PPO II - EmblemHealth

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2013 Evidence of Coverage for PPO II) II Medical Chapter Benefi 4: Medical ts Chart Benefi ts Chart (what is covered and what you pay) Services that are covered for you Services to treat kidney disease and conditions Covered services include: • Kidney disease education services to teach kidney care and help members make informed decisions about their care. For members with stage IV chronic kidney disease when referred by their doctor, we cover up to six sessions of kidney disease education services per lifetime. • Outpatient dialysis treatments (including dialysis treatments when temporarily out of the service area, as explained in Chapter 3) • Inpatient dialysis treatments (if you are admitted as an inpatient to a hospital for special care) • Self-dialysis training (includes training for you and anyone helping you with your home dialysis treatments) • Home dialysis equipment and supplies • Certain home support services (such as, when necessary, visits by trained dialysis workers to check on your home dialysis, to help in emergencies, and check your dialysis equipment and water supply) Certain drugs for dialysis are covered under your Medicare Part B drug benefi t. For information about coverage for Part B Drugs, please go to the section below, “Medicare Part B prescription drugs.” Skilled nursing facility (SNF) care * Prior authorization is required Coverage is limited to the fi rst 100 days of stay in a skilled nursing facility per Medicare defi ned benefi t period. (For a defi nition of “skilled nursing facility care,” see Chapter 12 of this booklet. Skilled nursing facilities are sometimes called “SNFs.”) Covered services include but are not limited to: • Semiprivate room (or a private room if medically necessary) • Meals, including special diets • Skilled nursing services • Physical therapy, occupational therapy, and speech therapy • Drugs administered to you as part of your plan of care (Th is includes substances that are naturally present in the body, such as blood clotting factors.) • Blood - including storage and administration. Coverage of whole blood and packed red cells begins with the fi rst pint used. What you must pay when you get these services In Network: $0 copayment for each Medicare-covered service Out of Network: $0 copayment for each Medicare-covered service If you reside in New York, Queens, Kings, Richmond or Bronx counties, you pay: In-Network: $65 copayment per day for days 1 - 20 for each benefi t period $125 copayment per day for days 21 - 100 for each benefi t period 75
76 2013 Evidence of Coverage for PPO II Chapter 4: Medical Benefi ts Chart (what is covered Medical and what Benefi you ts Chart pay) Services that are covered for you • Medical and surgical supplies ordinarily provided by SNFs • Laboratory tests ordinarily provided by SNFs • X-rays and other radiology services ordinarily provided by SNFs • Use of appliances such as wheelchairs ordinarily provided by SNFs • Physician/Practitioner services Generally, you will get your SNF care from network facilities. However, under certain conditions listed below, you may be able to pay innetwork cost sharing for a facility that isn’t a network provider, if the facility accepts our plan’s amounts for payment. • A nursing home or continuing care retirement community where you were living right before you went to the hospital (as long as it provides skilled nursing facility care). • A SNF where your spouse is living at the time you leave the hospital. Smoking and tobacco use cessation (counseling to stop smoking or tobacco use) If you use tobacco, but do not have signs or symptoms of tobaccorelated disease: We cover two counseling quit attempts within a 12-month period as a preventive service with no cost to you. Each counseling attempt includes up to four face-to-face visits. What you must pay when you get these services If you reside in Nassau, Rockland, Westchester and Suff olk counties, you pay: In-Network: $25 copayment per day for days 1 - 20 for each benefi t period $50 copayment per day for days 21 - 100 for each benefi t period For all counties, you pay: Out of Network: 25% of the Medicare allowable amount for each benefi t period. If you haven’t been diagnosed with an illness caused or complicated by tobacco use: In Network: $0 copayment for each Medicare-covered service
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55 Water Street, New York, New York
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PPO II - EmblemHealth

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