedures and related lab services.

$3.00 copayment per service.

In-Network

Anesthesiology Services

In-Network

Audiology Services Full coverage - $.50-$3 copay per

service

In-Network

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Medicaid Benefit Comparison

2016 Summary of Benefits for

i

Care Medicare Plan (HMO SNP)

Benefit Category

Medicaid Fee-for-Service

i

Care Medicaid SSI Plan

services.

Case Management Services (Targeted)

Full coverage. No copay. In-Network

Chiropractic services Full coverage

$.50 to $3.00 copayment per service

Chiropractic services are provided by Medicaid Fee-for-Service, not iCare.

$.50 to $3.00 copayment per service

Dental services Full coverage

$0.50 - $3.00 copay per service.

In-Network

$0 copay for Medicaid-covered services (Covered by iCare in Kenosha, Milwaukee, Racine and Waukesha counties. For members in other counties, these services are provided by

Medicaid Fee-for-Service).

Durable Medical Equipment and Supplies

Full coverage

$0.50 - $3.00 per item. Rental items are not subject to copayment.

In-Network

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Medicaid Benefit Comparison

2016 Summary of Benefits for

i

Care Medicare Plan (HMO SNP)

Benefit Category

Medicaid Fee-for-Service

i

Care Medicaid SSI Plan

Drugs (Prescription) Coverage of generic and brand name

prescription drugs, and some over-the-counter (OTC) drugs.

Members are limited to 5

prescriptions per month for opioid drugs.

Copayments:

• $0.50 for OTC drugs • $1.00 for generic drugs • $3.00 for brand

Copayments are limited to $12 per member, per provider, per month. OTCs are excluded from this $12 maximum.

Drugs excluded by Medicare Part D may be covered by Medicaid Fee-for-Service, not iCare.

Copayments:

• $0.50 for OTC drugs • $1.00 for generic drugs • $3.00 for brand

Copayments are limited to $12 per member, per provider, per month. OTCs are excluded from this $12 maximum.

Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services

Full coverage - No copayment In-Network

Home Care Services (Home Health, Private Duty Nursing and Personal Care)

Full coverage of private duty nursing, home health services, and personal care.

No copayment

In-Network

Hospice Care Services Full coverage

No copayment

In-Network

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Medicaid Benefit Comparison

2016 Summary of Benefits for

i

Care Medicare Plan (HMO SNP)

Benefit Category

Medicaid Fee-for-Service

i

Care Medicaid SSI Plan

Hospital Services - Inpatient

Full coverage

$3 copay per day with a $75.00 cap per stay.

In-Network

Hospital Services - Outpatient Hospital and Emergency Room

Full coverage

$3 copay per visit.

In-Network

Mental Health and Mental Health Day Treatment

Full coverage (not including room and board).

$0.50 to $3.00 copayment per service, limited to the first 15 hours or $825 of services, whichever comes first, provided per calendar year.

Copayment is not required when services are provided in a hospital setting.

In-Network

$0 copay for Medicaid-covered services. Nursing Home Services Full coverage No copayment. In-Network

Nursing and Private Duty Nursing

Full Coverage.

$0 copay

In-Network

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Medicaid Benefit Comparison

2016 Summary of Benefits for

i

Care Medicare Plan (HMO SNP)

Benefit Category

Medicaid Fee-for-Service

i

Care Medicaid SSI Plan

Physician Services (May include:

Physician Assistants, Nurse Practitioners, Rural Health Clinics)

Full coverage, including laboratory and radiology.

$.50 to $3.00 copayment per service limited to $30 per provider per calendar year. (No copay for emergency services, preventive services, anesthesia or clozapine management)

In-Network

Podiatry Services Full coverage

$.50 to $3.00 copayment per service; limited to $30 per provider per calendar year.

In-Network

Prenatal/Maternity Care (May include: Nurse Midwife)

Full coverage, including prenatal care coordination, and preventive mental health and substance abuse screening and counseling for women at risk of mental health or substance abuse problems.

Full coverage - No copayment.

In-Network

Reproductive Health Services - Family Planning Services

Full coverage with the exceptions listed below.

No copay for services provided by a family planning clinic or

contraceptive management.

Does not cover:

 reversal of voluntary sterilization,  infertility treatments,

 surrogate parenting and related

In-Network

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Medicaid Benefit Comparison

2016 Summary of Benefits for

i

Care Medicare Plan (HMO SNP)

Benefit Category

Medicaid Fee-for-Service

i

Care Medicaid SSI Plan

 services, including: o artificial insemination o obstetrical care o labor or delivery o prescription and over-the-counter drugs.

Respiratory Care for Ventilator – Assisted Recipients

Full Coverage.

$0 copay

In-Network

School-Based Services (under age 21)

Covered if listed in child’s

Individualized Education Program (IEP)

No copayment

In-Network

If listed in member’s Individualized Education Program (IEP), covered by Medicaid Fee-for-Service during regular school hours and by

iCare Medicaid SSI Plan when applicable after school hours, school breaks or during the summer. No copayment Skilled Nursing Services Full coverage No copayment In-Network

Transportation - Ambulance,

Specialized Medical Vehicle (SMV),

Full coverage of emergency and non-emergency medical

transportation to and from a covered service.

$0 copay for Medicaid-covered emergency transportation services.

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Medicaid Benefit Comparison

2016 Summary of Benefits for

i

Care Medicare Plan (HMO SNP)

Benefit Category

Medicaid Fee-for-Service

i

Care Medicaid SSI Plan

Common Carrier  $2 copayment for non-emergency

ambulance trips.

 $1 copayment per trip for transportation by SMV

(Specialized Medical Vehicle).  No copayment for transportation

by common carrier or emergency ambulance.

Call MTM at 1-866-907-1493 to arrange transportation.

Non-emergency transportation to and from a covered service is covered by Medicaid

Fee-for-Service, who has

contracted with MTM to arrange transportation.

 $2 copayment for

non-emergency ambulance trips.

 $1 copayment per trip for transportation by SMV (Specialized Medical Vehicle).  No copayment for transportation by common carrier or emergency ambulance. Call MTM at 1-866-907-1493 to arrange transportation. Therapy - Physical Therapy (PT), Occupational Therapy (OT), and Speech and Language Pathology (SLP)

Full coverage

$.50 to $3.00 copayment per service. Copayment obligation limited to the first 30 hours or $1,500, whichever occurs first, during one calendar year (copayment limits calculated

separately for each discipline).

In-Network

Vision Care Services Full coverage including eyeglasses.

$.50 to $3.00 copayment per service.

In-Network

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