Summary of Benefits Prime (HMO-POS), Value Plus (HMO)
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H5591 2019 SB_M Accepted: 9/4/18
Summary of Benefits
Prime (HMO-POS), Value Plus (HMO)
January 1–December 31, 2019
For more information about benefits or enrollment,
call us or visit our website at MartinsPoint.org/Medicare
1-888-408-8285 (TTY: 711)
We are available 8 am-8 pm, seven days a week from
October 1 to March 31; and Monday through Friday
the rest of the year.
Martin’s Point Generations Advantage,
891 Washington Ave., PO Box 9746, Portland, ME 04104Section 1: Introduction
his is a summary of drug and health services covered by the Martin’s Point
T
Generations Advantage Prime (HMO-POS) and Value Plus (HMO) plans.
January 1, 2019 - December 31, 2019 For Generations Advantage Prime (HMO-POS) plan:
Martin’s Point Generations Advantage is a health plan with a Medicare Our
ff service area includes: all counties in Maine, as well as Carroll,
contract offering HMO, HMO-POS, HMO SNP, Local and Regional PPO Cheshire, Coos, Grafton, Hillsborough, Rockingham, Sullivan, and
products. Enrollment in a Martin’s Point Generations Advantage plan Strafford counties in New Hampshire.
depends on contract renewal. The plan has a network of doctors, hospitals, pharmacies, and other
ff
This information may be available in other formats such as large print providers. For some services you can use providers that are not in
and Braille. For more information call Generations Advantage. our network.
The benefit information provided is a summary of what we cover and For Generations Advantage Value Plus (HMO) plan:
what you pay. It does not list every service that we cover or list every Our
ff service area includes: Androscoggin, Aroostook, Franklin,
limitation or exclusion. To get a complete list of services we cover, Hancock, Kennebec, Knox, Lincoln, Oxford, Penobscot, Piscataquis,
please request the Evidence of Coverage. Sagadahoc, Somerset, Waldo, Washington, and York counties in
To join Martin’s Point Generations Advantage Prime or Value Plus, you Maine, as well as Hillsborough and Strafford counties in New
must be entitled to Medicare Part A, be enrolled in Medicare Part B, Hampshire.
and live in our service area. The plan has a network of doctors, hospitals, pharmacies, and other
ff
providers. If you use the providers that are not in our network, the
plan may not pay for these services.
2019 Summary of Benefits for Martin’s Point Generations Advantage Prime (HMO-POS), and Value Plus (HMO) 1Section 2: S
ummary of Benefits
his is a summary of drug and health services covered by the Martin’s Point
T
Generations Advantage Prime (HMO-POS) and Value Plus (HMO) plans.
Plan Premium Table
The table below shows the monthly plan premium amount for each region we serve. In addition, you must keep paying your
Medicare Part B premium.
Monthly
Plan Name Plan Service Area Premium
Prime Cumberland County in Maine $0
(HMO-POS)
Androscoggin, Kennebec, Sagadahoc, and York counties in Maine $19
Cheshire, Hillsborough, Rockingham, Strafford, and Sullivan counties in New Hampshire $29
Aroostook, Franklin, Hancock, Knox, Lincoln, Oxford, Penobscot, Piscataquis, Somerset, Waldo, $89
and Washington counties in Maine; Carroll, Coos, and Grafton counties in New Hampshire
Value Plus Androscoggin, Kennebec, Sagadahoc and York counties in Maine; Hillsborough and Strafford $0
(HMO) counties in New Hampshire
Aroostook, Franklin, Hancock, Knox, Lincoln, Oxford, Penobscot, Piscataquis, Somerset, Waldo, $29
and Washington counties in Maine
Benefit Prime (HMO-POS) Plan Value Plus (HMO) Plan
Deductible You pay nothing. You pay nothing.
Our plan does not have a medical deductible.
Maximum out-of-pocket responsibility From Network Providers: $5,500 $6,700
(does not include prescription drugs) From network and Out of network providers
Our plan protects you by having yearly limits combined: $8,500
on your out-of-pocket costs for medical and
hospital care.
2019 Summary of Benefits for Martin’s Point Generations Advantage Prime (HMO-POS), and Value Plus (HMO) 2Section 2: S
ummary of Benefits
Benefit Prime (HMO-POS) Plan Value Plus (HMO) Plan
Inpatient hospital coverage You pay per admission: You pay per admission:
Our plan covers an unlimited number of days $300 per day for days 1-5;
ff $325 per day for days 1-5;
ff
for an inpatient hospital stay. $0 per day for days 6 and beyond
ff $0 per day for days 6 and beyond
ff
Outpatient hospital coverage You
ff pay $175 for Medicare-covered surgery You
ff pay $200 for Medicare-covered
services at an ambulatory surgical center. surgery services at an ambulatory
You pay $350 for Medicare-covered surgery
ff surgical center.
services at a hospital outpatient facility. You pay $350 for Medicare-covered
ff
surgery services at a hospital outpatient
facility.
Doctor visits Primary
ff care Primary
ff care
You pay $0 for each Primary Care You pay $0 for post-operative and
Provider (PCP) office visit for Medicare- post-discharge visits with your PCP.
covered services. You pay $0 for a brief emotional/
Specialists
ff behavioral assessment with your PCP.
You pay $40 for each specialist office visit You pay $10 for all other PCP services
for Medicare-covered services. and visits.
Specialists
ff
You pay $50 for each specialist office
visit for Medicare-covered services.
Preventive care You pay nothing. You pay nothing.
Any additional preventive services approved
by Medicare during the contract year will be
covered. There are some items not covered
at $0 cost.
Emergency care You pay $90 for each Medicare-covered You pay $90 for each Medicare-covered
You do not have to pay this amount if you are emergency room visit. emergency room visit.
admitted to a hospital within 24 hours for the
same condition.
Urgently needed services You pay $40 for each Medicare-covered You pay $40 for each Medicare-covered
Urgent care is covered nationwide. urgent care visit when performed at an urgent care visit when performed at an
urgent care center. urgent care center.
2019 Summary of Benefits for Martin’s Point Generations Advantage Prime (HMO-POS), and Value Plus (HMO) 3Section 2: S
ummary of Benefits
Benefit Prime (HMO-POS) Plan Value Plus (HMO) Plan
Diagnostic services/labs/imaging Diagnostic
ff radiology service (e.g., Diagnostic
ff radiology service (e.g.,
Services may require that your provider get MRI) You pay 20% of the cost of complex MRI) You pay 20% of the cost of complex
prior authorization (approval in advance). Please diagnostic radiology (PET, CT, MRI, MRA, diagnostic radiology (PET, CT, MRI, MRA,
refer to the Evidence of Coverage for more nuclear medicine). nuclear medicine).
information. Lab
ff services You pay 0% - 20% (genetic) Lab
ff services You pay 0% - 20% (genetic)
for lab services. for lab services.
Diagnostic
ff tests and procedures Diagnostic
ff tests and procedures
You pay 15% of the cost of simple You pay 15% of the cost of simple
diagnostic radiology. diagnostic radiology.
Outpatient
ff X-rays You pay 15% of the Outpatient
ff X-rays You pay 15% of the
cost for X-rays. cost for X-rays.
Hearing services Hearing
ff exam You pay $40 per visit for Hearing
ff exam You pay $50 per visit for
Medicare-covered hearing services. Medicare-covered hearing services.
Hearing
ff aids You pay $595, $695, or $895 Hearing
ff aids You pay $595, $695, or $895
copay per ear, depending on Tier selected. copay per ear, depending on Tier selected.
You pay $0 for 1 year of hearing aid fittings You pay $0 for 1 year of hearing aid fittings
and ongoing hearing aid evaluations and and ongoing hearing aid evaluations and
$0 for 2 years of batteries when used in $0 for 2 years of batteries when used in
conjunction with your hearing aid benefit. conjunction with your hearing aid benefit.
Dental services You pay $40 per visit for Medicare-covered You pay $40 per visit for Medicare-covered
Services may require that your provider get dental services (non-routine dental care dental services (non-routine dental care
prior authorization (approval in advance). Please required to treat illness or injury). required to treat illness or injury).
refer to the Evidence of Coverage for more
information.
Dental services - enhanced You pay $40 per visit for the enhanced Not a covered benefit.
preventive and basic dental preventive and basic dental services.
Members must use Delta Dental PPO/Martin’s
Point Generations Advantage network dentist to
obtain these supplemental dental benefits.
2019 Summary of Benefits for Martin’s Point Generations Advantage Prime (HMO-POS), and Value Plus (HMO) 4Section 2: S
ummary of Benefits
Benefit Prime (HMO-POS) Plan Value Plus (HMO) Plan
Vision services Annual
ff routine eye exam You pay $0 Annual
ff routine eye exam You pay $0
for an annual routine eye exam. for an annual routine eye exam.
Glaucoma
ff testing You pay $0 for Glaucoma
ff testing You pay $0 for
glaucoma testing. glaucoma testing.
Diabetic
ff retinopathy You pay $0 for a Diabetic
ff retinopathy You pay $0 for a
diabetic eye exam (retinopathy). diabetic eye exam (retinopathy).
Medicare-covered
ff physician services Medicare-covered
ff physician services
You pay $40 for Medicare-covered You pay $50 for Medicare-covered
physician services. physician services.
Mental health services Inpatient
ff visit You pay per admission: Inpatient
ff visit You pay per admission:
Services may require that your provider get ••$220 per day for days 1-7; ••$220 per day for days 1-7;
prior authorization (approval in advance). ••$0 per day for days 8 and beyond ••$0 per day for days 8 and beyond
Please refer to the Evidence of Coverage for Outpatient
ff therapy visit (group or Outpatient
ff therapy visit (group or
more information. individual) You pay $25 per visit. individual) You pay $25 per visit.
Skilled nursing facility For each benefit period you pay for For each benefit period you pay for
Services may require that your provider get Medicare-covered services: Medicare-covered services:
prior authorization (approval in advance). $0
ff for days 1-20 $0
ff for days 1-20
Please refer to the Evidence of Coverage for $165
ff per day for days 21-100 $165
ff per day for days 21-100
more information.
Physical therapy You pay $40 for each Medicare-covered visit. You pay $40 for each Medicare-covered visit.
Services may require that your provider get
prior authorization (approval in advance).
Please refer to the Evidence of Coverage for
more information.
Ambulance You pay $250 for each Medicare-covered You pay $250 for each Medicare-covered
Non-emergency ambulance transportation emergency ambulance service (one-way). ambulance service (one-way).
may require that your provider get prior
authorization (approval in advance). Please
refer to the Evidence of Coverage for more
information.
Transportation Not a covered benefit. Not a covered benefit.
2019 Summary of Benefits for Martin’s Point Generations Advantage Prime (HMO-POS), and Value Plus (HMO) 5Section 2: S
ummary of Benefits
Benefit Prime (HMO-POS) Plan Value Plus (HMO) Plan
Medicare Part B drugs You pay 20% of the cost of Medicare- You pay 20% of the cost of Medicare-
Services may require that your provider get covered services. covered services.
prior authorization (approval in advance). Please
refer to the Evidence of Coverage for more
information.
Outpatient Prescription Drugs (Generations Advantage Prime (HMO-POS) Plan)
Standard retail Preferred retail Mail-order
(30-day supply) (30-day supply) (90-day supply)
Phase 2: Initial Coverage
Cost-sharing Tier 1 $4 $0 $10 Cost sharing may change
(Preferred Generic) depending on the pharmacy
you choose and when you
Cost-sharing Tier 2 $18 $10 $45 enter another phase of the
(Generic) Part D benefit. For more
Cost-sharing Tier 3 $47 $40 $117.50 information on the additional
(Preferred Brand) pharmacy-specific cost sharing
and the phases of the benefit,
Cost-sharing Tier 4 $100 $95 $250 please refer to the Evidence
(Non-Preferred Drug) of Coverage for more
information.
Cost-sharing Tier 5 33% 33% 33%
(Specialty Tier)
2019 Summary of Benefits for Martin’s Point Generations Advantage Prime (HMO-POS), and Value Plus (HMO) 6Section 2: S
ummary of Benefits
Outpatient Prescription Drugs (Generations Advantage Value Plus (HMO) Plan)
Standard retail Preferred retail Mail-order
(30-day supply) (30-day supply) (90-day supply)
Phase 1: Deductible
$250 Part D deductible for Tiers 3 through 5 drugs
Phase 2: Initial Coverage
Cost-sharing Tier 1 $4 $0 $10 Cost sharing may change
(Preferred Generic) depending on the pharmacy
you choose and when you
Cost-sharing Tier 2 $18 $10 $45 enter another phase of the
(Generic) Part D benefit. For more
Cost-sharing Tier 3 $47 $40 $117.50 information on the additional
(Preferred Brand) pharmacy-specific cost sharing
and the phases of the benefit,
Cost-sharing Tier 4 $100 $95 $250 please refer to the Evidence
(Non-Preferred Drug) of Coverage for more
information.
Cost-sharing Tier 5 28% 28% 28%
(Specialty Tier)
Generations Advantage Prime (HMO-POS) and Value Plus (HMO) You can see the complete plan formulary (list of Part D
plans cover Part D drugs. In addition, we cover Part B drugs such as prescription drugs) and any restrictions, our plans’ pharmacy
chemotherapy and some drugs administered by your provider. directory and our plans’ provider directory on our website at
MartinsPoint.org/Medicare.
2019 Summary of Benefits for Martin’s Point Generations Advantage Prime (HMO-POS), and Value Plus (HMO) 7Section 2: S
ummary of Benefits
Benefit Prime (HMO-POS) Plan Value Plus (HMO) Plan
Wellness Wallet (dietary/nutrition, fitness The plan will reimburse up to $400 The plan will reimburse up to $300
benefit, naturopathic services, acupuncture, each year in total for dietary/nutrition, each year in total for dietary/nutrition,
and weight management programs) fitness benefit, naturopathic services, fitness benefit, naturopathic services,
Members can be reimbursed up to the maximum acupuncture, and weight management acupuncture, and weight management
amount allowed by their plan. Please refer to the programs. programs.
Evidence of Coverage for more information.
If you want to know more about the coverage and costs of Original Medicare, look in your Medicare & You 2019 Handbook. You can download
a copy of from the Medicare website (www.medicare.gov) or ask for a printed 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.
2019 Summary of Benefits for Martin’s Point Generations Advantage Prime (HMO-POS), and Value Plus (HMO) 8Section 2: S
ummary of Benefits
Benefit Prime (HMO-POS) Plan Value Plus (HMO) Plan
Point-of-Service Services available in the POS benefit: Not covered under this plan
The plan has a Point-of-Service (POS) benefit where Doctor Visits (Primary Care and
you can use an out-of-network provider for certain Specialist)
services. Under the POS, you will generally pay a Chiropractic Visits $45
ff
higher cost share when using an out-of-network Physician Specialist visits $45
ff
provider. Please refer to the Evidence of Coverage Podiatry visits $45
ff
for more information. Primary Care visits (allowed only outside
ff
the plan’s service area) $35
Outpatient Services
Diabetes self-management 20% for supplies
ff
and shoes, $0 for training
Durable Medical Equipment 30%
ff
Medicare Part B prescription drugs,
ff
including chemotherapy 20%
Outpatient diagnostic tests/procedures,
ff
X-rays, and lab services 0-30%
Outpatient mental health and substance
ff
abuse visits $30 individual/group
Outpatient rehabilitation services (Physical,
ff
Occupational and Speech therapy) $45
Outpatient surgery in a hospital or
ff
ambulatory surgical center $200/$375
Radiation therapy 30%
ff
Dental Services
Medicare-covered only dental services $45
ff
Hearing Services
Medicare-covered hearing services $45
ff
Vision Services
ffMedicare-covered vision services $45
ffAnnual routine eye exam 30%
2019 Summary of Benefits for Martin’s Point Generations Advantage Prime (HMO-POS), and Value Plus (HMO) 9Section 3: D
elta Dental Benefit Overview
Section 3: Dental Benefit Overview
The Generations Advantage Prime (HMO-POS) plan includes No
ff Claims Paperwork: Participating dentists will prepare and
the following benefits when seeing a Delta Dental PPO/Martin’s Point submit claims for you.
Generations Advantage network dentist. This benefit overview is Direct
ff Payment: Northeast Delta Dental pays participating dentists
provided for summary purposes only. directly, so you don’t have to pay the covered amount up front and
wait for reimbursement.
Plan Benefits
To find out if your dentist participates in the Delta Dental PPO/
We cover the following You pay $40 for Martin’s Point Generations Advantage dental network, please visit
services in-network: each visit. our website at MartinsPoint.org/Medicare, visit
www.nedelta.com/Dentist-Search, or call Northeast Delta
Exam
ff and routine cleaning once in a
Dental’s Customer Service Department at 1-800-832-5700
12-month period (Fluoride not included)
(TTY: 1-800-332-5905) Monday through Friday, 8 am–4:45 pm.
Problem-focused
ff exams as needed
Claim Process for Participating Dentists
Bitewing
ff X-rays once in a 24-month period
Present your Generations Advantage member ID card to your
X-rays
ff of individual teeth as necessary participating dentist at the time of your visit. Your participating dentist
Full-mouth/Panorex
ff X-rays once in a 5-year will submit your claim to Northeast Delta Dental. Members can
period register online to view claims and benefit information at
www.nedelta.com.
Surgical
ff and routine extractions
(Anesthesia not included) Non-participating Dentists
Emergency
ff relief of pain No benefits are available under your policy if you choose to visit a
dentist who is not participating in the Delta Dental PPO/Martin’s Point
Generations Advantage dental network. Non-participating dentists
Delta Dental PPO/Martin’s Point Generations are welcome to join the Delta Dental PPO/Martin’s Point Generations
Advantage Dental Network Advantage dental network at any time.
Plan benefits are available only when you receive your dental care
from a Delta Dental PPO/Martin’s Point Generations Advantage Identification Cards
network dentist: Your Generations Advantage member ID card includes your dental
No
ff Balance Billing: Participating dentists accept Northeast Delta group number and the Northeast Delta Dental customer service
Dental’s fees for services as payment in full. number. Your member ID number for dental benefits is the same as
your Generations Advantage Prime plan member ID number.
2019 Summary of Benefits for Martin’s Point Generations Advantage Prime (HMO-POS), and Value Plus (HMO) 10Martin’s Point Health Care complies with applicable Federal civil rights If you believe that Martin’s Point Health Care has failed to provide these
laws and does not discriminate on the basis of race, color, national services or discriminated in another way on the basis of race, color,
origin, age, disability, or sex. Martin’s Point Health Care does not national origin, age, disability, or sex, you can file a grievance with:
exclude people or treat them differently because of race, color, national Grievance Specialist, Martin’s Point Generations Advantage, PO Box
origin, age, disability, or sex. 9746, Portland, ME 04104, 1-866-544-7504, TTY: 711, Fax: 207-828-7874.
Martin’s Point Health Care: You can file a grievance in person, by mail, or by fax. If you need help
Provides free aids and services to people with disabilities to
ff filing a grievance, the Martin’s Point Generations Advantage Grievance
communicate effectively with us, such as: Specialist is available to help you.
••Qualified sign language interpreters You can also file a civil rights complaint with the U.S. Department
••Written information in other formats (large print, audio, accessibleof Health and Human Services, Office for Civil Rights, electronically
electronic formats, other formats) through the Office for Civil Rights Complaint Portal, available at
ff Provides free language services to people whose primary language is ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:
not English, such as: U.S. Department of Health and Human Services
••Qualified interpreters 200 Independence Avenue, SW
••Information written in other languages Room 509F, HHH Building
Washington, D.C. 20201
If you need these services, contact the Martin’s Point Generations 1-800-368-1019 (TDD: 1-800-537-7697)
Advantage Grievance Department.
Complaint forms are available at
www.hhs.gov/ocr/office/file/index.html.ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-866-544-7504 (TTY: 711).
ATTENTION : Si vous parlez français, des services d’aide linguistique vous sont proposés gratuitement. Appelez le 1-866-544-7504 (ATS : 711).
ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-544-7504 (TTY: 711).
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 1-866-544-7504（TTY：711）。
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ध्यान दिनुहोस्: तपार्इल
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् भने तपार्इक
ं ो निम्ति भाषा सहायता सेवाहरू निःशुलक
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oštećenim govorom ili sluhom: 711).
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ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-866-544-7504 (TTY: 711).
ATTENZIONE: In caso la lingua parlata sia l’italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-866-544-7504 (TTY: 711).
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-866-544-7504 (TTY:
711).
ध्यान दे:ं यदि आप हिंदी बोलते हैं तो आपके लिए मुफत् में भाषा सहायता सेवाएं उपलब्ध है।ं 1-866-544-7504 (TTY: 711) पर कॉल करे।ंFor more information about benefits or enrollment,
call us or visit our website at MartinsPoint.org/Medicare
1-888-408-8285 (TTY: 711)
We are available 8 am-8 pm, seven days a week from
October 1 to March 31; and Monday through Friday
the rest of the year.
Martin’s Point Generations Advantage,
891 Washington Ave., PO Box 9746, Portland, ME 04104You can also read
