2019 Summary of Benefits - Y0097_1304_M Accepted - NCDOI
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2019 Summary of Benefits Y0097_1304_M Accepted
How to Contact Gateway Health 1-877-GATEWAY (428-3929) (TTY 711) How to Find a Provider or Pharmacy GatewayHealthPlan.com Hours of Operation From October 1 to March 31, From April 1 to September 30, you can call us 7 days a week from you can call us Monday through Friday 8:00 a.m. to 8:00 p.m. Eastern time. from 8:00 a.m. to 8:00 p.m. Eastern time.
Dual Eligible (D-SNP) Plans Highlights
Medicare Assured Medicare Assured
DiamondSM (HMO SNP)† RubySM (HMO SNP)†
Monthly Plan Premium Monthly Plan Premium
$0* $28.90
Primary Care Visits Primary Care Visits
as low as $0 as low as $0
Deductible Deductible
$0 as low as $0
Preventive Care Preventive Care
Urgent & Emergency Care Urgent & Emergency Care
In and out-of-network In and out-of-network
Diagnostic Services/ Diagnostic Services/
Labs/Imaging Labs/Imaging
Generic prescriptions Generic prescriptions
as low as $0 as low as $0
†
To be eligible for the Diamond plan, you must have Medicare Parts A and B and Medical Assistance (Full or QMB). Also,
you must live in our service area and–with limited exceptions–you must not have End-Stage Renal Disease.
††
To be eligible for the Ruby plan, you must have Medicare Parts A and B and Medical Assistance (SLMB, QI or QDWI).
Also, you must live in our service area and–with limited exceptions–you must not have End-Stage Renal Disease.
Have Questions? 1-877-Gateway (428-3929) (TTY 711) 8 a.m. – 8 p.m. 7 days a week
2019 Summary of Benefits Gateway Health Medicare Assured Diamond (HMO SNP) Gateway Health Medicare Assured Ruby (HMO SNP) This is a summary of drug and health benefits for January 1, 2019 – December 31, 2019 The benefit information provided is a summary of what we cover and what you pay. It does not list every benefit that we cover or list every limit or exclusion. To get a complete list of benefits we cover, please request the “Evidence of Coverage” by calling 1-877-Gateway (TTY users call 711). From October 1 to March 31, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern time. From April 1 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern time. You can also view or download the Evidence of Coverage at www.MedicareAssured.com
To join Gateway Health Medicare Assured Diamond (HMO SNP) or Gateway Health Medicare
Assured Ruby (HMO SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B,
and live in our service area. Our service area includes the following counties:
North Carolina County Service Area
Beaufort Chowan Halifax Pitt
Bertie Cumberland Hertford Polk
Bladen Duplin Jones Sampson
Caswell Durham Northampton Warren
Chatham Greene Orange
Gateway Health Medicare Assured Diamond and Ruby plans are Medicare Advantage HMO
Special Needs Plans with a Medicare contract. These plans are designed specifically for
people who have Medicare and who are also entitled to assistance from Medicaid.
More About Original Medicare
If you want to know more about the cost and coverage 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.
Have Questions? 1-877-Gateway (428-3929) (TTY 711) 8 a.m. – 8 p.m. 7 days a weekGateway Health Medicare Gateway Health Medicare
Plan Benefits Assured DiamondSM (HMO SNP) Assured RubySM (HMO SNP)
Monthly Plan Premium $0 Monthly Plan Premium* $28.90 Monthly Plan Premium*
$0 or $85 per year for Part D for co-pay
Deductible $0
level 4, based on level of extra help
Maximum Out-of-Pocket
$3,400 Out-of-Pocket Limit for $6,700 Out-of-Pocket Limit for
Responsibility
In-Network Medicare-covered Services In-Network Medicare-covered Services
(does not include prescription drugs)
$275 Copay Days 1 to 5 and
Inpatient Hospital Coverage^ $0 Copay per day for days 1-90
$0 Copay Days 6 to 90
$200 Copay for Outpatient and
Outpatient Hospital Coverage^ $0 and Authorization required
$275 Copay for Observation Services
Doctor Visits $0* for PCP and Specialist visits $0 PCP visits and $35* Specialist visits
Preventive Care $0 $0
$90* Copay will not be waived if admitted
Emergency Care $0* to Hospital and cannot be applied towards
Deductible
$45* Copay will not be waived if admitted
Urgently Needed Services $0* to Hospital and cannot be applied towards
Deductible
Lab Services & Diagnostic
$0* and Authorization required $0* and Authorization required
Tests^
X-rays / Complex Imaging^
$0* and Authorization required $35* Copay
(e.g., CT scan/MRI)
Hearing Exam $0* for routine exams $0* for routine exams
$3,000 Maximum Every two years $750 Maximum Every two years
Hearing Aid
Both ears combined Both ears combined
Preventive Dental Services One cleaning & oral exam. One dental x-ray/
One dental x-ray every six months
one panoramic x-ray every 5 years. Filings,
(every six months) One panoramic x-ray every 5 years
simple extractions and two crowns per year.
1 Exam Every year 1 Exam Every year $35 Copay
Supplemental Eyewear: Limited to one Supplemental Eyewear: Limited to one
(1) pair of glasses or Contact Lenses each (1) pair of glasses or Contact Lenses each
Vision Services year. Vendor frames and standard lenses year. Vendor frames and standard lenses
or standard contact lenses at no cost per or standard contact lenses at no cost per
(Davis Vision Network) calendar year when purchased from Davis calendar year when purchased from Davis
vision collection. $200 toward non-vendor vision collection. $90 toward non-vendor
frames or $200 toward non vendor contact frames or $100 toward non vendor contact
lenses per calendar year. lenses per calendar year.
Mental Health Services $0* for Individual and Group Sessions $35* Copay for Individual and Group SessionsGateway Health Medicare Gateway Health Medicare
Plan Benefits Assured DiamondSM (HMO SNP) Assured RubySM (HMO SNP)
$0 Copay Days 1 to 20 and
Skilled Nursing Facility^ $0
$172* Copay Days 21 to 100
Physical Therapy^ $0* and Authorization required $35* Copay
$0* for Ground and Air. $200* Copay for Ground and Air.
Ambulance ^
Authorization required for Non-Emergency Authorization required for Non-Emergency
Medicare Services Medicare Services
50 trips, one way, Every year in Plan- 24 trips, one way, Every year in Plan-
approved Location. Requires 72 hour notice approved Location. Requires 72 hour notice
Transportation services are for medical Transportation services are for medical
related reasons only as defined by the plan. related reasons only as defined by the plan.
Transportation^ Mode of transportation also includes car. Mode of transportation also includes car.
Authorization (based on criteria established Authorization (based on criteria established
by Gateway Health) and scheduling by Gateway Health) and scheduling
rules apply. Beneficiary must call noted rules apply. Beneficiary must call noted
transportation vendor to receive service. transportation vendor to receive service.
$0 and Prior authorization required for certain 20% Coinsurance and Prior authorization
Medicare Part B Drugs^
Part B/Chemo drugs required for certain Part B/Chemo drugs
Foot Care^ (podiatry services) $0 and Authorization required $35 and Authorization required
Medical Equipment/Supplies
$0* and Authorization required 20%* Coinsurance and Authorization required
& Prosthetics^
Diabetic Testing Supplies $0 and Authorization required 20%* Coinsurance and Authorization required
Lab/Diagnostic Tests (Phys
$0 $0
Office or Freestanding Lab)
Lab/Diagnostic Tests
$0 and Authorization required $0 and Authorization required
(Outpatient Facility)
Therapeutic and $175 Copay for Diagnostic
$0 and Authorization required
Radiology Services $60 for Therapeutic $35 for X-Ray
X-Rays $0 $35 Copay
Cardiac and Pulmonary $35 Copay for Cardiac Rehab,
$0
Rehabilitation Services $30 Copay for Pulmonary Rehab
Toll-free telephonic coaching and nurse Toll-free telephonic coaching and nurse
advice from trained clinicians, 24 hours a day, advice from trained clinicians, 24 hours a day,
7 days a week regarding a recent diagnosis, 7 days a week regarding a recent diagnosis,
Nursing Hotline treatment options or surgery, current treatment options or surgery, current
symptoms, self-care home treatments, when symptoms, self-care home treatments, when
to go to the doctor, when to go to the Urgent to go to the doctor, when to go to the Urgent
Care Center or Emergency Room, preventive Care Center or Emergency Room, preventive
care and lab tests. care and lab tests.
Benefits continued on next page
*
Depending on your level of Medicaid eligibility and/or level of Extra Help #Once you pay $5,100 out-of-pocket,
the plan will pay all or most of the drug costs for the remainder of the calendar year. ^Prior authorization may be required
Have Questions? 1-877-Gateway (428-3929) (TTY 711) 8 a.m. – 8 p.m. 7 days a weekGateway Health Medicare Gateway Health Medicare
Plan Benefits Assured DiamondSM (HMO SNP) Assured RubySM (HMO SNP)
Benefit coordinated through Gateway
Personal Emergency Response Health Case Management Department.
Not Covered
System (PERS) Limited to one PERS device per member
per lifetime.
Inpatient Mental Health Care Days 1-150: $0 copay Days 1-5: $275 copay per day
Chiropractic Services $0 $20 Copay and Authorization required
Diabetes Programs and $0 and Authorization required for diabetes $0 and Authorization required for diabetes
self-management training, monitoring self-management training, 20% monitoring
Supplies supplies, therapeutic shoes or inserts supplies, therapeutic shoes or inserts
Outpatient Prescription Drugs
Part D Deductible: $0 to $85* Part D Deductible: $0 to $85*
Initial Coverage Limit: $3,820 Initial Coverage Limit: $3,820
Out-of-Pocket: $5,100# Out-of-Pocket: $5,100#
30-Day Supply 30-Day Supply
Tier 1 – Preferred Generic Drugs Tier 1 – Preferred Generic Drugs
All drugs – $0.00 All drugs – $0.00
Tier 2 – Generic Drugs Tier 2 – Generic Drugs
All drugs – $0.00, $1.25, or $3.40 All drugs – $0.00, $1.25, or $3.40,
or 15% of the cost or 15% of the cost
Tier 3 – Preferred Brand Drugs Tier 3 – Preferred Brand Drugs
Part D Prescription Drugs Generic drugs – $0.00, $1.25, or $3.40 Generic drugs – $0.00, $1.25, or $3.40,
Initial Coverage Period^ or 15% of the cost or 15% of the cost
Brand drugs – $0.00, $3.70, or $8.50, Brand drugs – $0.00, $3.70, or $8.50,
(Amounts also apply to or 15% of the cost or 15% of the cost
60 and 90-day supplies)
Tier 4 – Non-Preferred Drugs Tier 4 – Non-Preferred Drugs
Generic drugs – $0.00, $1.25, or $3.40, Generic drugs – $0.00, $1.25, or $3.40,
or 15% of the cost or 15% of the cost
Brand drugs – $0.00, $3.70, or $8.50, Brand drugs – $0.00, $3.70, or $8.50,
or 15% of the cost or 15% of the cost
Tier 5 – Specialty Tier Drugs Tier 5 – Specialty Tier Drugs
Generic drugs – $0.00, $1.25, or $3.40, Generic drugs – $0.00, $1.25, or $3.40,
or 15% of the cost or 15% of the cost
Brand drugs – $0.00, $3.70, or $8.50, Brand drugs – $0.00, $3.70, or $8.50,
or 15% of the cost or 15% of the costGateway Health Medicare Gateway Health Medicare
Plan Benefits Assured DiamondSM (HMO SNP) Assured RubySM (HMO SNP)
Optional Supplemental Benefits
Disease Management Program featuring:
• Health education materials, and
Health Education Not Covered
• Telephonic outreach for education and
support from Plan Care Managers
Provides membership at participating Provides membership at participating
network fitness centers at no cost, including: network fitness centers at no cost, including:
• Basic fitness membership to Plan • Basic fitness membership to Plan
approved fitness facility approved fitness facility
SilverSneakers • Orientation to the fitness center • Orientation to the fitness center
Fitness Program and instructions about how to use and instructions about how to use
equipment and services equipment and services
• One @Home Pak per year for those • One @Home Pak per year for those
members with limited access to a members with limited access to a
network fitness center. network fitness center.
Preventive Services, $0 copay for all preventive services covered $0 copay for all preventive services covered
Wellness/Education under Original Medicare at $0 sharing. Any under Original Medicare at $0 sharing. Any
additional preventive services approved by additional preventive services approved by
and other Supplemental Medicare mid-year will be covered by the Medicare mid-year will be covered by the
Benefit Programs plan or by Original Medicare. plan or by Original Medicare.
$275 Maximum Every three months $25 Maximum Every three months
Members will receive OTC catalog with Members will receive OTC catalog with
a quarterly limit for purchasing CMS- a quarterly limit for purchasing CMS-
Over-the-Counter Items approved non-prescription over-the-counter approved non-prescription over-the-counter
medication and health-related items through medication and health-related items through
(no cough/cold) catalog purchasing.(Limits and shipping catalog purchasing.(Limits and shipping
restrictions may apply) Maximum Plan restrictions may apply) Maximum Plan
Benefit Coverage carried forward expires at Benefit Coverage carried forward expires at
the end of the calendar year the end of the calendar year
Plan provides two additional counseling
Tobacco Cessation visits per attempt, in addition to the Not Covered
Medicare-covered benefit.
Benefit coordinated through Gateway Health
Case Management Department.
Bathroom/Home Limited to 4 in home safety devices per year.
Items limited to: toilet seat riser, toilet safety Not Covered
Safety Devices arm support, tub grab bars, tub and shower
anti slip treads, wall mount grab bars,
reaching aid and rug anchors
*
Depending on your level of Medicaid eligibility and/or level of Extra Help #Once you pay $5,100 out-of-pocket,
the plan will pay all or most of the drug costs for the remainder of the calendar year. ^Prior authorization may be required
Have Questions? 1-877-Gateway (428-3929) (TTY 711) 8 a.m. – 8 p.m. 7 days a weekImportant Information
for Those Receiving Extra Help
Gateway Health Medicare Assured DiamondSM
and Gateway Health Medicare Assured RubySM
Monthly Plan Premium for People who get Extra Help from Medicare
to Help Pay for their Prescription Drug Costs
If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs,
your monthly plan premium will be lower than what it would be if you did not get extra help from
Medicare. The amount of extra help you get will determine your total monthly plan premium as a
member of our Plan.
This table shows you what your monthly plan premium will be if you get extra help.
Gateway Health Gateway Health
Your level of extra help
Medicare Assured DiamondSM* Medicare Assured RubySM*
100% $0 $0
75% N/A $7.20
50% N/A $14.40
25% N/A $21.70
*This does not include any Medicare Part B premium you may have to pay.
If you aren’t getting extra help, you can see if you qualify by calling:
• 1-800-Medicare of TTY users call 1-877-486-2048 (24 hours a day/7 days a week),
• Your State Medicaid Office, or
• The Social Security Administration at 1-800-772-1213. TTY users should call 1-800-325-0778
between 7 a.m. and 7 p.m., Monday through Friday.
If you have any questions, please call Customer Service at 1-877-GATEWAY (428-3929), (TTY: 711)
from 8 a.m. – 8 p.m. Eastern Time, 7 days a week.
Have Questions? 1-877-Gateway (428-3929) (TTY 711) 8 a.m. – 8 p.m. 7 days a weekPre-Enrollment Checklist
Before making an enrollment decision, it is important that you fully understand our benefits and rules.
If you have any questions, you can call and speak to a customer service representative at
1-800-685-5209 (PA), 1-888-447-4505 (OH) or 1-855-847-6430 (NC). TTY users should call 711.
Understanding the Benefits
Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those
services that you routinely see a doctor. Visit GatewayHealthPlan.com or call 1-800-685-5209
(PA), 1-888-447-4505 (OH) or 1-855-847-6430 (NC). TTY users should call 711 to view a copy
of the EOC.
Review the provider directory (or ask your doctor) to make sure the doctors you see now are
in the network. If they are not listed, it means you will likely have to select a new doctor.
Review the pharmacy directory to make sure the pharmacy you use for any prescription
medicines is in the network. If the pharmacy is not listed, you will likely have to select a new
pharmacy for your prescriptions.
Understanding Important Rules
In addition to your monthly plan premium, you must continue to pay your Medicare Part B
premium. Depending on your level of extra help, part or all of this premium could be paid by
Medicare. If Medicare pays only a portion of this premium, we will bill you for the amount that
Medicare doesn’t cover. For more information about this extra help, contact your local Social
Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp.
Benefits, premiums and/or copayments/co-insurance may change on January 1, 2019.
Except in emergency or urgent situations, we do not cover services by out-of-network providers
(doctors who are not listed in the provider directory).
This plan is a dual eligible special needs plan (D-SNP). Your ability to enroll will be based on
verification that you are entitled to both Medicare and medical assistance from a state plan under
Medicaid. Other restrictions may apply.
Gateway HealthSM is an HMO plan with a Medicare contract. Enrollment in Gateway Health’s Diamond or Ruby plans depend on contract renewal.
This information is not a complete description of benefits. Call Member Service at 1-800-685-5209 (PA), 1-888-447-4505 (OH) or 1-855-847-6430 (NC).
TTY users should call 711 for more information.
Have Questions? 1-877-Gateway (428-3929) (TTY 711) 8 a.m. – 8 p.m. 7 days a weekYou can also read
