AgeWell New York · Web viewCervical and vaginal cancer screening Pelvic Exam Pap Test No For all...
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2019 CareWell (HMO SNP) Covered Services Requirements Services Requires Prior Authorization Limitations Abdominal aortic aneurysm screening No One-Time Screening ultrasound for people at risk. Must have family history of AAA or male 65-75yrs who smoked at least 100 cigarettes in his lifetime Air Ambulance Services No (Prior Authorization is required for non- emergency air ambulance services) Covered emergency ambulance services include air ambulance and ground ambulance services, to the nearest appropriate facility that can provide care if they are furnished to a member whose medical condition is such that other means of transportation could endanger the person’s health or if authorized by the plan Non-emergency transportation by air ambulance or ground ambulance is appropriate if it is documented that the member’s condition is such that other means of transportation could endanger the person’s health and that transportation by air ambulance is medically required Ground Ambulance Services No (Prior Authorization is required for non- emergency ground ambulance services) Annual Routine Physical Exam No Annual Routine Physical Exam is limited to one each year. Annual Routine Physical Exam includes comprehensive physical examination and evaluation of status of chronic diseases. Doesn’t include lab tests, radiological diagnostic tests or non-radiological diagnostic tests or diagnostic tests. Additional cost share may apply to any lab or diagnostic 1 | Page Effective 1/1/2019 Updated 5/20/2019 You will see this next to the Benefit or services which are related to your Contract with AgeWell New York.
Transcript of AgeWell New York · Web viewCervical and vaginal cancer screening Pelvic Exam Pap Test No For all...
2019 CareWell (HMO SNP) Covered Services Requirements
Services Requires Prior Authorization
Limitations
Abdominal aortic aneurysm screening
No One-Time Screening ultrasound for people at risk. Must have family history of AAA or male 65-75yrs who smoked at least 100 cigarettes in his lifetime
Air Ambulance Services No
(Prior Authorization is required for non-emergency air ambulance services)
Covered emergency ambulance services include air ambulance and ground ambulance services, to the nearest appropriate facility that can provide care if they are furnished to a member whose medical condition is such that other means of transportation could endanger the person’s health or if authorized by the plan
Non-emergency transportation by air ambulance or ground ambulance is appropriate if it is documented that the member’s condition is such that other means of transportation could endanger the person’s health and that transportation by air ambulance is medically required
Ground Ambulance Services No
(Prior Authorization is required for non-emergency ground ambulance services)
Annual Routine Physical Exam No Annual Routine Physical Exam is limited to one each year.Annual Routine Physical Exam includes comprehensive physical examination and evaluation of status of chronic diseases. Doesn’t include lab tests, radiological diagnostic tests or non-radiological diagnostic tests or diagnostic tests. Additional cost share may apply to any lab or diagnostic testing performed during your visit.
Annual wellness visit No Once every 12 monthsBone mass measurement No Once every 24 months or more frequently if medically necessaryBreast cancer
screening mammogramsNo One baseline mammogram between ages 35-39
One screening mammogram every 12 month for women 40 and olderClinical breast exams once every 24 months
Breast cancer Diagnostic mammogram
Yes Once a year or as many times as medically necessary
Cardiac rehabilitation services(Includes exercise, education, counselling)- Initial course treatment
Yes Limited to a maximum of 2, 1-hour sessions per day for up to 36 sessions with the option for an additional 36 sessions or an extended period of time if approved based on medical necessity./ Intensive cardiac rehab limited to 72, 1-hour sessions, up to 6 sessions per day, over a period of up to 18 weeks
Cardiovascular disease risk No One visit per year
1 | P a g eEffective 1/1/2019 Updated 5/20/2019
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2019 CareWell (HMO SNP) Covered Services Requirements
Services Requires Prior Authorization
Limitations
reduction visit (therapy for cardiovascular disease)Cardiovascular disease testing No Blood tests (Lipid Panel) for the detection of cardiovascular disease (or abnormalities
associated with an elevated risk of cardiovascular disease) once every 5 years (60 months)Cervical and vaginal cancer screening
Pelvic Exam Pap Test
No For all women: Pap tests and pelvic exams once every 24 monthsAt high risk or have had an abnormal pap test and are of childbearing age: one Pap test every 12 months
Chiropractic services No Manual manipulation of the spine to correct subluxation (one or more of the bones of your spine move out of position)
Colorectal cancer screening Colonoscopy
(screening/preventive)
Yes For people 50 and older: Flexible sigmoidoscopy (or screening barium enema as an alternative) every 48 months; One of the following every 12 months: Guaiac-based fecal occult blood test or Fecal immunochemical test; DNA based colorectal screening every 3 years;For people at high risk: Screening colonoscopy (or screening barium enema as an alternative) every 24 months;For people not at high risk: Screening colonoscopy every 10 years (120 months), but not within 48 months of a screening sigmoidoscopyIMPORTANT: If a screening colonoscopy or screening flexible sigmoidoscopy results in the biopsy or removal of a lesion or growth during the same visit, the procedure is considered diagnostic and cost-share applies
Colorectal cancer Colonoscopy (surgical)
Yes
Dental services Limited Preventive services Comprehensive services
Contact HealthPlex 1-800-468-9868 for coverage and authorization
Preventive dental: Oral exams one every 6 months; Prophylaxis (cleaning) one every 6 months+; Dental x-ray(s) one every 6 monthsComprehensive dental: Entitled to dentures under Prosthodontic once every 5 years
Depression screening No One screening for depression per yearDiabetes screening No Based on test results, we cover up to 2 diabetes screenings every 12 months, if there is a
history of HTN, High cholesterol/triglyceride level, obesity or hyperglycemia; or if 2 or more apply: 65 years or older, obesity, family history, or gestational diabetes
Diabetes self-management training No You qualify for initial training and up to 2 hours of follow-up training each year
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2019 CareWell (HMO SNP) Covered Services Requirements
Services Requires Prior Authorization
Limitations
Diabetic services and supplies No Supplies to monitor your blood glucoseDiabetic therapeutic shoes and inserts
No One pair per calendar year of therapeutic custom molded shoes (including inserts provided with such shoes)Two additional pairs of inserts, or one pair of depth shoes, and three pairs of inserts (not including the non-customized removable inserts provided with such shoes)
Durable medical equipment and related supplies
Yes Covered items include, but are not limited to: wheelchairs, crutches, powered mattress systems, diabetic supplies, hospital beds ordered by a provider for use in the home, IV infusion pumps, speech generating devices, oxygen equipment, nebulizers, and walkers.
Emergency care (US + Territories Only)
No Medical symptoms that require immediate medical attention to prevent loss of life, loss of a limb, or loss of function of a limb. The medical symptoms may be an illness, injury, severe pain, or a medical condition that is quickly getting worse.If you are admitted to the hospital within 24 hours for the same condition, you do not pay the copay.
Hearing services No (Contact EPIC Hearing 1-877-606-3742 for coverage)
Diagnostic hearing and balance evaluations performed by your provider to determine if you need medical treatment are covered as outpatient care when furnished by a physician, audiologist, or other qualified provider1 Routine Hearing Exam per year
Hearing aids Yes (Contact EPIC Hearing 1-877-606-3742 for coverage)
We cover $500 towards the purchase of hearing aids once every 2 yearsIncludes fitting and evaluation for hearing aids.
HIV screening No Increased risk: one screening exam every 12 monthsWomen who are pregnant: 3 screening exams during pregnancy
Home health agency care Yes Must total fewer than 8 hours per day and 35 hours per weekMedicare requirements for skilled care apply.
Hospice care Covered under Original Medicare
Medicare-certified hospice program is covered by Original Medicare. You are eligible for the hospice benefit when your doctor and the hospice medical director have given you a terminal prognosis certifying that you’re terminally ill and have 6 months or less to live if your illness runs its normal course ( For more information see EOC and Medicare.gov )
Immunizations Influenza
No Flu shots once a year in the fall or winter with additional flu shots, if medically necessaryPneumonia vaccines, Hepatitis B, and other vaccines if you are at risk and meet Medicare
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2019 CareWell (HMO SNP) Covered Services Requirements
Services Requires Prior Authorization
Limitations
Pneumococcal Hepatitis B
Part B coverage rulesClaims must be submitted
Inpatient hospital care Yes Benefit period begins the day you are admitted as an inpatient in the hospital and ends when you haven’t received any inpatient care for 60 consecutive days
Amounts may change in 2019Inpatient mental health care Yes Up to 90 days of medically necessary hospitalization and 40 additional days in a Psychiatric
hospital
Amounts may change in 2019Medical nutrition therapy No This benefit is for people with diabetes, renal (kidney) disease (but not on dialysis), or after a
kidney transplant when ordered by your doctor.3 hours of one-on-one counseling services during your first year, 2 hours each year after that
Medicare Diabetes Prevention Program (MDPP)
No MDPP services will be covered for eligible Medicare beneficiaries
Medicare Part B prescription drugs
Yes Step Therapy may apply to certain drugs.
Medicare Part D prescription Drugs
Yes Deductible $415 for all part D Prescription Drug. Amounts may be less depending on the level of Medicaid/LIS.
Obesity screening and therapy to promote sustained weight loss
No If you have body mass index 30 or more
Outpatient diagnostic tests and therapeutic services and supplies
Preventive Diagnostic procedures and tests
X-Rays Lab services Diagnostic procedures and
Yes Prior Authorization is not required for Lab, tests such as Sonogram/Ultrasound, Electrocardiogram, or X-Rays.
4 | P a g eEffective 1/1/2019 Updated 5/20/2019
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2019 CareWell (HMO SNP) Covered Services Requirements
Services Requires Prior Authorization
Limitations
tests such as:-Echocardiogram-EKG-Sonogram-Ultrasound
Surgical and medical supplies
Blood Services Therapeutic radiological
services Diagnostic radiological
services (CT, MRI, PET scan, MRA, etc)
Outpatient hospital services Yes
(Prior Authorization is not required for tests such as Sonogram/Ultrasound, Electrocardiogram, X-Ray and Lab)
We cover medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or injuryCovered services include, but are not limited to:
• Services in an emergency department or outpatient clinic, such as observation services or outpatient surgery
• Laboratory and diagnostic tests billed by the hospital • Mental health care, including care in a partial-hospitalization program, if a
doctor certifies that inpatient treatment would be required without it • X-rays and other radiology services billed by the hospital Medical supplies such
as splints and casts • Certain screenings and preventive services • Certain drugs and biologicals that you can’t give yourself
Outpatient mental health care Yes Cover individual or group outpatient mental health care
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2019 CareWell (HMO SNP) Covered Services Requirements
Services Requires Prior Authorization
Limitations
Rehabilitation services Occupational therapy Physical therapy Speech-language pathology
(Speech therapy)
Prior Authorization is not required for rehabilitation services provided on site.
Yes – if a member is sent out of the facility.
Evaluations are payable at your contracted rate. Therapy is covered under your Capitation agreement with AgeWell New York. Claims must be submitted per your contract for reimbursement.
External OT, PT or SLP care must be authorized and is capped per Original Medicare guidelines: PT and SLP combined is covered up to $2,010 and for OT up to $2,010.
Outpatient substance abuse services
Yes Cover individual and group outpatient substance abuse services
Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers
Yes Outpatient Surgery includes services provided at hospital outpatient facilities and ambulatory surgical centers.
Partial hospitalization services YesPhysician/Practitioner services, including doctor’s office
PCP Specialist
No(Prior Authorization is needed for tests that require Contrasts or Anesthesia)
Annual Routine Physical Exam includes comprehensive physical examination and evaluation of status of chronic diseases. Doesn’t include lab tests, radiological diagnostic tests or non-radiological diagnostic tests or diagnostic tests. Additional cost share may apply to any lab or diagnostic testing performed during your visit.
Podiatry services Nail debridement and
clipping
No Nail debridement and clippingMust meet Medicare criteria for Podiatry services
Prostate cancer screening exams No For men age 50 and older once every 12 months: digital rectal exam or prostate specific antigen test
Prosthetic devices and related supplies
Yes Devices (other than dental) that replace all or part of a body part or function. These include, but are not limited to: colostomy bags and supplies directly related to colostomy care, pacemakers, braces, prosthetic shoes, artificial limbs, and breast prostheses (including a surgical brassiere after a mastectomy)
Pulmonary rehabilitation services Yes Limited to up to 36 sessions, no more than two sessions per dayScreening and counseling to No One alcohol misuse screening for adults who misuse alcohol but aren’t alcohol dependent
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2019 CareWell (HMO SNP) Covered Services Requirements
Services Requires Prior Authorization
Limitations
reduce alcohol misuse If you screen positive for alcohol misuse, you get up to 4 face-to-face counseling sessions per year
Screening for lung cancer with low dose computed tomography
No Covered once every 12 months for people 55-77 years who have a history of tobacco smoking
Screening for sexually transmitted infections (STIs) and counseling to prevent STIs
No Cover tests once every 12 months or at certain times during pregnancyCover up to 2 individual 20 to 30 minutes face-to-face counseling sessions each year
Services to treat Kidney disease and conditions
Yes Kidney disease education Dialysis
Skilled nursing facility (SNF) care
N/A The CareWell capitation payments are unaffected by a member’s skilled care after a hospitalization or fall. The 3-day hospitalization is not applicable to CareWell as these members are residents of your facility. As a contracted provider you receive your PMPM for each member month of residence. Any skilled care, or Part A stay, does not affect your Medicare contract with AgeWell New York. Claims must be coded and submitted as you would for original Medicare to support capitation and your MDS and Case Mix Index. The CareWell Team is onsite to assist and ensure treatment and care is available in an effort to keep members out of the hospital and assist with changes in member’s status and needs.*See also: Rehabilitation Services
Smoking and tobacco use cessation (counseling to stop smoking or tobacco use)
No If you use tobacco but do not have signs of tobacco related disease we cover two counseling sessions within a 12 month period If you use tobacco and have been diagnosed with a tobacco related disease we cover two counseling sessions with 12 month period, however, there is a cost share(Each counseling attempt includes up to 4 face-to-face visits)
Supervised Exercise Therapy (SET)
Yes Up to 36 sessions over a 12-week period are covered if the SET program requirements are met. SET may be covered beyond 36 sessions over 12 weeks for an additional 36 sessions over an extended period of time if deemed medically necessary by a health care provider.
Transportation Not CoveredUrgently needed services No If you are admitted to the hospital within 24 hours for the same condition, you do not
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2019 CareWell (HMO SNP) Covered Services Requirements
Services Requires Prior Authorization
Limitations
(US + Territories Only) pay the copayVision Care No (Contact National Vision
Associates 1-844-344-1250 for coverage and authorization)
Eye Wear Yes (Contact National Vision Associates 1-844-344-1250 for coverage and authorization)
For people with diabetes one screening for diabetic retinopathy per yearOne pair of eyeglasses with standard frames (or one set of contact lenses) after cataract surgery that implants an intraocular lens.
“Welcome to Medicare” Preventive visit
No One time visit only within the first 12 months you have Medicare Part B
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