SB PLATINO BLINDAO copy - Triple-S Advantage · 2019-10-14 · PLATINO BLINDAO (HMO-SNP)GETTING...

ADVANTAGE

SUMMARY OF BENEFITSPLATINO BLINDAO (HMO-SNP)

2020

PLATINO BLINDAO (HMO-SNP)

ABOUT THIS PLAN

Platino Blindao (HMO-SNP) is a Medicare Advantage HMO plan with a Medicare contract. Enrollment in the Plan depends on contract renewal.

Triple-S Advantage, Inc. is a health maintenance organization (HMO) with a Medicare contract, and a contract with the Puerto Rico Government Health Plan (GHP). Enrollment in Triple-S Advantage, Inc. depends on contract renewal. Triple-S Advantage, Inc. is an independent licensee of the BlueCross BlueShield Association.

This plan is available to anyone who has both Medical Assistance from the State and Medicare.

Co-pays and co-insurances may vary based on the level of Extra Help you receive. Please contact the plan for further details.

To join Platino Blindao (HMO-SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B, be a U.S. citizen or lawfully present in the United States, not have End Stage Renal Disease (ESRD), be Medicaid-eligible and live in our service area. Our service area includes the following counties in Puerto Rico: Adjuntas, Aguada, Aguadilla, Aguas Buenas, Aibonito, Añasco, Arecibo, Arroyo, Barceloneta, Barranquitas, Bayamón, Cabo Rojo, Caguas, Camuy, Canóvanas, Carolina, Cataño, Cayey, Ceiba, Ciales, Cidra, Coamo, Comerío, Corozal, Culebra, Dorado, Fajardo, Florida, Guánica, Guayama, Guayanilla, Guaynabo, Gurabo, Hatillo, Hormigueros, Humacao, Isabela, Jayuya, Juana Díaz, Juncos, Lajas, Lares, Las Marías, Las Piedras, Loíza, Luquillo, Manatí, Maricao, Maunabo, Mayagüez, Moca, Morovis, Naguabo, Naranjito, Orocovis, Patillas, Peñuelas, Ponce, Quebradillas, Rincón, Río Grande, Sabana Grande, Salinas, San Germán, San Juan, San Lorenzo, San Sebastián, Santa Isabel, Toa Alta, Toa Baja, Trujillo Alto, Utuado, Vega Alta, Vega Baja, Vieques, Villalba, Yabucoa, and Yauco.

Benefits, premium, and/or copayments/coinsurance may change on January 1 of each year.

H5774_109920E033_M CMS Accepted


GETTING CARE

Platino Blindao (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 may receive all plan covered services, but you will need to pay higher cost sharing that the one you pay when using in network providers. You can go to www.sssadvantage.com to see your plan’s provider and pharmacy directories. You can also view the complete plan formulary (list of Part D prescription drugs) to see what drugs are covered and if there are any restriction. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

IF YOU HAVE QUESTIONS

For more information, please call Member Service at the phone number below or visit us at www.sssadvantage.com. If you are a member of this plan, call toll-free 1-888-620-1919 (TTY/TDD 1-866-620-2520). If you are not a member of this plan, call toll-free 1-877-207-8777 (TTY/TDD 1-866-620-2520). You can call us Monday through Sunday from 8:00 a.m. to 8:00 p.m. Atlantic standard time. 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.

http://www.sssadvantage.com/


http://www.medicare.gov/


NOTICE OF NON-DISCRIMINATION

This document is available for free in Spanish. This document is also available in alternate formats such as Braille, large print and audio. Please contact Members Services if you need plan information on other format or language.

COVERED BENEFITS, PREMIUMS AND LIMITATIONS

The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of covered services, please request the Evidence of Coverage calling our Member Services department or visiting our website www.sssadvantage.com.

Premiums and Benefits Platino Blindao (HMO-SNP) What you should know

Monthly Plan Premium $0 monthly premium. You must continue to pay your Medicare Part B premium.

Medicare Part B monthly reduction

$80 per month.

This means that your Part B Premium will be less while you are a member of Platino Blindao.

Deductible You pay nothing. This plan does not have a deductible.

Maximum Out-of-Pocket Responsibility (does not include prescription drugs)

$3,400 annually. This is the most you will pay for copays, coinsurance and other costs for in-network medical services for the year.




Inpatient Hospital Coverage

You pay nothing.

This plan covers an unlimited number of days for an inpatient hospital stay.

Outpatient Hospital Coverage

You pay nothing. Some services may require prior authorization.

Doctor Visits

o Primary

o Specialists

o Surgeries and/or procedures in a physician’s office

o You pay nothing.

o You pay nothing.

o You pay nothing.

Referral is required for specialist visits and all services provided out of the Preferred Provider Network. Referral is not required for the condition ASES classifies as special coverage, once the diagnosis has been established for: HIV/AIDS, Tuberculosis, Leprosy, Systemic Lupus Erythematosus (SLE), Cystic Fibrosis, Cancer, Hemophilia, ESRD (Levels 3, 4 and 5), Multiple Sclerosis, Scleroderma, Pulmonary Hypertension, Aplastic Anemia, Rheumatoid Arthritis, Autism, Skin cancer, Skin cancer: carcinoma IN SITU, Skin cancer: Invasive Melanoma or squamous cells with evidence of metastasis, Phenylketonuria, adults with Hepatitis C as emergency/urgency treatments in post transplanted patients. When a member is referred to a specialist by a PCP and the specialist prescribes a medication, no countersignature of the



prescription will be required from the PCP. Referral is not required for visits and all services provided related to pathological laboratories. The following specialties do not require referral for the initial visit and services in the initial visit, in the Provider Network: Cardiologist, Gastroenterologist, Endocrinologist, Ophthalmologist, Pneumologist, and Rheumatologist. Referral is not required for certain specialist including visits and all services provided by the specialist, such as Nephrologist, Urologist and Gynecologist. For other specialties, referral is not required in the Preferred Provider Network. Surgery and procedures in a physician’s office may require prior authorization.

Preventive Care You pay nothing.

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



Emergency Care You pay nothing. If you are admitted to the hospital within 24 hours for the same condition for which you were evaluated in the emergency room, you pay nothing for the emergency room visit. Services in the United States may also be managed through reimbursement according to Medicare rates and the location where the services were provided.

Urgently Needed Services

You pay nothing. Services in the United States may also be managed through reimbursement according to Medicare rates and the location where the services were provided.



Diagnostic Services/Labs/ Imaging

o Diagnostic radiology service (e.g., MRI)

o Lab services

o Diagnostic tests and procedures

o Outpatient x-rays

o Therapeutic Radiology services

o You pay nothing.

o You pay nothing.

o You pay nothing.

o You pay nothing.

o You pay nothing.

Some services may require prior authorization.

Hearing Services

o Hearing exam

o Routine hearing exam

o Hearing aid fitting

/evaluation

o Hearing aid

o You pay nothing.

o You pay nothing.

o You pay nothing.

o You pay nothing.

One (1) routine hearing exam every year. One (1) hearing fitting/evaluation every year. Up to $1,500 every year for Hearing Aids.



Dental Services

o Preventive: Oral exam, Cleaning, Fluoride and x-rays

o Comprehensive:

Endodontics, Prosthodontics, Oral/Maxillofacial surgery, Restorative services, Periodontics and other general services.

o You pay nothing.

o You pay nothing.

• One (1) Cleaning; every six months

• Dental x-ray(s) • One (1) Fluoride

treatment every six months

• One (1) Oral exam every six months

Up to $1,500 plan coverage limit for supplemental comprehensive dental benefits every year A maximum benefit limit applies for some services. Comprehensive Dental Services may require preauthorization. Ask your Dentist if the service you need requires prior authorization before rendering it.

Vision Services o Eye exam o Routine eye exam o One pair of eyeglasses

or contact lenses after each cataract surgery

o Contact lenses, Eyeglasses (frame & lenses), Eyeglasses Frame, Eyeglasses Lenses

o You pay nothing. o You pay nothing. o You pay nothing.

o You pay nothing.

$500 for prescription eyeglasses (frame and lenses) or contact lenses every year. You are responsible for the balance that exceeds the amount of the benefit stipulated in your coverage.



Mental Health Services

o Inpatient o Outpatient individual

therapy visit o Outpatient group

therapy visit o Partial

Hospitalization

o You pay nothing. o You pay nothing.

o You pay nothing.

o You pay nothing.

Our plan covers unlimited days for an inpatient hospital stay. Some Partial Hospitalization services may require prior authorization.

Skilled Nursing Facility (SNF)

You pay nothing.

Up to 100 days in a SNF per benefit period. A 3-day prior hospital stay is required. Requires prior authorization.

Physical therapy You pay nothing.

Services in a Comprehensive Outpatient Rehabilitation Facility (CORF) requires prior authorization.

Ambulance You pay nothing.

Copay applies for one (1) way trip. Non-emergency transportation requires prior authorization.

Transportation

You pay nothing. We cover twenty (20) one-way trips per year for medical appointments in any medical facility and picking up prescriptions in pharmacies. Method of transportation includes but is not limited to taxi, bus, van or other available methods of transportation, such as an automobile through a contracted provider.



Some services may require prior authorization by exception after exhausting coverage limit.

Medicare Part B Drugs You pay nothing.

Some services may require prior authorization. Step Therapy may apply from: Part B to Part B, Part B to Part D, Part D to Part B.

Other Rehabilitation Services

o Occupational therapy visit

o Speech and language therapy visit

o Pulmonary rehabilitation services

o Cardiac rehabilitation services

o You pay nothing.

o You pay nothing.

o You pay nothing.

o You pay nothing.

Services in a Comprehensive Outpatient Rehabilitation Facility (CORF), cardiac and pulmonary rehabilitation services require prior authorization.

Foot Care (podiatry services)

o Foot exams and treatment

o Routine foot care

o You pay nothing.

o You pay nothing.

Up to four (4) routine footcare visits every year, including the initial visit. Referral required for Medicare-covered visits.



Medical Equipment/Supplies

o Durable Medical Equipment (e.g., wheelchairs, oxygen)

o Prosthetics (e.g., braces, artificial limbs)

o Medical supplies

o Diabetes supplies

o Non-preferred brands and manufacturers: 10% coinsurance. Preferred brands and manufacturers: You pay nothing.

o Orthotic and non-surgically implanted prosthetic devices: You pay nothing. Surgically implanted prosthetic devices, urinary system & neurostimulator: 10% coinsurance.

o Non-preferred

brands and manufacturers: 10% coinsurance. Preferred brands and manufacturers: You pay nothing.

o You pay nothing.

Some durable Medical Equipment, Prosthetics and Medical supplies may require prior authorization.



Wellness Programs

o Wellness program

o Teleconsulta

o Teleconsejo

o You pay nothing.

o You pay nothing.

o You pay nothing.

Wellness program; this program provides health education material, group interventions and telephone-based education on nutrition and weight management based on your health profile. Teleconsulta nurse line for health consultations, available 24 hours, 7 days a week. Teleconsejo emotional support line available 24 hours, 7 days a week.

Outpatient Surgery

o Ambulatory Surgical Center

o Ambulatory Hospital Facility

o You pay nothing.

o You pay nothing.

Some services may require prior authorization.

Chiropractic

o Medicare-covered visits to correct subluxation

o Routine visits

o You pay nothing.

o You pay nothing.

Manipulation of the spine to correct a subluxation (When one or more of the bones of your spine move out of position). Referral is required for Medicare covered services (manipulations). Up to five (5) routine chiropractic visits every year, including the initial visit.


Outpatient Prescription Drugs

For more information on the additional pharmacy- specific cost-sharing and the phases of the benefit, please call us or access our Evidence of Coverage online.

Rx Preferred Retail 30-day supply

Rx Preferred Retail 90-day supply

Rx Mail Order Supply

Phase 1: Initial Coverage Tier 1: Preferred

Generic You pay nothing. You pay nothing. You pay nothing.

Tier 2: Generic You pay nothing. You pay nothing. You pay nothing.

Tier 3: Preferred Brand You pay nothing. You pay nothing. You pay

nothing. Tier 4: Non-

Preferred Brand You pay nothing. You pay nothing. You pay nothing.

Tier 5: Specialty Drugs You pay nothing. You pay nothing. You pay

nothing. Tier 6: Select Care Drugs You pay nothing. You pay nothing. You pay

nothing.


Outpatient Prescription Drugs

For more information on the additional pharmacy- specific cost-sharing and the phases of the benefit, please call us or access our Evidence of Coverage online.

Rx Standard Retail 30-day supply

Rx Standard Retail 90-day supply

Phase 1: Initial Coverage Tier 1: Preferred

Generic You pay nothing. You pay nothing.

Tier 2: Generic You pay nothing. You pay nothing.

Tier 3: Preferred Brand You pay nothing. You pay nothing.

Tier 4: Non-Preferred Brand You pay nothing. You pay nothing.

Tier 5: Specialty Drugs You pay nothing. You pay nothing.

Tier 6: Select Care Drugs You pay nothing. You pay nothing.

Supplemental Benefits

Premiums and Benefits Platino Blindao (HMO-SNP)

What you should know

Worldwide emergency/urgently needed care

You pay nothing. We cover emergency/urgent care visits outside the United States and its territories as a supplemental benefit. Services are covered through reimbursement in accordance to Triple-S Advantage, Inc. rates. Maximum coverage limits up to $75.00 for incurred costs for emergency/urgent care services.


Supplemental Benefits Premiums and Benefits Platino Blindao

(HMO-SNP) What you should know

Alternative Medicine/Acupuncture

o Alternative Medicine

o Acupuncture

o You pay nothing.

o You pay nothing.

Up to twelve (12) combined visits every year.

Nutritional/Dietary Benefit

You pay nothing.

A maximum of 4 individual visits per year to a nutritionist.

Over-the-Counter drugs You pay nothing. $40 every three (3) months.

Some covered categories are: Non-narcotic analgesics, anorectal agents, antidiarrheal, antiemetic, artificial tears and eye lubricants, allergy, cough and cold medications, dermatological agents, laxatives, minerals & electrolytes, multivitamins, nasal agent, nutrients (Omega 3 or fish oil), otic agents, smoking deterrents, urinary analgesics, vaginal products, vitamins, adult diapers and pads and blood pressure monitor. The Blood Pressure Monitor is covered up to one (1) every 5 years.


Additional Benefits Covered by the Medicaid Office of the Puerto Rico Health Department (Puerto Rico’s Medicaid Program) under Medicare Platino

Being eligible for the Health Program of the Government of Puerto Rico and Medicaid Office of the Puerto Rico Health Department (Puerto Rico’s Medicaid Program), you will receive the following services as part of your Plan, which otherwise you would have to pay. You pay the following copay for the services below.

Benefit

Category

Medicaid

Platino Blindao (HMO-SNP)

Inpatient Hospital Services

Coverage begins on first day of Medicare, and Platino Wrap around apply on any non-covered benefit under the MAO supplementary benefit coverage, and included as covered services on Medicaid state plan. Access to a semi-private room (bed available twenty-four (24) hours a day, every Calendar Day of the year. Coverage Code 100: $0.00 Coverage Code 110: $4.00 Coverage Code 120: $5.00 Coverage Code 130: $8.00

In Network Members with Coverage Codes 100, 110, 120 and 130 applies the following: No limit to the number of days covered by the plan each hospital stay. $0 annual service category deductible. $0 copay per admission Wrap hospitalization coverage begins on first day on Medicare non-coverage, without limitation.

Inpatient Hospital for Mental Diseases

Coverage begins on first day of Medicare, and Platino Wrap around apply on any non-covered benefit under the MAO supplementary benefit coverage, and included as covered services on Medicaid state plan. Access to a

In Network Members with Coverage Codes 100, 110, 120 and 130 applies the following: No limit to the number of days covered by the plan each hospital stay. $0 annual service category deductible. $0 copay per admission




Benefit

Category

Medicaid


semi-private room (bed available twenty-four (24) hours a day, every Calendar Day of the year. Coverage Code 100: $0.00 Coverage Code 110: $4.00 Coverage Code 120: $5.00 Coverage Code 130: $8.00

Wrap mental health hospitalization coverage begins on first day on Medicare non-coverage, without limitation.

Inpatient Substance Use Disorder

Coverage begins on first day of Medicare, and Platino Wrap around apply on any non-covered benefit under the MAO supplementary benefit coverage, and included as covered services on Medicaid state plan. Access to a semi-private room (bed available twenty-four (24) hours a day, every Calendar Day of the year. Coverage Code 100: $0.00 Coverage Code 110: $4.00 Coverage Code 120:

In Network Members with Coverage Codes 100, 110, 120 and 130 applies the following: No limit to the number of days covered by the plan each hospital stay. $0 copay per admission




Benefit

Category

Medicaid


$5.00 Coverage Code 130: $8.00

Outpatient Substance Use Disorder

Coverage begins on first day of Medicare, and Platino Wrap around apply on any non-covered benefit under the MAO supplementary benefit coverage, included as covered services on Medicaid state plan. Access to a semi-private room (bed available twenty-four (24) hours a day, every Calendar Day of the year. Coverage Code 100: $0.00 Coverage Code 110: $1.00 Coverage Code 120: $1.50 Coverage Code 130: $2.00

In Network Members with Coverage Codes 100, 110, 120 and 130 applies the following: Emergency and crisis intervention services twenty-four (24) hours a day, seven (7) days a week. Each Medicare-covered individual and group therapy visit related to Substance Use Disorder: $0 copay per session

Outpatient Mental Health Care and Professional Services

All mental health related OPD services and twenty-four (24) hours a day, seven (7) days a week emergency and crisis intervention non-covered by Medicare

In Network Members with Coverage Codes 100, 110, 120 and 130 applies the following: Emergency and crisis intervention services twenty-four (24) hours a day, seven (7) days a week. $0 copay per session




Benefit

Category

Medicaid


or the MAO supplementary benefits but included in the State Plan. Coverage Code 100: $0.00 Coverage Code 110: $1.00 Coverage Code 120: $1.50 Coverage Code 130: $2.00

Laboratory and High-Tech Laboratories

Laboratory testing and necessary procedures related to generating a Health Certificate not-covered by Medicare or the MAO supplementary benefits but included in the State Plan. Coverage Code 100: $0.00 Coverage Code 110: .50¢ Coverage Code 120: $1.00 Coverage Code 130: $1.50

In Network Members with Coverage Codes 100, 110, 120 and 130 applies the following: You pay $0 copay for each diagnostic procedure, X-rays, tests and lab services. You pay $0 copay for each Therapeutic Radiology and Diagnostic Radiological services. Some services may require prior authorization.




Benefit

Category

Medicaid


EPSDT under 21 years

EPSDT requirements non-covered by Medicare and/or the MAO supplementary benefits but included in the State Plan. EPSDT Checkups must include all of the following: A comprehensive health and developmental history; Developmental assessment, including mental, emotional, and Behavioral Health development; Measurements (including head circumference for infants); An assessment of nutritional status; A comprehensive unclothed physical exam; Immunizations according to the guidance issued by the Advisory Committee on Immunization Practices (ACIP) (the vaccines themselves are provided and paid for by the Health Department for the

In Network Members with Coverage Codes 100, 110, 120 and 130 applies the following: $0 copay




Benefit

Category

Medicaid


Medicaid and CHIP Eligible. Certain laboratory tests; Anticipatory guidance and health education; Vision screening; Tuberculosis; Hearing screening; and Dental and oral health assessment. (Reference must be made to the corresponding CMS EPSDT guidelines and ASES policy). Coverage Code 100: $0.00 Coverage Code 110: $0.00 Coverage Code 120: $0.00 Coverage Code 130: $0.00

Family Planning

Family Planning services not-covered by Medicare and/or the MAO supplementary benefits but included in the State Plan. Puerto Rico’s Medicaid benefits provide reproductive health and family planning counseling.





Benefit

Category

Medicaid


Such services shall be provided voluntarily and confidentially, including circumstances where the beneficiary is under age eighteen (18). Family planning services will include, at a minimum, the following: education and counseling; pregnancy testing; infertility assessment; sterilization services in accordance with 42 CFR 441.200 subpart F; laboratory services; cost and insertion/removal of non-oral products, such as long acting reversible contraceptives (LARC); at least one of every class and category of FDA-approved contraceptive; at least one of every class and category of FDA-approved contraceptive method; and other FDA approved contraceptive medications or




Benefit

Category

Medicaid


methods when it is Medically Necessary and approved through a Prior Authorization or through an exception process and the prescribing Provider can demonstrate at least one of the following situations: • Contra-indication with drugs that the enrollee is already taking, and no other methods covered/available that can be used by the enrollee. • History of adverse reaction by the enrollee to the contraceptive methods covered. • History of adverse reaction by the enrollee to the contraceptive medications that are covered. Coverage Code 100: $0.00 Coverage Code 110: $0.00 Coverage Code 120: $0.00




Benefit

Category

Medicaid


Coverage Code 130: $0.00

Tobacco Cessation

Tobacco cessation services not-covered by Medicare and/or the MAO supplementary benefits but included in the State Plan. Coverage Code 100: $0.00 Coverage Code 110: $0.00 Coverage Code 120: $0.00 Coverage Code 130: $0.00


Maternity Services

Maternity services not-covered by Medicare and/or the MAO supplementary benefits but included in the State Plan. Abortions when the pregnancy is a result of rape or incest as certified by a physician. Coverage Code 100: $0.00 Coverage Code 110: $0.00





Benefit

Category

Medicaid


Coverage Code 120: $0.00 Coverage Code 130: $0.00

Medical and Surgical

Medical and Surgical services not-covered by Medicare and/or the MAO supplementary benefits but included in the State Plan. Voluntary sterilization of men and women of legal age and sound mind, provided that they have been previously informed about the medical procedure’s implications, and that there is evidence of Enrollee’s written consent by completing the Sterilization Consent Form included as Appendix (O) (18) of the Contract. Coverage Code 100: $0.00 Coverage Code 110: $1.00 Coverage Code 120: $1.50 Coverage Code 130: $2.00

In Network Members with Coverage Codes 100, 110, 120 and 130 applies the following: Voluntary sterilization to men and women of appropriate age previously oriented about medical procedure implications. The physician must evidence patient’s written consent. Ambulatory surgical center visit: $0 copay Outpatient hospital facility visit: $0 copay Some services may require prior authorization.




Benefit

Category

Medicaid


Vision Services

Vision services not-covered by Medicare and/or the MAO supplementary benefits but included in the State Plan. Eyeglasses or lenses for beneficiaries between the ages of 0-20 years when medically necessary will be covered, the benefit of eyeglasses and lens consists of a single or multifocal lens and a standard frame eyeglasses every 24 months. All types of lens must be pre-authorized except intraocular lenses. Repair or replacement of eyeglasses within 24 months when this is medically necessary and approved by the pre-authorization will be covered. Coverage Code 100: $0.00 Coverage Code 110: $1.00 Coverage Code 120: $1.50 Coverage Code 130: $2.00

In Network Members with Coverage Codes 100, 110, 120 and 130 applies the following: $0 copay per Medicare-covered eye exam. Diagnosis and treatment for diseases and conditions of the eye, including an annual glaucoma screening for people at risk. (1) One routine eye exam per year $0 copay for routine vision exam $0 copay for eyewear and contact lenses. Up to $500 per year for prescription




Benefit

Category

Medicaid


Dental Services

Dental services not-covered by Medicare and/or the MAO supplementary benefits but included in the State Plan. The following are the benefits included in the GHP; • All preventative and corrective services for children under age twenty-one (21) mandated by the EPSDT requirement • Pediatric Pulp Therapy (Pulpotomy) for children under age twenty-one (21); • Stainless steel crowns for use in primary teeth following a Pediatric Pulpotomy; • Preventive dental services for Adults; • Restorative dental services for Adults; • One (1) comprehensive oral exam per year; • One (1) periodical exam every six months; • One (1) defined problem-limited oral exam; • One (1) full series of

In Network Members with Coverage Codes 100, 110, 120 and 130 applies the following: $0 copay for Medicare-covered dental benefits and preventive dental benefits as described in chapter 4 of your Evidence of Coverage. $0 copay Benefit limit: Up to $1,500 every year for comprehensive dental services Comprehensive dental services may require prior authorization. Ask your Dentist if the service you need requires prior authorization before rendering it.it.




Benefit

Category

Medicaid


intra oral radiographies, including bite, every three (3) years. • One (1) initial periapical intra-oral radiography; • Up to five (5) additional periapical/intra-oral radiographies per year; • One (1) single film-bite radiography per year; • One (1) two-film bite radiography per year; • One (1) panoramic radiography every three (3) years; • One (1) adult cleanse every six (6) months; • One (1) child cleanse every six (6) months; • One (1) topical fluoride application every six (6) months for enrollees under nineteen (19) years old; • Fissure sealants for life for enrollees up to fourteen (14) years old (including decidual molars up to eight (8) years old when




Benefit

Category

Medicaid


medically necessary because of cavity tendencies; • Amalgam restoration; • Resin restorations; •Root Canal; • Palliative treatment; and • Oral Surgery Preventive (Child)100-$0.00 / 110-$0.00 /120- $0.00 /130- $0.00 Preventive (Adult)100-$0.00 / 110-$1.00 /120- $1.50 /130- $2.00 Restorative 100-$0.00 / 110-$1.00 /120- $1.50 /130- $2.00

Hearing Exams

Hearing related services not-covered by Medicare and/or the MAO supplementary benefits but included in the State Plan. Hearing aids for beneficiaries over 20 years old are excluded from coverage. Refer to ESPDT for hearing cover services. Coverage Code 100: $0.00

In Network Members with Coverage Codes 100, 110, 120 and 130 applies the following: $0 copay for Medicare-covered hearing exam. Up to one (1) routine hearing exam every year. $0 copay for routine hearing exams and fitting/evaluation for hearing aid services $0 copay for hearing aids




Benefit

Category

Medicaid


Coverage Code 110: $1.00 Coverage Code 120: $1.50 Coverage Code 130: $2.00

Up to $1,500 maximum benefit for hearing aids every year for both ears combined.

Preventive Services

Immunization services not-covered by 1- Medicare Part B 2- MAO Part D drug

formulary 3- MAO

supplementary plan benefits

4- Not covered by the Puerto Rico Department of Health Immunization Program

but included in the Puerto Rico Medicaid State Plan. Coverage Code 100: $0.00 Coverage Code 110: $0.00 Coverage Code 120: $0.00 Coverage Code 130: $0.00





Benefit

Category

Medicaid


Physical, Occupational and Speech Therapy

Physical, Occupational and Speech Therapy Coverage Code 100: $0.00 Coverage Code 110: $1.00 Coverage Code 120: $1.50 Coverage Code 130: $2.00

In Network Members with Coverage Codes 100, 110, 120 and 130 applies the following: $0 copay per each physical therapy, speech language therapy and occupational therapy service. Services provided in CORF require prior authorization.

Prescription Drugs

Prescription drugs non-covered by Medicare and/or the MAO supplementary benefits but included in the State Plan. Any cost sharing not included on the MAO benefit design as approved by CMS, including deductible, co insurances or coverage gaps exceeding the State plan The drug needs to be in the GHP formulary and needs to be subject to the applicable edits as established in the GHP Formulary of Medications in

Members with Coverage Codes 100, 110, 120 and 130 applies the following: Tier 1: Preferred Generic Drugs

In-network retail pharmacies for one-month (30-day) supply:

- Preferred Retail Cost-Sharing Pharmacies- $0 copay per prescription drug.

- Standard Retail Cost-Sharing Pharmacies- $0 copay per prescription drug.

Tier 2: Generic Drugs




Tier 3: Preferred Brand Drugs




Benefit

Category

Medicaid


Coverage (FMC). It also needs to comply with the followings:

• All MAOs pharmacy benefit will provide full year drug coverage with their CMS approved Part D Drugs Formulary, and subject to established Platino copayments as the only out of pocket contribution.

• Drugs not included in the MAOs Part D Drugs Formulary should undergo CMS required exception process for possible approval of non-covered drugs. If exception process denial is sustained by the MAOs, including the appeal process, but if the drug is covered by the GHP Formulary of Medications in Coverage (FMC),




Tier 4: Non-Preferred Brand Drugs In-network retail pharmacies for one-

month (30-day) supply: - Preferred Retail Cost-Sharing

Pharmacies- $0 copay per prescription drug.


Tier 5: Specialty Specialty Generic Drugs




Specialty Brand Drugs






Benefit

Category

Medicaid


the drug will be covered under Wrap-Around. The prescriber physician needs to exhaust available MAO Formulary on the needed drug category.

Coverage Code: 100-$0.00 / 110-$0.00 /120- $0.00 /130- $0.00 Preferred (Children 0-21) Coverage Code: 100-$0.00 / 110-$1.00 /120- $2.00 /130- $3.00 Preferred (Adult)**** Coverage Code: 100-$0.00 / 110-$0.00 /120- $0.00 /130- $0.00 Non-Preferred (Children 0-21) Coverage Code: 100-$0.00 / 110-$3.00 /120- $4.00 /130- $6.00 Non-Preferred (Adult)**** Coverage Code: 100-$0.00 / 110-$0.00 /120- $0.00 /130-


Tier 6: Non-Preferred Drugs In-network retail pharmacies for one-month (30-day) supply: - Preferred Retail Cost-Sharing

Pharmacies- $0 copay per prescription drug.


(Children 0-21) $0 copay (Outpatient Substance Use Disorder) $0 copay




Benefit

Category

Medicaid


$0.00 Outpatient Substance Abuse

1Medicare Platino cannot establish copayments higher than the ones specified in the Wrap Around table. Platino wrap services are subject to the maximum co-payments in the table with exemptions and zero co-payments for Medicaid/CHIP beneficiaries and certain services as follows: Medicaid/CHIP Beneficiaries

• Children from 0 to less than 21 years of age; • Pregnant woman (during pregnancy and the 60-day post-partum period); • American Indians and Alaskan Natives (AI/AN) • Institutionalized Individuals; and • Individuals receiving hospice care.

Services • Emergency services, including ambulatory, hospital and post-stabilization

services as defined in federal regulations 1932(b)(2) of the Act and 42 CFR 438.114(a);

• Family planning services and supplies; • Preventative services provided to children less than 18 years of age • Pregnancy related services and counseling and drugs for cessation of tobacco

use; • Provider-preventable services as defined in 42 CFR 447.26(b); and • Non-emergency visit to a hospital emergency room may be waived by calling

the MCO call center and receiving a code to waiver co-pay. The following services are not included in the Medicaid coverage but are provided by the Department of Health.

1Vaccines for children from 0-20 years of age • Hepatitis B • Rotavirus (RV) • DTaP (Diphtheria toxoids and acellular pertussis vaccine)


• HIB (Conjugated vaccine HIB) • PCV13 Y PPSV23 (Pneumococcal vaccines) • Polio (IPV) • 2Influenza vaccines (dimmed virus LAIV o la IIV). • MMR • Varicella (VAR) • Hepatitis A • Antimeningococcal Vaccines - HIb-MenCY [MenHibrix], MenACWY-D

[Menactra], MenACWY-CRM (Menveo) MenB (Meningeococos serogrupo B Men B -4C [Bexserol] y Men B- FHbp [Trumenba]

• Tdap • Human Papillomavirus (VPH)

Vaccines for adults from 21 > 65 years of age • 2Influenza • Td /Tdap (Tetanus Diphtheria, Pertussis) • Varicella • VPH Human Papillomavirus • Zoster • MMR • Pneumococcal polysaccharide (PPSV23) • Pneumococcal 13-valent conjugate (PCV13) • Menningococcal • Hepatitis A • Hepatitis B

Multi-language Interpreter Services

English: ATTENTION: If you speak English, language assistance

services, free of charge, are available to you. Call 1-888-620-1919 (TTY: 1-

866-620-2520).

Spanish: ATENCIÓN: si habla español, tiene a su disposición servicios

gratuitos de asistencia lingüística. Llame al 1-888-620-1919 (TTY: 1-866-

620-2520).

Chinese: 注意：如果您使用繁體中文，您可以免費獲得語言援助服務

。請致電1-888-620-1919 (TTY: 1-866-620-2520).

French: ATTENTION: Si vous parlez français, des services d'aide

linguistique vous sont proposés gratuitement. Appelez le 1-888-620-1919

(TTY: 1-866-620-2520).

Vietnamese: CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn

ngữ miễn phí dành cho bạn. Gọi số 1-888-620-1919 (TTY: 1-866-620-

2520).

German: ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen

kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-

888-620-1919 (TTY: 1-866-620-2520).

Korean: 주의: 한국어를 사용하시는 경우, 언어 지원 서비스를

무료로 이용하실 수 있습니다. 1-888-620-1919 (TTY: 1-866-620-2520)

번으로 전화해 주십시오.

Arabic: بالمجان لك تتوافر اللغوية المساعدة خدمات فإن ،اللغة اذكر تتحدث كنت إذا :ملحوظة.

.(2520-620-866-1 :والبكم الصم هاتف رقم) 1919-620-888-1 برقم اتصل

Hindi: ध्यान दें: यदद आप द िंदी बोलते ैं तो आपके दलए मफु्त में भाषा स ायता सेवाएिं उपलब्ध ैं। 1-888-

620-1919 (TTY: 1-866-620-2520) पर कॉल करें।

Italian: ATTENZIONE: In caso la lingua parlata sia l'italiano, sono

disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-

888-620-1919 (TTY: 1-866-620-2520).

Portugués: ATENÇÃO: Se fala português, encontram-se disponíveis

serviços linguísticos, grátis. Ligue para 1-888-620-1919 (TTY: 1-866-620-

2520).

French Creole: ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou

lang ki disponib gratis pou ou. Rele 1-888-620-1919 (TTY: 1-866-620-

2520).

Polish: UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej

pomocy językowej. Zadzwoń pod numer 1-888-620-1919 (TTY: 1-866-

620-2520).

Japanese: 注意事項：日本語を話される場合、無料の言語支援をご利

用いただけます。1-888-620-1919 (TTY: 1-866-620-2520)まで、お電話

にてご連絡ください。

Ukrainian: УВАГА! Якщо ви розмовляєте українською мовою, ви

можете звернутися до безкоштовної служби мовної підтримки.

Телефонуйте за номером 1-888-620-1919 (телетайп: 1-866-620-2520).

Catalan: ATENCIÓ: Si parleu Català, teniu disponible un servei d”ajuda

lingüística sense cap càrrec. Truqueu al 1-888-620-1919 (TTY o teletip: 1-

866-620-2520).

Y0082_4036_17_012_E CMS Accepted

Y0082_3032_17_CI_034_E

NOTICE INFORMING INDIVIDUALS ABOUT NONDISCRIMINATION AND

ACCESSIBILITY REQUIREMENTS AND NONDISCRIMINATION STATEMENT:

DISCRIMINATION IS AGAINST THE LAW

Triple-S Advantage, Inc. complies with applicable federal civil rights laws and does not

discriminate on the basis of race, color, national origin, age, disability or sex. Triple-S Advantage,

Inc. does not exclude people or treat them differently because of race, color national origin, age,

disability, or sex.

Triple-S Advantage, Inc.:

• 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 Spanish, such

as:

o Qualified interpreters

o Information written in other languages.

If you need these services, contact a Service Representative.

If you believe that Triple-S Advantage, Inc. 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:

Service Representative

P.O Box 11320, San Juan, PR

00922-1320

Telephone: 1-888-620-1919, TTY: 1-866-620-2520

Fax. 787-993.3261, e-mail: [email protected]

You can file a grievance in person or by mail, fax, or e-mail. If you need help filing a grievance,

a Service Representative is available to help you.

You can also file a civil rights complaint with the US Department of Health and Human Services,

Office of Civil Rights electronically through the Office of 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

mailto:[email protected]

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

Y0082_3032_17_CI_034_E

and Human Services, 200 Independence Avenue SW., Room 509F, HHH Building, Washington,

DC 20201, 1-800-368-1019, 800-537-7697 (TDD).

Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html.

ATTENTION: If you speak English, language assistance services, free of charge, are available

to you. Call 1-888-620-1919 (TTY: 1-866-620-2520).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-888-620-1919

(TTY: 1-866-620-2520) 。

ATENCIÓN: si usted habla español, servicios de asistencia lingüística están disponibles libre de

cargo para usted. Llame al: 1-888-620-1919 (TTY: 1-866-620-2520).

http://www.hhs.gov/ocr/office/file/index.html

SB PLATINO BLINDAO copy - Triple-S Advantage · 2019-10-14 · PLATINO BLINDAO (HMO-SNP)GETTING...

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