Medicare Advantage Benefits, Allowances and Programs

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Health New England Medicare Advantage is an HMO and HMO-POS Plan with a Medicare contract. Enrollment in Health New England Medicare Advantage depends on contract renewal. Health New England complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. ATTENTION: If you speak any language other than English, language assistance services, free of charge, are available to you. Call (413) 787-0010 or TTY 711. Health New England cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (413) 787-0010 o TTY 711. Health New England cumpre as leis de direitos civis federais aplicáveis e não exerce discriminação com base na raça, cor, nacionalidade, idade, deficiência ou sexo. ATENÇÃO: Se fala português, encontram-se disponíveis encontram-serviços linguísticos, grátis. Ligue para (413) 787-0010 ou TTY 711.

Member Services Local: (413) 787-0010 Toll-Free: (877) 443-3314 TTY: 711 Hours 8:00 a.m. – 8:00 p.m. Monday – Friday

(Oct. 1 – Mar. 31: 8:00 a.m. – 8:00 p.m., seven days a week)

Email Us

Email us with your questions at [email protected] and one of our Member Services representatives will respond to you directly.

Mailing Address Health New England Attn: Medicare Advantage One Monarch Place Suite 1500 Springfield, MA 01144-1500 Website healthnewengland.org/medicare Prescription Drugs Toll-Free: (800) 393-0395 TTY: 711

24 hours a day, seven days a week

Medicare (U.S. Government Office) Toll-Free: (800) 633-4227

TTY: (877) 486-2048

24 hours a day, seven days a week medicare.gov

Our knowledgeable and friendly Member Services representatives

are available to answer your questions and provide you with any

information you may need. We are glad to help you.

How to Contact Health New England

and Other Important Information

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We are committed to meeting your

health care needs.

In addition to providing coverage if

you ever need medical services, we

want to help you stay healthy and

improve your overall well-being.

As a Health New England Medicare

Advantage member, you have

access to various tools and clinical

programs designed to help you

stay healthy, seek care, manage

any complex health conditions and

manage your medications.

*

Benefits, Allowances

and Programs

*_{For members enrolled in a Health New England} Medicare Advantage plan with prescription benefits.

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Benefits, Allowances and Programs

1

Beyond basic health care benefits

Hearing Aids

Save thousands of dollars with our hearing aid benefit, provided through TruHearing®_{. Health New} England Medicare Advantage plans cover up to two hearing aids (one per ear) when purchased through TruHearing,*_{with a copayment of $699 per aid for the Advanced option or $999 per aid for} the Premium option. For more details, see pages 11 and 12.

Hearing Exams

Your plan covers one supplemental routine hearing exam per calendar year with a copayment. You can obtain this service from in-network providers and they will bill Health New England for the service.

Nutritional Education

Your plan provides medical nutrition education. This benefit includes up to four one-hour visits per calendar year. You can obtain this service from in-network providers and they will bill Health New England for the service.

Physical Exam and Well-Care Visit

**

Original Medicare only covers an annual well-care visit to develop or update a personalized prevention plan based on your current health and risk factors. Health New England covers the annual well-care visit along with a comprehensive physical, hands-on exam each year as an additional benefit at no cost to you.

Health New England also offers members a $20 gift-card incentive for completing either an annual well-care visit or annual physical exam. Once you’ve had either your well-care visit or physical in 2021, log into our secure online Member Portal at my.healthnewengland.org and fill out a brief Preventive Care Visit Submission Form to receive your gift card. If you have questions, or aren’t able to access our Member Portal to complete the form, please call our Member Services team at the numbers listed in the beginning of this booklet.

Vision Care

With our EyeMed®_{additional benefit, you pay nothing for one routine eye exam with refraction per} calendar year. You also get an allowance for your prescription eyewear every two calendar years. This allowance is applied at the point of service when obtained from an in-network EyeMed provider. Covered items include eyeglasses (lenses and/or frames) and contact lenses. For more details, see page 14.

*_{You must see a TruHearing provider to use this benefit. Other providers are available in our network.} Please note, hearing aids purchased through other providers are not covered.

**_{This program is limited to one reward per year and must be claimed by 12/31/2021. Information submitted} is subject to claims verification. Your PCP must bill this visit as an annual physical or well-care visit.

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Over-the-Counter (OTC) Care

As a Medicare Advantage member, you are eligible for OTC benefits. As part of the FirstLine Essentials OTC benefit, you get a $40 credit every three months (credits expire at the end of each quarter). Use your credits to purchase OTC products from FirstLine Essentials’ website, mobile app, call center or mail-in order form. An OTC items catalog will be sent to you directly from FirstLine Essentials in the mail. For more details, see page 17.

Allowances and reimbursements

We want to help make it a little easier for you to make important lifestyle choices. That’s why your Health New England Medicare Advantage plan provides several allowances and reimbursements to help you stay healthy.

Each allowance is subject to the limits described in the Allowances Chart below. You will pay for the items or services first, then you will submit appropriate receipts and documentation for reimbursement from Health New England. The OTC benefit and prescription eyewear allowance are offered at point of service and are not reimbursements.

Allowances Chart

Amount

Over-the-Counter Care—Credits applied every three months for purchase of over-the-counter items listed in the FirstLine Essentials OTC catalog only. (Credits expire each quarter and do not accumulate.)

$40

Every three months

Prescription Eyewear—Allowance at point of service every two calendar years. (Benefit must be obtained from an in-network EyeMed®_provider.)

$100

Every two calendar years

Dental—Reimbursement per calendar year.

$250

Per calendar year Fitness Center, Weight Watchers®_,_Acupuncture,

and Activity Tracker—Combined total reimbursement per calendar year.

$150

Per calendar year Wig (Applies if you are on or have recently undergone

chemotherapy.) Reimbursement per calendar year. Per calendar year

$350

Note: Each allowance is paid on a calendar year basis except for the quarterly OTC credit. A calendar year is the twelve month period from January to December. Any unused portion of an allowance cannot be carried over from the one or two calendar year period to the next.

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It’s important to

know the care

options available to

you when you need

them, especially

during a period

of illness or while

managing a chronic

health condition.

These tools and

programs help you

get the right care

when you need it

and can help you

save money.

Tools and programs for managing

your health

Comprehensive Health Assessment

Members of Health New England Medicare Advantage receive free, online access to the Healthy Directions web portal, powered by WebMD ONE®_{, at webmdhealth.com/hne. Take advantage of the} portal’s many helpful tools and complete your Comprehensive Health Assessment within the first 90 days of your plan membership so we can help you manage your health effectively. For more details, see page 10.

Options for Seeking Care

For non-emergency or routine care, we always recommend that you consult your primary care provider (PCP) first, whenever possible. However, if you can’t reach your PCP, Health New England offers other options:

Nurse Advice Line

Free health advice is available from experienced Registered Nurses 24 hours a day, 7 days a week by calling Health New England’s health information line at (866) 389-7613. A team of medical professionals is available to answer questions about your health, help you determine whether to seek additional care, and address medication questions. These caring professionals will listen carefully to your concerns and give you information to help you choose the care that’s right for you. Teladoc® *_{for $0 Copay}

As a Health New England Medicare Advantage member, you have access to Teladoc,*_{our telehealth service. You can request a phone,} mobile app or online video consultation with a U.S. board-certified physician, 24 hours a day, 7 days a week, 365 days a year, to treat non-emergency, non-chronic medical issues such as colds and the flu, abdominal pain, allergies, rashes and more. For more details, see page 13.

Remember, these options do not replace your PCP. If you need

immediate medical attention, call 911 or go to the nearest emergency room. For non-emergency issues, please contact your PCP first.

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Support for Managing Complex Conditions

Care Management

Our Care Management programs are available to help members with long-term health challenges. Experienced care managers and care coordinators will help manage your care and your relationships with physicians and health care providers. If you are going through a period of illness or managing a chronic health condition, we encourage you to take advantage of this special program to manage your health and help reduce your health care costs. Once enrolled into a program, a nurse or social worker will work with you to help you manage your health condition and risk factors through regular phone calls and check-ins.

We offer the following Care Management programs:

• Behavioral Health (including depression, mental health, substance use disorder and social case management)

• Complex Care Management

• Care Coordination

• Disease Management (including asthma, chronic obstructive pulmonary disease, congestive heart failure, coronary artery disease, diabetes and hypertension)

• Diabetes and Congestive Heart Failure Care Management Program

For members who have been diagnosed with both Diabetes and Congestive Heart Failure (CHF), you may be eligible to enroll in our Diabetes/CHF Care Management Program. Please talk with your doctor. Upon enrollment and successful completion of the Diabetes/CHF Care Management Program, you will be eligible for copayment reimbursement for visits with your primary care provider, endocrinologist, podiatrist, cardiologist, certified diabetic educator, and nutritional counselor.

• Falls Prevention Program

For members who have an abnormality of gait diagnosis or are at risk for falling, you may be eligible to enroll in our Falls Prevention Program. Please talk with your doctor. The goals of this program are to decrease falls, thereby preventing injuries and hospital or rehab stays, and maintain independence. Upon enrollment and successful completion of the Falls Prevention Program, you will be eligible for copayment reimbursement for your physical and occupational therapy.

• Transitions of Care Program

This program is available to help members plan a smooth transition after a hospital stay. We offer one-on-one support from a certified nurse at no additional cost. The nurse offers coaching that will help guide you before and during your transition to home or a rehabilitation facility.

If you are interested in a Care Management program, you can enroll by calling our Care Management team today at (800) 842-4464 or (413) 787-4000, ext. 3940.

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Home Services

Matrix In-Home Health Visits

Health New England works closely with Matrix Medical Network to offer a comprehensive in-home health visit at no cost to Medicare Advantage members. Scheduled at your convenience in your own home, the Matrix visit is nearly an hour of uninterrupted time with a licensed, board-certified medical provider who reviews your medical history and medications, and can answer your health questions. If you’d like more information about a Matrix in-home health visit, call (855) 205-0431 or go to MatrixForMe.com.

Mom’s Meals Program – Post-Discharge

We partner with Mom’s Meals to provide meals to Medicare Advantage members who are discharged from an inpatient hospital stay or a skilled nursing facility. Upon discharge, if you qualify, our Care Management team will submit a request on your behalf to have up to 28 fully-prepared, nutritious meals (up to 2 meals per day for 14 days depending on your plan)1_{delivered to your home by Mom’s} Meals at no cost to you. This home meal benefit must be requested within 30 days of discharge. For more details, see pages 15 and 16.

Help Managing Medications

*

Medication Therapy Management Program

If you have complex health needs, take multiple prescription drugs and have high prescription drug costs, you may be eligible to participate in our Medication Therapy Management Program.*

This program provides members with a chance to review medications with a medical professional— either a pharmacist or registered nurse. This program is available at no charge and is included with our Medicare Part D benefits.

Participating in our Medication Therapy Management program can: • Empower you to take an active role in your medication management • Enhance your medication use to improve your quality of life

• Reduce your health care costs

• Reduce your risk of medication-related problems

Also, by switching to a generic alternative medication, you can save money on copays each time you fill a prescription and reduce your prescription drug costs, which can help you from reaching the coverage gap, also called the “donut hole.”

For more information, visit healthnewengland.org/medicare/MTM.

1_{Up to 2 meals per day for 7 days for Medicare Value and Choice plans.}

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Access our secure online Member Portal at

my.HealthNewEngland.org

As a Health New England Medicare Advantage member, you can view all of your health care claims and benefits online through our convenient secure online Member Portal. All you need to do is go to my.HealthNewEngland.org and register to take advantage of the following helpful features:

• Request a new ID card.

• View recently processed medical and pharmacy1_claims. • Find a provider and see who’s accepting new patients. • Reference benefits included in your health plan.

• View monthly premiums, if applicable.

• Learn about your personal pharmacy benefits, manage mail-order prescriptions, look up drugs and pharmacies, and more.1

• Get quick access to Teladoc,®_{your telehealth benefit.}

• Access your EyeMed®_{benefit and find participating providers.}

1_{Pharmacy claims and benefits apply only to members with a Health New England Medicare Advantage plan} with prescription drug benefits.

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Call TruHearing to learn more and schedule an appointment

Hours:

8:00 am to 8:00 pm, Mon–Fri

(844) 319-7458

TTY: 711

Think you might

have hearing loss?

Try our free, fast online screening

Visit:

Screening.TruHearing.com

Accessible from your tablet, computer, or smartphone

Get Back the Joy of Hearing

Better hearing helps you stay connected to the ones you love. That’s why Health New England Medicare Advantage offers you a hearing aid benefit through TruHearing®_.

Your hearing aid benefit includes:

Personalized Care

Guidance and assistance from a TruHearing Hearing Consultant Professional exam from a local, licensed provider

Three follow-up visits for fitting and adjustments to ensure you’re completely satisfied with your hearing aids

Next-Generation Sound

Powerful hearing aids help you hear what matters most, wherever you are

Device sensors automatically adjust for a natural sound, even while you’re moving

Own Voice Processing (OVP®_{) recognizes your voice and makes it}

sound more natural

Devices for Your Lifestyle

Bluetooth connectivity for streaming your favorite music, TV and phone calls straight to your ears1

Rechargeable battery options that provide an all-day charge in 3-4 hours2

A smart app that acts as a hearing aid remote control, allows you to interface with your provider and even tracks your physical activity3

(844) 319-7458| TTY: 711

What’s in it for me?

You get a comprehensive health assessment with a detailed health risk report and recommendations for improvement.

The Daily Habits tool to help you maintain or improve in areas such as: • exercise • nutrition • tobacco cessation • stress management • emotional health • weight management • sleep

Health trackers to help you follow your medical, health and wellness goals

A symptom checker

A search tool for

information about specific medical topics and

general well-being tips

Healthy recipes

Self-help videos

A personal health record

Easy access on your smartphone with the WebMD ONE®_app

Healthy Directions Web Portal

Powered by WebMD ONE

®

Health New England has partnered with WebMD ONE®_{to bring you} your own Healthy Directions Web Portal.

The portal is your one-stop shop for health and wellness information, tools and resources. To access the portal, follow these steps:

• Type the following URL into your browser: webmdhealth.com/hne

• Once you have created an account and logged in to your Healthy Directions Web Portal, please take the

Comprehensive Health Assessment.

This provides important information to help us assist you in

managing your health. We ask that you complete this assessment within the first 90 days of membership in your plan.

If you don’t have access to the internet or if you have questions, contact Member Services at: (877) 443-3314 or TTY 711,

8:00 a.m. to 8:00 p.m., Monday through Friday (October 1 through March 31: 8:00 a.m. to 8:00 p.m., 7 days a week). You can also contact our Healthy Directions team at [email protected].

Comprehensive Health Assessment

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11

Hours:

8:00 am to 8:00 pm, Mon–Fri

(844) 319-7458

TTY: 711

Think you might

have hearing loss?

Try our free, fast online screening

Visit:

Screening.TruHearing.com

Accessible from your tablet, computer, or smartphone

Get Back the Joy of Hearing

Better hearing helps you stay connected to the ones you love. That’s why Health New England Medicare Advantage offers you a hearing aid benefit through TruHearing®_.

Your hearing aid benefit includes:

Personalized Care

Guidance and assistance from a TruHearing Hearing Consultant Professional exam from a local, licensed provider

Three follow-up visits for fitting and adjustments to ensure you’re completely satisfied with your hearing aids

Next-Generation Sound

Powerful hearing aids help you hear what matters most, wherever you are

Device sensors automatically adjust for a natural sound, even while you’re moving

Own Voice Processing (OVP®_{) recognizes your voice and makes it}

sound more natural

Devices for Your Lifestyle

Bluetooth connectivity for streaming your favorite music, TV and phone calls straight to your ears1

Rechargeable battery options that provide an all-day charge in 3-4 hours2

A smart app that acts as a hearing aid remote control, allows you to interface with your provider and even tracks your physical activity3

(844) 319-7458| TTY: 711

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Your 2021 Hearing Coverage

Your benefit covers up to two Advanced or Premium hearing aids per year with copayments starting at $699.

1_{Smartphone-compatible hearing aids connect directly to iPhone}®_{, iPad}®_{, and iPod}®_{Touch devices. Connectivity}

also available to many Android®_{phones with use of an accessory. TV streaming available through most TVs with}

use of an accessory.

2_{Rechargeable features may not be available in all models and styles.} 3_{In-app interfacing requires provider activation.}

4_{Must be performed by a TruHearing network provider.}

Health New England Medicare Advantage is an HMO and HMO-POS Plan with a Medicare contract. Enrollment in Health New England Medicare Advantage depends on contract renewal. Other providers are available in our network.

ATTENTION: If you speak any language other than English, language assistance services, free of charge, are available to you. Call (413) 787-0010 (TTY 711). Health New England cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (413) 787-0010 (TTY 711). Health New England cumpre as leis de direitos civis federais aplicáveis e não exerce discriminação com base na raça, cor, nacionalidade, idade, deficiência ou sexo. ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (413) 787-0010 (TTY 711).

other trademarks, product names, and company names are the property of their respective owners. Three follow-up visits must be used within one year after the date of initial purchase. Free battery offer is not applicable to the purchase of rechargeable hearing aid models. Three-year warranty includes repairs and one-time loss and damage replacement. Hearing aid repairs and replacements are subject to provider and manufacturer fees. For questions regarding fees, contact a TruHearing hearing consultant. HNE_AEP_F_0520

Your benefit also includes:

+Risk-free 45-day trial period +_{48 free batteries with}

non-rechargeable models

+Full 3-year manufacturer warranty (844) 319-7458 | TTY: 711

(844) 319-7458

| TTY: 711

Hours: 8:00 am to 8:00 pm, Mon–Fri

32 Channels | 6 Programs 48 Channels | 6 Programs

Your Plan: Retail: $2,445/aid Retail: $3,125/aid

Routine Exam In-Network4 Medicare Advantage Plans

$699

copay/aid

$999

copay/aid See your Evidence of Coverage

*Rechargeable battery option is available on select styles at no additional cost.

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Your 2021 Hearing Coverage

Your benefit covers up to two Advanced or Premium hearing aids per year with copayments starting at $699.

1_{Smartphone-compatible hearing aids connect directly to iPhone}®_{, iPad}®_{, and iPod}®_{Touch devices. Connectivity}

also available to many Android®_{phones with use of an accessory. TV streaming available through most TVs with}

use of an accessory.

2_{Rechargeable features may not be available in all models and styles.} 3_{In-app interfacing requires provider activation.}

4_{Must be performed by a TruHearing network provider.}

other trademarks, product names, and company names are the property of their respective owners. Three follow-up visits must be used within one year after the date of initial purchase. Free battery offer is not applicable to the purchase of rechargeable hearing aid models. Three-year warranty includes repairs and one-time loss and damage replacement. Hearing aid repairs and replacements are subject to provider and manufacturer fees. For questions regarding fees, contact a TruHearing hearing consultant. HNE_AEP_F_0520

H8578_2021_107_M Accepted TruHearing.com/Select

Your benefit also includes:

+Risk-free 45-day trial period +_{48 free batteries with}

non-rechargeable models

+Full 3-year manufacturer warranty (844) 319-7458 | TTY: 711

(844) 319-7458

| TTY: 711

Hours: 8:00 am to 8:00 pm, Mon–Fri

32 Channels | 6 Programs 48 Channels | 6 Programs

Your Plan: Retail: $2,445/aid Retail: $3,125/aid

Routine Exam In-Network4 Medicare Advantage Plans

$699

copay/aid

$999

copay/aid See your Evidence of Coverage

*Rechargeable battery option is available on select styles at no additional cost.

*

new image

Teladoc® gives you access 24 hours, 7 days a week to a U.S. board-certified doctor through the

convenience of phone, video or mobile app visits. It's an affordable option for quality medical care. GET THE CARE YOU NEED

Teladoc doctors can treat many medical conditions, including:

• Cold & flu symptoms • Allergies • Pink eye • Respiratory infection • Sinus problems • Skin problems • And more!

With your consent, Teladoc is happy to provide

information about your Teladoc visit to your primary care physician.

Teladoc.com/HNE Teladoc.com/mobile 1-800-Teladoc (835-2362)

©2002-2020 Teladoc, Inc. All rights reserved. Complete disclaimer at Teladoc.com/HNE. Apple and the Apple logo are trademarks of Apple Inc., registered in the U.S. and other countries. App Store is a service mark of Apple Inc. 136206706_041817 10E-103B

Health New England Medicare Advantage is an HMO and HMO-POS Plan with a Medicare contract. Enrollment in Health New England Medicare Advantage depends on contract renewal. This information is not a complete description of benefits. Call (413) 787-0010 (TTY: 711) for more information. Other providers are available in our network. Health New England complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. ATTENTION: If you speak any language other than English, language assistance services, free of charge, are available to you. Call (413) 787-0010 or TTY 711. Health New England cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (413) 787-0010 o TTY 711. Health New England cumpre as leis de direitos civis federais aplicáveis e não exerce discriminação com base na raça, cor, nacionalidade, idade, deficiência ou sexo. ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (413) 787-0010 ou TTY 711.

H8578_2020_105_M Accepted

So many reasons

to use Teladoc

Talk to a doctor anytime, anywhere you happen to be Receive quality care via phone, video

or mobile app

Prompt treatment median call back

is 10 min

4 5 6

A network of doctors that can treat every member of the family

Prescriptions sent to pharmacy of choice if medically neccessary

Teladoc is less expensive than the

ER or urgent care

1 2 3

Talk to a doctor anytime. Your copay is $0

(effective 1/1/2021).

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Vision benefits never

looked so good

W I T H YO U R H E A LT H N E W E N G L A N D

M E DIC A R E A DVA N TA G E V I S IO N B E N E F I T S, YO U... W E L C O M E T O YO U R

E Y E M E D V I S IO N B E N E F I T !

• Pay nothing for one routine eye exam with refraction per calendar year when performed by an in-network EyeMed provider.

• Get an allowance for prescription eyewear, including eyeglass lenses and/or frames and contact lenses when obtained at an in-network EyeMed provider.

• Have access to one of the nation’s largest networks of independent eye doctors and national retail and regional retail providers. • Receive care when it’s convenient for

you – with extended weeknight and weekend hours and online appointment scheduling.

$100

allowance at point of service every two years on prescription eyewear Plus...

40%

off additional pairs of glasses or prescription sunglasses¹

20%

off any remaining balance over the frame allowance²

To find an in-network EyeMed provider near you and to learn more, go to eyemed.com (select “Access” in the Choose Network drop-down menu) or call (866) 723-0596.

¹ Available at in-network EyeMed provider locations ² Not insured benefits. Discounts on non-covered services may not be available through all providers or in all stores. PDF-1909-R-768

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15

Better Health Begins with

the Meals We Eat

H

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Addvvaannttaaggee mmeemmbbeerrss ddiisscchhaarrggiinngg ffrroomm aann iinnppaattiieenntt hhoossppiittaall oorr sskkiilllleedd nnuurrssiinngg ffaacciilliittyy ((SSNNFF)) ssttaayy..

After discharge, if you qualify, you can receive

fully-prepared, nutritious meals. Meals are delivered to your home at no cost to you. This home delivered meal benefit must be requested within 30 days of discharge from an acute inpatient hospital or SNF.

Health-Specific Menus

Dietitian designed to support the nutritional needs of most common health conditions

Reliability

High quality, refrigerated meals arrive at your home when you need them the most

Simple

Meals last for 14 days in the fridge—just heat, eat and enjoy in 2 minutes or less

How it Works

If you qualify, Health New England's care management team will contact you to coordinate your request. We will help you choose the nutritional option that is best for your health condition, and we’ll submit your request to Mom’s Meals on your behalf.

You will receive a welcome call from Mom's Meals. Then, your meals will be delivered directly to your home.

1

2

3

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The Right Nutrition

Menus tailored to meet the needs of most major health conditions.

Heart-Friendly Renal-Friendly Diabetes-Friendly Gluten Free Vegetarian* Pureed Lower Sodium Cancer Support General Wellness

If you have questions about this service, contact Health New England's Care Management team at (800) 842-4464 or (413) 787-4000, ext. 3940. www.momsmeals.com

Sample Menu

FRUIT BREAKFAST PIZZA and Turkey Sausage HAM, EGG & CHEESE SCRAMBLE

and Peaches with Cherries

BEEF STEW and Corn Bread BBQ PULLED PORK SANDWICH

and Potato Salad

CHEESE LASAGNA and Spiced Fruit Crisp TURKEY BREAST WITH WILD RICE

and Spiced Fruit Medley

Your well-being is important to us. Meal by meal, bite by bite, we are with you to provide the nutrition you need.

B R E A K FA S T L U N C H D I N N E R

Health New England Medicare Advantage is an HMO and HMO-POS Plan with a Medicare contract. Enrollment in Health New England Medicare Advantage depends on contract renewal. You must use Mom's Meals to receive this service. Other providers are available in our network. Health New England complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. ATTENTION: If you speak any language other than English, language assistance services, free of charge, are available to you. Call (413) 787-0010 (TTY 711). Health New England cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (413) 787-0010 (TTY 711). Health New England cumpre as leis de direitos civis federais aplicáveis e não exerce discriminação com base na raça, cor, nacionali-dade, idade, deficiência ou sexo. ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (413) 787-0010 (TTY 711).

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FirstLine

™

Essentials

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H88557788__22002211__115599__MM AAcccceepptteedd SFpre-HNEESS-2021

Over-the-Counter Care at No Cost to You

FirstLine Essentials is an OTC benefit that gives you credits to spend on over-the-counter care. Shop toothpaste, pain relief, vitamins, cough drops and more. As a member, it’s all included with your Health New England Medicare Advantage plan.

How it Works

1. A credit of $40 is added to your account every three months. 2. Use your credits to buy over-the-counter products.

3. Credits expire every three months.

Choose from

250+

products

Questions?

Call us toll-free at (877) 443-3314, TTY 711, Monday – Friday, 8 a.m. – 8 p.m. (Oct. 1 – Mar. 31, 8 a.m. – 8 p.m., seven days a week).

Or visit healthnewengland.org/medicare/otc-2021

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If you are enrolled in one of our Medicare Advantage HMO and HMO-POS plans, you may go to any network provider without a referral from your primary care provider. Members enrolled in our Health New England Medicare Premium No Rx (HMO), Health New England Medicare Basic No Rx (HMO), Health New England Medicare Plus (HMO), Health New England Medicare Choice (HMO), Health New England Medicare Premium (HMO), and Health New England Medicare Value (HMO) plans must use Health New England network providers for all routine medical care.

If you are enrolled in the Health New England Medicare Select (HMO-POS) plan, you can choose to get routine medical care from network providers or use your Point of Service benefit to get care from non-network providers. You pay more when you use non-network providers for routine medical care. Out-of-network/non-contracted providers are under no obligation to treat Health New England Medicare Advantage members, except in emergency situations. Please call our Member Services number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services.

If you have questions about your Medicare plan or your enrollment, please call us to speak with a Health New England Member Services representative.

Local: (413) 787-0010 | TTY: 711 Toll-Free: (877) 443-3314 | TTY: 711

Hours: 8 a.m. — 8 p.m. / Mon. — Fri. (Oct. 1 — Mar. 31: 8 a.m. — 8 p.m., seven days a week)

For questions related to Prescription Drug coverage, please contact our Pharmacy Benefit Manager OptumRx at (800) 393-0395, 24 hours a day, 7 days a week. TTY users should call 711.

To be a member of our plan, you must live in our service area, be entitled to Medicare Part A and be enrolled in Medicare Part B, with limited exceptions. Our service area consists of Berkshire, Franklin, Hampden and Hampshire Counties in Massachusetts.

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We encourage you to take

advantage of your additional

benefits and allowances to help

manage your health. We have

included three copies of the

reimbursement request form

with submission instructions.

Additional Benefits

Reimbursement

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21

H8578_MED39170919_C Rev: 9/20

Additional Benefits Page 1

REQUEST FOR MEMBER REIMBURSEMENT FORM

Date: Member Name: Health New England ID Number:

(Shown on the front of your ID Card)

Member Address:

ADDITIONAL BENEFITS

Fitness Center/Weight Watchers®_/

Acupuncture/Dental, Activity Tracker and Wig Allowances

One Monarch Place, Suite 1500 Springfield, MA 01144-1500

(413) 787-0010 | (877) 443-3314 | TTY: 711 healthnewengland.org/medicare

Reimbursement is for (check each reimbursment you are requesting below):

q Fitness Center

q Weight Watchers

®

q

Acupuncture

q Activity Tracker

(Above limited to $150 per calendar year combined)

Service/Purchase Date(s): Service/Purchase Location(s):

Fitness Center/Weight Watchers location, etc. Amount Requested: $

q

Dental Services (limited to $250 per calendar year)

Service/Purchase Date(s): _{Amount Requested:}

$ Provider Name/Dental Practice:

q Wig

*_{—if on or recently}

undergone chemotherapy

(limited to $350 per calendar year)

Service/Purchase Date(s): Amount Requested:

$

*_{Please include Original Itemized Receipt and written statement from your doctor stating you} are on or had chemotherapy. Also, include Proof of Payment in one of the following formats: canceled check (front and back), bank encoded front of check, credit card statement, or a credit card or cash register receipt.

I certify that this information is true and accurate and that services were received and paid for in the amount requested and that I have not previously submitted for these services. I acknowledge that if any information on this form is misleading or fraudulent, my coverage may be canceled and I may be subject to criminal and/or civil penalties for false health care claims. I also understand that Health New England may request any additional information it deems necessary to verify that services were received and payment was made.

Member Signature: _____________________________________________________ Date: ________________

Signature required for payment

Please see additional submission information on the back of this form.

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H8578_MED39170919_C Additional Benefits Page 2

Additional Submission Information:

Health New England will reimburse you directly for the services that qualify under each allowance. Health New England will not send payment to the service provider. You should keep a copy of your completed form and any receipts submitted. Please allow 4 to 6 weeks for processing. NOTE: Reimbursement requests for a prior year must be received by Health New England no later than March 31.

Once you have completed this form and attached all itemized paid receipts and documentation (where applicable), please mail the form and attachments to the below address for processing. Health New England Medicare Advantage

Attn: Claims Department

If you have any questions about the Additional Benefits Reimbursement Form or your additional benefits, please call Health New England Medicare Advantage Member Services at:

(413) 787-0010 or toll-free (877) 443-3314, TTY: 711.

A representative is available 8:00 a.m. – 8:00 p.m., Monday through Friday (October 1 – March 31: 8:00 a.m. – 8:00 p.m., seven days a week).

ADDITIONAL BENEFITS

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23

H8578_MED39170919_C Rev: 9/20

Member Address:

ADDITIONAL BENEFITS

q Fitness Center

q Weight Watchers

®

q

Acupuncture

q Activity Tracker

q

q Wig

$

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Additional Submission Information:

(413) 787-0010 or toll-free (877) 443-3314, TTY: 711.

ADDITIONAL BENEFITS

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25

H8578_MED39170919_C Rev: 9/20

Member Address:

ADDITIONAL BENEFITS

q Fitness Center

q Weight Watchers

®

q

Acupuncture

q Activity Tracker

q

q Wig

$

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Additional Submission Information:

(413) 787-0010 or toll-free (877) 443-3314, TTY: 711.

ADDITIONAL BENEFITS

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27

One Monarch Place, Suite 1500, Springfield, MA 01144-1500 (413) 787-4000 | (800) 842-4464 | healthnewengland.org

Notice Informing Individuals of Nondiscrimination and Accessibility

Health New England complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health New England does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

Health New England:

 Provides free aids and services to people with disabilities to communicate effectively with us, such as:

o Qualified sign language interpreters

o Written information in other formats (large print, audio, accessible electronic formats, other formats)  Provides free language services to people whose primary language is not English, such as:

o Qualified interpreters

o Information written in other languages

If you need these services, contact Susan O’Connor, Vice President and General Counsel.

If you believe that Health New England has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Susan O’Connor, Vice President and General Counsel, One Monarch Place, Suite 1500, Springfield, MA 01104-1500, Phone: (888) 270-0189, TTY: 711, Fax: (413) 233-2685 or [email protected]. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Susan O’Connor, Vice President and General Counsel, is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human

Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington, DC 20201, (800) 368-1019, (800) 537-7697 (TDD). Complaint forms are available athttp://www.hhs.gov/ocr/office/file/index.html. Multi-Language Services

We’re here to help you. We can give you information in other formats and different languages. All translation services are free to members. If you have questions regarding this document, please call the toll-free member phone number listed on your health plan ID card, (TTY:711), Monday through Friday, 8:00 a.m. - 6:00 p.m. BeHealthy Partnership members, this information is about your BeHealthy Partnership benefits. If you have questions, need this document translated, need someone to read this or other printed information to you, or want to learn more about any of our benefits or services, call the toll-free member phone number listed on your health plan ID card, (TTY: 711), Monday through Friday, 8:00 a.m. – 6:00 p.m. For questions about your Behavioral Health, call MBHP at: (800) 495-0086 (TTY: (617) 790-4130) 24 hours a day, 7 days a week, or visit

www.masspartnership.com.

Medicare Advantage members, Health New England Medicare Advantage is an HMO and HMO-POS Plan with a Medicare contract. Enrollment in Health New England Medicare Advantage depends on contract renewal. If you have any questions regarding this document, please contact the toll-free member phone number listed on your health plan ID card, (TTY: 711).

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English You have the right to get help and information in your language at no cost. To request an interpreter, call the toll-free member phone number listed on your health plan ID card, press 0. (TTY: 711)

Spanish Tiene derecho a recibir ayuda e información en su idioma sin costo. Para solicitar un intérprete, llame al número de teléfono gratuito para miembros que se encuentra en su tarjeta de identificación del plan de salud y presione 0. (TTY: 711)

Portuguese Você tem o direito de obter ajuda e informação em seu idioma e sem custos. Para solicitar um intérprete, ligue para o número de telefone gratuito que consta no cartão de ID do seu plano de saúde, pressione 0. (TTY: 711)

Chinese 您有權免費以您使用的語言獲得幫助和訊息。如需口譯員，請撥打您的保健計劃ID卡上列

出的免費會員電話號碼，按0。(TTY: 711)

French

Creole Ou gen dwa pou jwenn èd ak enfòmasyon nan lang natifnatal ou gratis. Pou mande yon entèprèt, rele nimewo gratis manm lan ki endike sou kat ID plan sante ou, peze 0. (TTY: 711) Vietnamese Quý vịcó quyền được giúp đỡvà cấp thông tin bằng ngôn ngữcủa quý vịmiễn phí. Đểyêu cầu được thông

dịch viên giúp đỡ, vui lòng gọi số điện thoại miễn phídành cho hội viên được nêu trên thẻ ID chương trình bảo hiểm y tếcủa quývị, bấm số0. (TTY: 711).

Russian Вы имеете право на бесплатное получение помощи и информации на вашем языке. Чтобы подать запрос переводчика позвоните по бесплатному номеру телефона, указанному на обратной стороне вашей идентификационной карты и нажмите 0. Линия (телетайп: 711) Arabic فيرعتةقاطبىلعيناجملاوضعلافتاهمقربلصتا،مجرتمبلطل.اًناجمكتغلبتامولعملاوةدعاسملاىلعلوصحلاكلقحي كتطخ ،ةيحصلا مث طغضا ىلع 0 . ( TTY:711 ) Mon-Khmer, Cambodian អ្នកមានសិទ្ធិទ្ទ្ួួលជំនួយនិងព័ត៌មានជាភាសារបស់អ្នកដោយមិនអ្ស់ថ្លៃ។ដ ដួើមបីដសដនើស ួំអ្នកបកប្បបសូមទ្្ួូរស័ពទ្ដៅដលខឥតដដញថ្លៃសំរាប់សមាជិកប្លមានកត់ដៅកនុងប័ណ្ណ ID គំដរាងសខភាពរបស់អ្នករ ួដួដ ដួើដយ ដួ0។(TTY: 711)

French Vous avez le droit d'obtenir gratuitement de l'aide et des renseignements dans votre langue. Pour demander à parler à un interprète, appelez le numéro de téléphone sans frais figurant sur votre carte d’affilié du régime de soins de santé et appuyez sur la touche 0. (ATS: 711).

Italian Hai il diritto di ottenere aiuto e informazioni nella tua lingua gratuitamente. Per richiedere un interprete, chiama il numero telefonico verde indicato sulla tua tessera identificativa del piano sanitario e premi lo 0. Dispositivi per non udenti (TTY: 711).

Korean 귀하는 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다.통역사를 요청하기 위해서는 귀하의 플랜_ID카드에 기재된 무료 회원 전화번호로 전화하여₀번을 누르십시오. TTY 711 Greek Έχετε το δικαίωμα να λάβετε βοήθεια και πληροφορίες στη γλώσσα σας χωρίς χρέωση. Για να ζητήσετε διερμηνέα, καλέστε το δωρεάν αριθμό τηλεφώνου που βρίσκεται στην κάρτα μέλους ασφάλισης, πατήστε 0. (TTY: 711).

Polish Masz prawo do uzyskania bezpłatnej informacji i pomocy we własnym języku. Po usługi tłumacza zadzwoń pod bezpłatny numer umieszczony na karcie identyfikacyjnej planu medycznego i wciśnij 0.(TTY: 711). Hindi Gujarati _{તમારી}_{ભાષામાાં}_વિના_{મૂલ્યે}_મદદ_અને_{માહિતી}_{મેળિિાનો}_તમને_{અવિકાર}_છે_._{દુભાવષયાની}_{વિનાંતી}_કરિા માટેતમારાિેલ્થપ્લાનIDકાર્ડ પરજણાિેલાટૉલ-ફ્રીનાંબરપરકૉલકરોઅને 0 દબાિો.(TTY: 711). Lao _{ທ່ານມ}_{ີ ສ}_{ິ ດທ}_{ີ່ ຈະໄດ້ຮັບການຊ່ວຍເຫ}_{ຼ ຼ}_{ອແລະຂ}_{້ ມູນຂ່າວສານທ}_ຼ _{ີ່ ເປັນພາສາຂອງທ່ານບ} ຼ ່ ມີ ຄ່າໃຊ້ຈ່າຍ.ເພ ່ ອຂ ຮ້ອງນາຍພາສາ,ໂທຟຣີ ຫາຫມາຍເລກໂທລະສັບສ າລັບສະມາຊິກທີ່ ໄດ້ລະບຸໄວ້ໃນບັດສະມາຊິ ກຂອງທ່ານ,ກົດເລກ0. (TTY: 711).

Albanian Ju keni të drejtë të merrni ndihmë dhe informacion falas në gjuhën tuaj. Për të kërkuar një përkthyes, telefononi në numrin që gjendet në kartën e planit tuaj shëndetësor, shtypni 0. (TTY: 711).

Tagalog May karapatan kang makatanggap ng tulong at impormasyon sa iyong wika nang walang bayad. Upang humiling ng tagasalin, tawagan ang toll-free na numero ng telepono na nakalagay sa iyong ID card ng planong pangkalusugan, pindutin ang 0. (TTY: 711).

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29

Notes

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31

Notes

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At Health New England, our mission is to improve the health and lives of the people in our communities, and we are deeply committed to the individuals we serve every day. Based in Springfield, Massachusetts, we have been meeting

the health care needs of our members for more than 30 years.

Medicare Advantage Benefits, Allowances and Programs

Our knowledgeable and friendly Member Services representatives

In addition to providing coverage if

stay healthy, seek care, manage

Hearing Aids

Physical Exam and Well-Care Visit

Over-the-Counter (OTC) Care

Allowances Chart

It’s important to

and can help you

Options for Seeking Care

Support for Managing Complex Conditions

Home Services

Help Managing Medications

Access our secure online Member Portal at

Think you might

Your hearing aid benefit includes:

What’s in it for me?

Healthy Directions Web Portal

Comprehensive Health Assessment

Get Back the Joy of Hearing

Your 2021 Hearing Coverage

Your 2021 Hearing Coverage

new image

Teladoc® gives you access 24 hours, 7 days a week to a U.S. board-certified doctor through the

So many reasons

Talk to a doctor anytime. Your copay is $0

M E DIC A R E A DVA N TA G E V I S IO N B E N E F I T S, YO U... W E L C O M E T O YO U R

Better Health Begins with

How it Works

The Right Nutrition

FirstLine

Over-the-Counter Care at No Cost to You

Choose from

We encourage you to take

ADDITIONAL BENEFITS

Additional Submission Information:

ADDITIONAL BENEFITS

q Fitness Center

Additional Submission Information:

ADDITIONAL BENEFITS

q Fitness Center

Additional Submission Information:

ADDITIONAL BENEFITS

Notice Informing Individuals of Nondiscrimination and Accessibility

出的免費會員電話號碼，按0。(TTY: 711)

Notes

Where you matter.