<Plan name>《會員手冊》
簡介
本章將向您介紹本計畫承保的服務、這些服務存在的限制[insert if the plan has cost-sharing: 以及您為每項服務支付的費用]。此外,還將介紹本計畫未涵蓋的福利。關鍵術語及其定義按英文字母順序列於《會員手冊》的最後一章中。
[Plans should refer to other parts of the Member Handbook using the appropriate chapter number, section, and/or page number. For example, "refer to Chapter 9, Section A, page 1." An instruction [insert reference, as applicable] appears with many cross references throughout the Member Handbook. Plans may always include additional references to other sections, chapters, and/or member materials when helpful to the reader.]
[Plans must update the Table of Contents to this document to accurately reflect where the information is found on each page after plan adds plan-customized information to this template.]
目錄
A. 您的承保服務[insert if the plan has cost-sharing: 和 自付費用] 2
H. 本計畫、Medicare或[insert name of state-specific Medicaid program]未承保的福利。 45
本章將向您介紹本計畫所承保的服務[insert if the plan has cost-sharing: 以及您為每項服務支付的費用]。此外,還向您介紹了未承保的服務。您的《會員手冊》第5章提供了有關藥物福利的資訊。[Insert if applicable: 本章還對某些服務存在的限制進行了說明。]
[Plans with cost-sharing, insert: 對於某些服務,您需承擔自付費用,稱為共付額。這是一筆固定金額(如 $5),在您每次獲得該服務時支付。您需在獲得醫療服務時支付共付額。]
[Plans with no cost-sharing for any services described in this chapter, insert: 因為您從[Insert name of state-specific Medicaid program]獲得協助,只要您遵守本計畫的規則,您就不用為所承保的服務支付任何費用。有關本計畫之規則的詳細資訊,請參閱您的《會員手冊》第3章。]
如果您在理解承保服務方面需要幫助,請致電[<phone number(s)>聯絡您的護理協調員and/or 會員服務部]。
[As applicable, plans insert the subsection heading and information below.]
[Plans providing required coverage and permissible flexibilities to members subject to a public health emergency declaration (e.g., the COVID-19 pandemic) concisely describe the coverage and flexibilities here or include general information about the coverage and flexibilities along with any cross references, as applicable. Plans include whether such coverage and flexibilities are contingent upon the duration of the public health emergency, which may or may not last for the entire year. Plans also include any specific contact information, as applicable, where members can get more details.]
對於承保的服務,我們不允許我們的網路醫療服務提供者向您收取費用。我們直接向其付款,保護您免遭任何收費。即使我們向醫療服務提供者支付的費用低於其收取的服務費用,也是如此。
對於承保的服務,您永遠不必向醫療服務提供者支付任何費用。如果您支付了費用,請參閱《會員手冊》的第7章或致電會員服務部。
[Plans may add references to long-term care or home and community-based services.]
福利表介紹了本計畫所承保的服務。該表按英文字母順序列出了承保服務並對其進行了說明。[Plans that include an index at the end of the chapter should insert: 要在表中查找某項服務,您也可以使用本章末尾的索引。]
當符合以下規則時,我們會為福利表中列出的服務承保。[Plans that do not have cost-sharing, insert: 只要您滿足下述要求,您無需為福利表中列出的服務支付任何費用。]
我們必須按照Medicare和[Insert name of state-specific Medicaid program]制定的規則為您提供Medicare和[insert name of state-specific Medicaid program]承保的服務。
服務[Plans may revise as applicable: (including medical care, behavioral health and substance use services, long-term services and supports, supplies, equipment, and drugs)]必須是醫療所需的。「醫療所需」是指您為預防、診斷或者治療某種病情狀況或維持當前健康狀況所需的服務、用品或藥物。這包括讓您不必進入醫院或療養院所需的護理。這也意味著符合公認的醫療實踐標準的服務、用品或藥物。[Plans may revise and use the state-specific definition of “medically necessary” and ensure that it is updated and used consistently in Chapter 12 and throughout member materials.]
[Insert if applicable: 您從網路醫療服務提供者處獲得醫療服務。網路醫療服務提供者是與我們合作的服務提供者。在大多數情況下,您從網路外醫療服務提供者處獲得的護理將不在承保範圍內,除非是緊急情況或急需護理,或者除非您的計畫或網路醫療服務提供者已為您提供轉介。有關使用網路內和網路外醫療服務提供者的更多資訊,請參閱《會員手冊》的第3章。]
[Insert if applicable: 您有一個基層照護服務提供者 (PCP) 或一個護理團隊來提供和管理您的醫療事宜。[Plans that do not require referrals, omit the rest of this paragraph:]在大多數情況下,您必須獲得您的PCP的批准才能使用您的PCP以外的醫療服務提供者或使用計畫網路內的其他服務提供者。這稱為轉介。《會員手冊》的第3章提供了有關獲得轉介以及何時不需要轉介的更多資訊。]
[Plans may add information about any continuity of care requirements as directed by the state.]
[Insert if applicable: 僅當您的醫生或其他網路醫療服務提供者事先獲得我們的批准時,我們才會承保福利表中列出的某些服務。這稱為事前授權 (PA)。我們在福利表中[insert as appropriate: 用星號 (*) or或註腳or粗體or斜體]標記了需要PA的承保服務。[Insert if applicable: [此外,對於福利表中未列出的以下服務,您也必須獲得PA: [insert list]。]
[Instructions to plans offering Value-Based Insurance Design (VBID) Model benefits:
Plans may deliver to each clinically-targeted enrollee a written summary of those benefits so that such enrollees are notified of VBID benefits for which they are eligible. For VBID plans that choose to deliver a written notice, VBID plans must follow the VBID guidance on communications for delivering a written notice when offering targeted supplemental or VBID benefits. (See CY 2024 Value-Based Insurance Design Communications and Marketing Guidelines).
If applicable, plans must update the Benefits Chart and include a supplemental benefits chart including a column that details the exact targeted reduced cost-sharing amount for each specific service, and/or the additional supplemental benefits being offered. Specific services should include details as it relates to VBID benefits.
If applicable, plans with VBID should mention reduced cost-sharing for their MA benefits, as well as that members may qualify for a reduction or elimination of their cost-sharing for Part D drugs in Plans with VBID may include the reduction or elimination of their cost-sharing for Part D drugs in Chapter 6, Section C.]
[Insert if offering VBID Model benefits:
針對患有某些慢性病的參與者的重要福利信息
如果您由計畫提供者診斷患有以下定義之慢性病並符合某些醫療標準,您可能有資格獲得針對性補充福利和/或減少分攤費用:
[List all applicable chronic conditions here。]
[As applicable, plans offering benefits under VBID that require participation in a health and wellness program or to see a high-value provider, include those limitations and then direct the enrollee that they will be provided additional information with how to take advantage of these additional supplemental benefits. (See CY 2024 Value-Based Insurance Design Communications and Marketing Guidelines).]
For further detail, please go to the Help with Certain Chronic Conditions row in the Medical Benefits Chart below.]
[Insert if offering VBID benefits:
[Plans participating in VBID should use this section to describe the plans strategy for advance care planning and any other wellness and health care planning (WHP) services that are being offered:]
適用於所有參與健康和醫療保健計畫 (WHP) 服務的參與者的重要福利資訊
由於[insert 2024 plan name]參與了[insert VBID program name],您將有資格獲得以下WHP服務,包括預先護理計畫 (ACP) 服務:
[Include a summary of WHP services that are to reach all VBID plan enrollees in CY 2024. The description must include language that WHP and ACP are voluntary and enrollees are free to decline the offers of WHP and ACP.]
[Include information on how and when the enrollee would be able to access WHP services.]
[Instructions to plans offering WHP benefits:
In addition to offering advance care planning as a covered benefit, plans participating in the VBID Model may deliver to each VBID PBP enrollee a written summary of WHP benefits so that such enrollees are notified of the benefits for which they are eligible. For VBID plans that choose to deliver a written notice, VBID plans must follow the VBID guidance on communications for a written summary when offering WHP benefits (See CY 2024 Value-Based Insurance Design Communications and Marketing Guidelines).
If applicable, plans should mention that enrollees may qualify for cost-sharing or co-payment reductions].
[Insert if offering VBID flexibility benefits and targeted supplemental benefits to Low Income Subsidy (LIS) enrollees, as defined in the Plan Communication User Guide (PCUG):]
[Instructions to plans offering VBID benefits:]
Plans may deliver to each LIS-targeted enrollee a written summary of those benefits so that such enrollees are notified of VBID benefits for which they are eligible. For VBID plans that choose to deliver a written notice, VBID plans must follow the VBID guidance on communications for delivering such a written notice when offering targeted supplemental or VBID benefits. (See CY 2024 Value-Based Insurance Design Communications and Marketing Guidelines).
Plans who choose to reduce cost-sharing for an item or service, including Part D drugs covered by Medicare Advantage Prescription Drug (MA-PD) plan through member participation in a plan-sponsored disease management or similar program, must include a summary of the additional supplemental benefits they would receive as well as the activities and/or programs the member must complete in order to receive the benefit.
If applicable, plans must update the Benefits Chart and include a supplemental benefits chart including a column that details the exact targeted reduced cost-sharing amount for each specific service, and/or the additional supplemental benefits being offered. Specific services should include details as it relates to VBID benefits.
If applicable, plans with VBID should mention that members may qualify for a reduction or elimination of their cost-sharing for Part D drugs in Chapter 6, Section C.
[Insert only if offering VBID mandatory supplemental benefit flexibility to Cover New and Existing Technologies or Food and Drug Administration (FDA) approved Medical Devices:]
適用於有資格接受新技術和現有技術或FDA批准的醫療設備護理之VBID計畫參與者的重要福利資訊。
由於[insert 2024 plan name]參與了[insert VBID program name],您可能有資格接受新技術和現有技術或FDA批准的醫療設備護理:
[Include a description of the new and existing technologies or FDA approved medical devices specifying eligibility for the benefit and associated cost-sharing as an enrollee in the VBID plan in 2024. The description must include language that enrollees are free to decline the benefit and how they would notify the plan of declining this supplemental benefit.]
[Instructions to plans offering Coverage of New and Existing Technologies or FDA-approved Medical Devices as a mandatory supplemental benefit:
Plans may deliver to each VBID PBP’s enrollee a written summary of coverage of new and existing technologies or FDA-approved medical devices so that such enrollees are notified of the benefits for which they are eligible. For VBID plans that choose to deliver a written notice, VBID plans must follow the VBID guidance on communications for delivering a written summary when offering coverage of new and existing technologies or FDA-approved medical devices (See CY 2024 Value-Based Insurance Design Communications and Marketing Guidelines).]
[Insert if plan is offering targeted “Uniformity Flexibility” supplemental benefits and/or “Special Supplemental Benefits for the Chronically Ill (SSBCI)” in Section B-19 of the Plan Benefit Package submission: 關於患有某些慢性病的會員的重要福利資訊。如果您患有以下慢性病並符合某些醫療標準,您可能有資格獲得額外福利 [insert if applicable:和/或減少分攤費用]:
[List all applicable chronic conditions here.]
[If offering SSBCI, include information about the process and/or criteria for determining eligibility for SSBCI. Plan must also deliver a written summary of the SSBCI offered to each chronically ill member eligible for SSBCI.]
更多相關資訊,請參閱福利表中的「某些慢性病相關指南」部分。]
[Insert
as applicable: 大部分or所有]
預防性服務都是免費的。在福利表中,預防性服務旁邊會有這個蘋果標誌
。
[Insert any additional applicable Medicaid program coverage here such as community supports.]
[Instructions on completing the Benefits Chart:
For all preventive care and screening test benefit information, plans that cover a richer benefit do not need to include the given description (unless it is still applicable) and may instead describe the plan benefit.
Optional supplemental benefits are not permitted in this chart; optional supplemental benefits should be described in Section E.
Include the following where appropriate: 與您的醫療服務提供者溝通並獲得轉介。
Plans must include any services provided in excess of the Medicare and Medicaid requirements and identify preventive services with the apple icon.
HMO POS plan types must provide information about which services must be obtained from network providers, which services can be obtained out-of-network under the POS benefit, and any differences in cost-sharing for covered services obtained out-of-network under the POS benefit.
Plans should clearly indicate which benefits are subject to PA. (This can be done with asterisks, footnotes, bold type, or italic type. Plans must select only one method of indication, describe it in terms easily understandable by members, make the indication and description prominently visible, and use it consistently throughout the document.)
Plans may insert any additional benefit information that is based on the plan’s approved benefit package and not already included in the Benefits Chart or in the exclusions section. Plans insert any additional benefits in the chart alphabetically.
Plans must add any Medicaid benefits covered to the chart as instructed by the state. Insert any additional benefits in the chart alphabetically. If directed by the state, include all non-waiver services in the chart and all HCBS waiver services as a separate section after the chart. Each 1915(c) waiver should be listed separately, with the appropriate services also listed. The remainder of the sections should then be renumbered.
Plans must describe any restrictive policies, limitations, or monetary limits that might affect a member’s access to services within the chart.
Plans may add references to the list of exclusions as appropriate. If an excluded benefit is highly similar to an allowed benefit, the plan must add an appropriate reference to the list of exclusions. If the benefit does not resemble any exclusion, then the plan should not reference the exclusion list.
Plans should include all non-waiver LTSS in the chart in alphabetical order.
Plans with no cost-sharing for any type of service (i.e., no cost-sharing at all) may delete the “what you must pay” column from the table. Plans with any type of cost-sharing for services, including for pharmacy services, must leave the “what you must pay” column in the table.
Plans offering targeted supplemental benefits in Section B-19 of the Plan Benefit Package submission must:
Deliver to each clinically-targeted member a written summary of those benefits so that such member are notified of the “Uniformity Flexibility” benefits for which they are eligible.
Update the Benefits Chart to include details, as applicable, about the exact targeted reduced cost-sharing amount for each specific service and/or the additional supplemental benefits being offered.]
[When a benefit continues from one page to the next, plans enter a blank return before right aligning and inserting at the bottom of the first part of the description: 此福利下頁繼續。At the top of the next page where the benefit description continues, plans enter the benefit name again in bold followed by(續). Plans may refer to 耐用醫療器材 (DME) 和相關用品and other benefits later in this chart as examples. Plans should also be aware that the flow of benefits from one page to the next may vary after plan-customized information is added, which may necessitate adding and/or removing these instructions in other services as needed.]
[Plans should modify this section throughout to reflect Medicaid or plan-covered supplemental benefits as appropriate as well as any copays that may differ for Medicaid.]
本計畫支付的服務 |
您須支付的費用 |
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腹主動脈瘤篩查 我們為有風險的患者支付一次性超聲檢查費用。僅當您存在某些風險因素並且從您的醫師、醫師助理、執業護士或臨床護理專科醫師處獲得轉介的情況下,本計畫才會承保這項篩查。 [List any additional benefits offered.] |
$0 [List copays for additional benefits.] |
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針灸 如果您患有慢性腰痛(定義如下),我們會在90天內支付最多12次針灸治療費用:
此外,如果您的慢性腰痛病情有所改善,我們會額外支付8次針灸治療費用。對於慢性腰痛,您每年接受的針灸治療不得超過20次。 如果您沒有好轉或更加嚴重,則必須停止針灸治療。 [List any additional benefits offered.] |
$0 [List copays for additional benefits.] |
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酒精濫用的篩查和諮詢 我們為濫用酒精但不依賴酒精的成年人支付一次酒精濫用篩查費用。這也包括孕婦。 如果您的酒精濫用篩查結果呈陽性,則您每年可以與有資質的基層照護服務提供者 (PCP) 或基層照護機構的從業者進行最多四次簡短的面對面諮詢(如果您在諮詢期間有行爲能力且保持清醒)。 [List any additional benefits offered.] |
$0 |
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救護車服務 承保的救護車服務包括地面、固定翼和旋轉翼(直升機)救護車服務。救護車會將您送到最近的可為您提供醫療服務的場所。 您的病情必須嚴重到以其他方式前往醫療服務場所可能會危及您的健康或生命。 其他情況下的救護車服務必須獲得我們的批准。在非緊急情況下,我們可能支付救護車費用。您的病情必須嚴重到以其他方式前往醫療服務場所可能會危及您的生命或健康。 |
$0 |
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年度健康檢查 您可以每年做一次健康檢查。這是為了能夠根據您當前的風險因素制定或更新預防計畫。我們每12個月為這項檢查支付一次費用。 註:您的第一次年度健康就診不能在歡迎加入Medicare就診後的12個月內進行。但是,在您參與B部分12個月後,您無需進行歡迎加入Medicare就診即可獲得年度健康就診。 [List any additional benefits offered.] |
$0 |
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骨質密度檢查 我們為符合條件的會員(通常是有骨質流失風險或骨質疏鬆症風險的人)支付某些程式費用。這些程式將確定骨質密度、發現骨質流失或確定骨骼質量。 我們每24個月支付一次服務費用,如為醫療所需,我們支付服務費用的次數則會更頻繁。我們還為請醫生查看結果並發表意見而付費。 [List any additional benefits offered.] |
$0 [List copays for additional benefits.] |
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乳腺癌篩查(乳房X光檢查) 我們承保以下服務:
[List any additional benefits offered.] |
$0 [List copays for additional benefits.] |
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心血管(心臟)復健服務 我們支付心臟復健服務費用,如鍛煉、指導和諮詢。會員必須符合一定條件並獲得醫生的[insert as appropriate: 轉介or醫囑]。 我們還承保加强型心臟復健計畫,比其它心臟復健計畫強度更大。 |
$0 |
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降低心血管(心臟)疾病風險就診(心臟病治療) 我們每年向您的基層照護服務提供者 (PCP) 支付一次就診費用,如為醫療所需,可以支付更多診次,以幫助您降低心臟病患病風險。[insert: 就診or就診]期間,您的醫生可能會:
[List any additional benefits offered.] |
$0 [List copays for additional benefits.] |
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心血管(心臟)疾病檢測 我們每五年(60個月)支付一次驗血費用,以檢查心血管疾病。這些血液檢驗還可以檢查由於心臟病高風險而導致的缺陷。 [List any additional benefits offered.] |
$0 [List copays for additional benefits.] |
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宮頸癌和陰道癌篩查 我們承保以下服務:
[List any additional benefits offered.] |
$0 [List copays for additional benefits.] |
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整脊服務 我們承保以下服務:
[List any Medicaid or plan-covered supplemental benefits offered. Also list any restrictions, such as the maximum number of visits.] |
[List copays.] [List copays for supplemental benefits.] |
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大腸癌篩查
[List any additional benefits offered.] |
$0 [List copays for additional benefits.] |
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[Include row if applicable and modify to accurately describe the Medicaid and/or supplemental benefit offered.] 牙科服務 某些牙科服務,包括清洗、補牙和假牙,可透過[insert name of Medicaid program or integrated name]牙科計畫獲得。 [Plans that offer optional supplemental dental benefits at an additional cost insert: 注:本計畫提供額外的牙科服務。相關詳細資訊,請查看第E節中的福利表。] |
[If plan offers supplemental benefit, the maximum copay amount is $10.] |
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抑鬱症篩查 我們每年支付一次抑鬱症篩查費用。篩查必須在可以提供後續治療和轉介的基層照護服務機構進行。 [List any additional benefits offered.] |
$0 [List copays for additional benefits.] |
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糖尿病篩查 如果您有以下任何一種風險因素,我們會為這項篩查(包括空腹血糖測試)付費:
在其他某些情況下(如您超重並且有糖尿病家族史),也可能會承保檢測。 根據檢測結果,您可能有資格每12個月進行最多兩次糖尿病篩查。 [List any additional benefits offered.] |
$0 [List copays for additional benefits.] |
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糖尿病自我管理培訓、服務與用品 我們為所有糖尿病患者(無論他們是否使用胰島素)支付以下服務費用:
[List any additional benefits offered.] |
$0 [List copays for additional benefits.] |
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耐用醫療器材 (DME) 和相關用品 有關「耐用醫療器材 (DME)」的定義,請參閱《會員手冊》的第12章 我們承保以下項目:
可能還包括其他用品。 此福利下頁繼續 |
[List copays, including how they vary for equipment covered by Medicare and Medicaid, if applicable.] [Include if applicable: 您對Medicare氧氣設備承保的費用分攤為[insert copay amount or coinsurance percentage]每[insert required frequency of payment]。] [Plans that use a constant cost-sharing structure for oxygen equipment insert: 您的費用分攤在投保36個月後將不會改變。]
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耐用醫療器材 (DME) 和相關用品(續) [Plans that do not limit the DME brands and manufacturers that they cover, insert: 我們為Medicare和Medi-Cal通常承保的所有醫療所需的DME支付費用。如果我們的供應商在您的地區不銷售特定的品牌或製造商,您可以詢問他們是否可以為您特別訂購。] [Plans that limit the DME brands and manufacturers that they cover, insert the following (for more information about this requirement, refer to Chapter 4 of the Medicare Managed Care Manual): 伴隨此 Member Handbook,我們向您發送了本計畫的DME清單。這份清單列出了我們承保的DME品牌和製造商。您還可以在我們的網站<URL>上找到最新的品牌、製造商和供應商清單。 一般來說,本計畫在這份清單上涵蓋了Medicare和Medicaid所承保的任何品牌和製造商的DME。我們不承保其他品牌和製造商,除非您的醫生或其他醫療服務提供者告訴我們您需要該品牌。但是,如果您是本計畫的新會員並且正在使用的DME品牌不在我們的清單上,我們將繼續為您支付該品牌的費用,最長期限為90天。在這段時間,請與您的醫生溝通,決定在90天期限後哪種品牌在醫療上對您來說是合適的。(如果您與您的醫生意見不一致,您可以要求他們將您轉介至其他醫生來徵求其他意見。) 如果您(或您的醫生)不同意本計畫的承保決定,您或您的醫生可以提出上訴。如果您不同意醫生關於哪種產品或品牌適合您的病情狀況的決定,您也可以提出上訴。有關提出上訴的更多資訊,請參閱《會員手冊》的第9章。] |
[Plans that wish to vary cost-sharing for oxygen equipment after 36 months insert details including whether original cost-sharing resumes after 5 years and you are still in the plan.] [If cost-sharing is different for members who made 36 months of rental payments prior to joining the plan insert: 如果在投保 [insert plan name]前為 [insert cost-sharing].] |
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急診照護 急診照護是指以下服務:
醫療緊急狀況是指伴有劇烈疼痛或嚴重損傷的病情狀況。這種情況非常嚴重,如果不立即就醫,任何具有一般健康和醫學知識的人都可以預期它會導致:
[Also identify whether the plan only covers emergency care within the U.S. and its territories as required or also covers emergency care as a supplemental benefit that provides world-wide emergency/urgent coverage.] |
$0 如果您在網路外醫院接受急診照護,然後在您的急診狀況穩定後需要住院護理,[plans should insert information as needed to accurately describe emergency care benefits:(例如,您必須回到網路內醫院才能繼續承保您的醫療費用。只有在獲得本計畫批准的情況下,您才能留在網路外醫院接受住院治療。)] |
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[如果計畫生育服務受承保,plans should modify this as necessary.] 計畫生育服務 法律允許您為某些計畫生育服務選擇任何醫療服務提供者 – 無論是網路醫療服務提供者還是網路外醫療服務提供者。這表示您可以選擇任何醫生、診所、醫院、藥房或計畫生育辦公室。 我們承保以下服務:
我們還為其他某些計畫生育服務付費。但是,您必須使用我們的網路內醫療服務提供者來提供以下服務:
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[List copays.] |
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健康和保健教育方案 [These are programs focused on health conditions such as high blood pressure, cholesterol, asthma, and special diets. Programs designed to enrich the health and lifestyles of members include weight management, fitness and stress management. Describe the nature of the programs here.] [If this benefit is not applicable, plans should delete this row.] |
[List copays.] |
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[Plans should modify this section to reflect plan-covered benefits as appropriate.] 聽力服務 我們承保由您的醫療服務提供者進行的聽力和平衡測試。這些測試會讓您瞭解是否需要治療。當您從醫生、聽覺矯正專家或其他有資質的醫療服務提供者處獲得該項服務時,將以門診保健服務形式承保。 |
[List copays.] [List copays for additional benefits.] |
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[If this benefit is not applicable, plans should delete this row.] 幫助治療某些慢性病 [Plans that offer targeted “Uniformity Flexibility” supplemental benefits and/or “Special Supplemental Benefits for the Chronically Ill (SSBCI),” which members with certain chronic condition(s) may be eligible to receive from a network provider, should include information about the specific benefits and (as applicable) reduced cost-sharing. If offering SSBCI, plans must also list the chronic conditions and benefits and describe the nature of the benefits and the eligibility criteria. The benefits listed here must be approved in the Plan Benefit Package submission.] |
[List copays.] |
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愛滋病毒篩查 我們為以下人群每12個月支付一次愛滋病毒篩查費用:
對於懷孕的女性,我們在懷孕期間最多支付三次愛滋病毒篩查測試的費用。 [List any additional benefits offered.] |
$0 [List copays for additional benefits.] |
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家庭保健機構護理 [Plans should modify this section to reflect Medicaid or plan-covered supplemental benefits as appropriate.] 在您獲得家庭保健服務之前,醫生必須告知我們您需要這些服務,並且這些服務必須由家庭保健機構提供。您必須處於閒居家中狀態,即您離家出門對您來說需要重大努力。 我們承保以下服務,並且也可能為未列於下方的其他服務付費:
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[List copays.] |
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家庭輸液治療 本計畫支付家庭輸液治療的費用,這是指在家中將藥物或生物物質注入您的靜脈或皮下。在家中輸液需要用到以下各項:
本計畫承保的家庭輸液服務包括但不限於:
[List any additional benefits offered.] |
[List copays.] [List copays for additional benefits.] |
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臨終關懷 如果您的醫療服務提供者和臨終醫療主任確定您的預後為終末期,您有權選擇臨終關懷。這意味著您患有絕症,預計只有六個月或更短的生命。您可以從Medicare認證的任何臨終關懷方案中獲得護理。本計畫必須幫助您找到經Medicare認證的臨終關懷方案。您的臨終關懷醫生可以是網路醫療服務提供者或網路外醫療服務提供者。 承保服務包括:
與您的終末期預後相關的臨終關懷服務以及Medicare A部分或B部分承保的服務
對於本計畫承保但Medicare A部分或Medicare B部分未承保的服務:
對於本計畫的Medicare D部分福利可能承保的藥物:
註:如果您需要非臨終關懷,請致電您的護理協調員和/或會員服務部來安排服務。非臨終關懷是與您的終末期預後無關的護理。 [Insert if applicable, edit as appropriate: 本計畫可為未選擇臨終關懷福利的臨終會員提供臨終關懷諮詢服務(僅限一次)。] |
[List copays.] [Include information about cost-sharing for hospice consultation services if applicable.] |
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免疫接種 我們承保以下服務:
我們為符合Medicare D部分承保規則的其他疫苗接種付費。更多相關資訊,請參閱《會員手冊》的第6章。 [List any additional benefits offered.] |
$0 [List copays for additional benefits.] |
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住院護理 包括急症住院、住院康復、長期護理醫院和其他類型的住院醫院服務。住院治療從您據醫囑正式入院之日開始。您出院的前一天是為住院的最後一天。 [List any restrictions that apply.] 我們承保以下服務以及未列於下方的其他醫療所需服務:
此福利下頁繼續 |
$0 在您的急診狀況穩定後,您必須獲得本計畫的批准才能在網路外醫院接受住院治療。 |
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住院治療(續)
如果您需要移植,Medicare批准的移植中心將審查您的病例並決定您是否適合移植。[Plans should include the following, modified as appropriate: 移植服務提供者可以在當地,也可以在服務地區之外。如果當地的移植服務提供者願意接受Medicare費率,則您可以在當地或您所在社區的護理模式之外獲得移植服務。如果本計畫在社區護理模式之外提供移植服務,並且您選擇在那裡進行移植,則我們會為您和另外一人安排或支付住宿和旅費。][Plans may further define the specifics of transplant travel coverage.]
註:如需住院,您的醫療服務提供者必須開具醫囑以正式讓您作為住院患者入院。如果您沒有正式入院,即使您在醫院過夜,您仍可能被視為門診患者而不是住院病人。如果您不確定自己是住院病人還是門診病人,則應當詢問醫院工作人員。 您還可以在名為「您是住院患者還是門診患者?」的情況說明書中瞭解更多資訊若您擁有Medicare – 敬請咨詢!」。這份情況說明書可從網站上獲得,網址為www.medicare.gov/sites/default/files/2021-10/11435-Inpatient-or-Outpatient.pdf或可致電 1-800-MEDICARE (1‑800-633-4227) 獲取。TTY用戶請致電1-877-486-2048。撥打這些號碼是免費的,每週7天、每天24小時開通。 |
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精神病院住院服務 我們承保需要住院的心理健康服務。[List days covered, restrictions such as 190-day lifetime limit for inpatient services in a psychiatric hospital. The 190-day limit does not apply to inpatient mental health services provided in a psychiatric unit of a general hospital.] [List any additional benefits offered.] |
$0 |
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[Plans with no day limitations on a plan’s hospital or nursing facility coverage may modify or delete this row as appropriate.] 住院:非承保住院期間在醫院或專業照護設施 (SNF) 獲取的承保服務 如果您已使用所有的住院福利或您的住院不合理且並非醫療所需,我們不會支付您的住院費用。 但是,對於某些住院護理不在承保範圍的情況,我們可能會為您在醫院或護理設施獲得的服務付費。要瞭解更多資訊,請聯繫會員服務部。 我們承保以下服務,並且也可能為未列於下方的其他服務付費:
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$0 |
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腎病服務與用品 我們承保以下服務:
您的Medicare B部分藥物福利會為某些用於透析的藥物付費。相關資訊,請參閱該表中的「Medicare B部分處方藥」。 |
$0 |
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肺癌篩查 如果您滿足以下條件,本計畫將每12個月支付一次肺癌篩查費用:
第一次篩查後,本計畫會根據您的醫生或其他有資質的提供者的書面醫囑,每年再支付一次篩查費用。 [Modify section to accurately describe benefitis and list any additional benefits offered.] |
$0 |
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醫學營養治療 這項福利適用於未進行透析的糖尿病或腎病患者。此外,也適用於由您的醫生為您作出[insert as appropriate: 轉介or醫囑]而進行於腎臟移植後。 在您獲得Medicare醫療營養治療服務的第一年,我們會為您支付三小時的一對一諮詢服務。如為醫療所需,我們可能會批准額外的服務。 此後,我們將每年支付兩小時的一對一諮詢服務費用。如果您的病情、治療或診斷發生變化,您可以透過醫生的[insert as appropriate: 轉介or醫囑]獲得更多時間的治療。如果您在下一個日曆年需要治療,則醫生必須每年都開具這些服務並更新[insert as appropriate: 轉介or醫囑]。如為醫療所需,我們可能會批准額外的服務。 [List any additional benefits offered.] |
$0 [List copays for additional benefits.] |
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Medicare糖尿病預防方案 (MDPP) 本計畫承保MDPP服務。MDPP旨在幫助您改善健康行為。它提供以下方面的實踐培訓:
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$0 |
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Medicare B部分處方藥 [Plans that do or expect to use Medicare Part B step therapy should indicate the Medicare Part B drug categories below that are or may be subject to Medicare Part B step therapy as well as a link to a list of drugs subject to Medicare Part B step therapy. Plans may update the link throughout the year and add any changes at least 30 days prior to implementation per 42 CFR 422.111(d).] 這些藥物在Medicare B部分的承保範圍內。本計畫承保以下藥物:
此福利下頁繼續 |
$0 |
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Medicare B部分處方藥(續) [Insert if applicable: 點擊以下連結,您將看到可能需要分步治療的Medicare B部分藥物清單:<hyperlink>。] 我們在Medicare B部分和Medicare D部分處方藥福利下也承保了一些疫苗。 《會員手冊》的第5章對我們的門診處方藥福利進行了說明。它解釋了若要獲得處方藥承保,您必須遵守的規則。 《會員手冊》的第6章説明了透過本計畫您為門診處方藥支付哪些費用。 |
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[Plans should modify this section to reflect Medicaid or plan-covered supplemental benefits as appropriate or eliminate this section if not covered.] 護理設施護理 護理設施 (NF) 是為無法在家中獲得護理而又無需住院的人群提供護理的地方。 我們承保的服務包括但不限於:
此福利下頁繼續 |
[List copays.] |
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護理設施護理(續)
通常由網路內設施為您提供護理。但是,您也可能可以從我們網路以外的設施獲得護理。如果以下處所接受本計畫的給付金額,則您可以從該處獲得護理:
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肥胖篩查和減肥治療 如果您的身體質量指數為30或更高,我們會支付諮詢費用幫助您減輕體重。您必須在基層照護服務機構進行諮詢。這樣,可以利用您的全面預防計畫對其進行管理。請與您的基層照護服務提供者交談,以瞭解更多資訊。 [List any additional benefits offered.] |
$0 [List copays for additional benefits.] |
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鴉片類藥物治療方案 (OTP) 服務 本計畫承保以下治療鴉片類藥物使用障礙 (OUD) 的服務:
[List any other medically necessary treatment or additional benefits offered, with the exception of meals and transportation.] |
$0 |
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門診診斷測試和治療服務及用品 我們承保以下服務以及未列於下方的其他醫療所需服務:
[Plans can include other covered tests as appropriate.] |
$0 |
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醫院門診服務 我們承保您在醫院門診部為診斷或治療疾病或損傷而獲得的醫療所需的服務,例如:
[List any additional benefits offered.] |
$0 [List copays for additional benefits.] |
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[Plans should modify this section to reflect Medicaid or plan-covered supplemental benefits as appropriate.] 門診心理保健 我們承保由以下人士提供的心理健康服務:
[List any additional benefits offered.] |
$0 [List copays for additional benefits.] |
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[Plans should modify this section to reflect Medicaid or plan-covered supplemental benefits as appropriate.] 門診復健服務 我們承保物理治療、職業治療和言語治療。 您可以從醫院門診部、獨立治療師辦公室、綜合門診復健機構(CORF)和其他設施獲得門診復健服務。 |
$0 |
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物質濫用門診服務 我們承保以下服務,並且也可能為未列於下方的其他服務付費:
[Modify this list accurately describe benefits offered or add any additional benefits offered.] |
[List copays.] |
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門診手術 我們承保醫院門診設施和門診手術中心的門診手術和服務。 |
$0 |
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[Plans should modify this section to reflect Medicaid or plan-covered supplemental benefits as appropriate.] 部分住院服務 部分住院治療是一種結構化的積極精神治療方案。該方案作為醫院門診服務提供或由社區心理健康中心提供。這比您在醫生或治療師辦公室獲得的醫療服務更密集。這樣您就可以不必住院。 [Network plans that do not have an in-network community mental health center may add: 注:由於我們的網路中沒有社區心理健康中心,我們僅承保醫院門診服務形式的部分住院服務。] |
$0 |
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醫師/提供者服務(包括在醫生診室就診) 我們承保以下服務:
此福利下頁繼續 |
$0 [List copays for additional benefits.] |
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醫師/提供者服務(包括在醫生診室就診)(續)
此福利下頁繼續 |
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醫師/提供者服務(包括在醫生診室就診)(續)
[List any additional benefits offered.] |
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足病治療服務 我們承保以下服務:
[List any additional benefits offered.] |
$0 [List copays for additional benefits.] |
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前列腺癌篩查檢查 [Plans that cover men under age 65 must include: 對於50歲及以上的男性,] 我們每12個月支付一次以下服務費用:
[List any additional benefits offered.] |
$0 [List copays for additional benefits.] |
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[Plans should modify this section to reflect Medcaid or plan-covered supplemental benefits as appropriate.] 假體裝置及相關用品 假體裝置用於替代全部或部分身體部位或功能。我們承保以下假體裝置,也可能為未列於下方的其他裝置付費:
我們承保一些與假體裝置相關的用品。我們還承保維修或更換假體裝置的費用。 我們提供了一些與白內障摘除或白內障手術後相關的保險。相關詳細資訊,請參閱本表下文中的「視力保健」。 [Plans that pay for prosthetic dental devices, delete the following sentence:] 我們不承保義齒裝置的費用。 |
$0 |
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肺復健服務 我們為患有中度至極重度慢性阻塞性肺病 (COPD) 的會員承保肺復健方案的費用。您必須獲得爲您治療COPD的醫生或醫療服務提供者給予的肺復健 [insert as appropriate: 轉介or醫囑]。 [List any additional benefits offered.] |
$0 [List copays for additional benefits.] |
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性傳播感染 (STI) 篩查和諮詢 我們承保衣原體、淋病、梅毒和乙型肝炎的篩查費用。這些篩查面向 [plans that cover women under age 65 should include: 孕婦和] 某些STI感染風險較高的人群。基層照護服務提供者必須安排這些檢查。我們每12個月支付一次或在懷孕期間的特定時間支付這些檢查的費用。 我們每年還為STI感染風險增加的性活躍成年人承保最多兩次面對面的高強度行為諮詢。每次諮詢可長達20至30分鐘。僅當由基層照護服務提供者提供時,我們才會將這些諮詢服務作為預防性服務予以承保。這類諮詢必須在基層照護服務設施進行,如醫生診室。 [Also list any additional benefits offered.] |
$0 [List copays for additional benefits.] |
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專業照護設施 (SNF) 照護 我們承保以下服務,並且也可能為未列於下方的其他服務付費:
通常由網路內設施為您提供護理。但是,您也可能可以從我們網路以外的設施獲得護理。如果以下處所接受本計畫的給付金額,則您可以從該處獲得護理:
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吸煙和戒煙 如果您吸煙,但沒有煙草相關疾病的跡象或症狀,並且想要或需要戒煙:
如果您吸煙並被診斷患有煙草相關疾病或正在服用可能受煙草影響的藥物:
[List any additional benefits offered.] |
$0 [List copays for supplemental benefits.] |
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監督運動療法 (SET) 我們為患有症狀性外周動脈疾病 (PAD) [insert if applicable: 並從負責 PAD 治療的醫生處獲得PAD轉介] 的會員承保SET費用。 本計畫承保:
SET方案必須是:
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急需護理 緊急護理是為了應對以下情況所給予的護理:
如果急需緊急護理,您應首先嘗試從網路醫療服務提供者處獲得。但是,當您無法聯繫到網路醫療服務提供者時(例如當您在本計畫的服務地區之外或在週末時),您可以使用網路外醫療服務提供者。 [Include in-network benefits. Also identify whether this coverage is within the U.S. and its territories or is supplemental world-wide emergency/urgent coverage.] |
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[Plans should modify this section to reflect Medicaid and plan-covered supplemental benefits as appropriate. Add the apple icon if listing only preventive services.] 視力保健 我們為眼部疾病和眼部損傷的診斷和治療支付門診醫生服務費用。例如,這包括每年對糖尿病患者進行糖尿病性視網膜病變的眼科檢查,以及對年齡相關性黃斑變性的治療。 對於青光眼高危人群,我們每年支付一次青光眼篩查費用。青光眼高危人群包括:
[Plans should modify this description if the plan offers more than is covered by Medicare.] 每次白內障手術後,醫生植入了人工晶狀體時,我們會支付一副眼鏡或隱形眼鏡的費用。 如果您做了兩次單獨的白內障手術,則必須在每次手術後各配一副眼鏡。即使您在第一次手術後沒有配用一副眼鏡,您也不能在第二次手術後獲得兩副眼鏡。 |
[List copays.] [List copays for additional benefits.] |
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「歡迎加入Medicare」預防性就診 我們承保一次「歡迎加入Medicare」預防性就診。這次就診包括:
註:我們僅在您擁有Medicare B部分的前12個月內承保「歡迎加入Medicare」預防性就診。在您預約時,請告訴您醫生的診室人員您想安排「歡迎加入Medicare」預防性就診。 |
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[Include this section if you offer optional supplemental benefits in the plan and describe benefits below. Plans must explain how these benefits are different than what is covered under Medicaid. You may include this section either in the Member Handbook or as an insert to the Member Handbook.]
本計畫提供一些額外的福利,這些福利不在Original Medicare承保範圍內,也不包含在您的福利套餐中。這些額外福利稱為「可選的補充福利」。如果您希望獲得這些可選的補充福利,您必須進行註冊 [insert if applicable: 并且可能需要為他們支付額外的保費。][insert as applicable: 本節或隨附的插頁] 中描述的可選附加福利與任何其他福利一樣,需要遵循相同的上訴程序。
[Insert plan specific optional supplemental benefits, premiums, deductible, copays, and coinsurance and rules using a chart like the Benefits Chart above. Insert plan specific procedures on how to elect optional supplemental coverage, including application process and effective dates and on how to discontinue optional supplemental coverage, including refund of premiums. Also, insert any restrictions on members’ re-applying for optional supplemental coverage (e.g., must wait until next annual enrollment period).]
[If your plan offers a visitor/traveler program to members who are out of your service area, insert this section, adapting and expanding the following paragraphs as needed to describe the traveler benefits and rules related to getting the out-of-area coverage. If you allow extended periods of enrollment out-of-area per the exception in 42 CFR §422.74(b)(4)(iii) (for more than 6 months up to 12 months), also explain that here based on the language suggested below:
如果您一次離開計畫服務地區的時間超過6個月,但沒有永久搬家,我們通常必須讓您退出本計畫。但是,我們提供訪客/旅行者方案[specify areas where the visitor/traveler program is being offered],讓您在離開我們的服務地區長達12個月時,仍可以繼續參與本計畫。根據我們的訪客/旅行者方案,您可以以網路內分攤費用價格獲得所有計畫承保的服務。當您使用訪客/旅行者福利時,請聯繫我們來幫助您尋找醫療服務提供者。
如果您在訪客/旅行者地區,您可以在<end date>之前一直參與本計畫。如果您在<end date>之前沒有返回本計畫的服務地區,我們將終止您在本計畫中的會員資格。]
[Plans should modify this section to include additional benefits covered outside the plan by Medicaid fee-for-service and/or a Medicaid managed care plan, as appropriate.]
我們不承保以下服務,但可透過Medicare或[insert name state-specific name of Medicaid program]獲得。
如果您的醫療服務提供者和臨終醫療主任確定您的預後為終末期,您有權選擇臨終關懷。這意味著您患有絕症,預計只有六個月或更短的生命。您可以從Medicare認證的任何臨終關懷方案中獲得護理。本計畫必須幫助您找到經Medicare認證的臨終關懷方案。您的臨終關懷醫生可以是網路醫療服務提供者或網路外醫療服務提供者。
有關在您獲得臨終關懷服務期間我們所承保的方案的更多資訊,請參閱第D節的福利表。
對於與您的終末期預後相關的臨終關懷服務以及Medicare A部分或B部分承保的服務
臨終關懷提供者向Medicare收取為您服務的費用。Medicare為與您的終末期預後相關的臨終關懷服務付費。您無需為這些服務支付任何費用。
對於與您的終末期預後非相關的Medicare A部分或B部分承保的服務
醫療服務提供者將向Medicare收取為您服務的費用。Medicare為Medicare A部分或Medicare B部分所承保的服務付費。您無需為這些服務支付任何費用。
對於本計畫的Medicare D部分福利可能承保的藥物
臨終關懷和本計畫絕不會同時承保藥物。更多相關資訊,請參閱您的《會員手冊》第5章。
註:如果您需要非臨終關懷,請致電您的護理協調員安排服務。非臨終關懷護理是與您的終末期預後無關的護理。
本章節將向您介紹排除於本計畫之外的福利。「排除」是指我們不為這些福利付費。Medicare和Medicaid也不為這些福利承保。
下方清單說明了我們在任何情況下都不承保的服務和方案,以及只在某些情況下才排除的一些服務與用品。
我們不為本章節(或本《會員手冊》的任何其他章節)列出的排除的醫療福利付費,但列出的特定情況除外。即使您在急診設施内接受服務,本計畫也不會為這些服務支付任何費用。如果您認為本計畫應為未承保的某項服務付費,您可以提出上訴。有關提出上訴的資訊,請參閱《會員手冊》的第9章。
除了福利表中說明的任何排除或限制之外,本計畫也不承保以下用品與服務:
[The services listed in the remaining bullets are excluded from Medicare’s and Medicaid’s benefit packages. If any services below are plan-covered supplemental benefits, are required to be covered by Medicaid or have become covered due to a Medicare or Medicaid change in coverage policy, delete them from this list. When plans partially exclude services excluded by Medicare, they need not delete the item but may revise the text to describe the extent of the exclusion. Plans may add parenthetical references to the Benefits Chart for descriptions of covered services and items as appropriate. Plans may also add exclusions as needed.]
根據Medicare和[insert name state-specific name of Medicaid program]標準被認為不是「合理和醫療所需」的服務,除非我們將這些服務列為承保服務
實驗性醫療和外科治療、用品和藥物,除非Medicare、Medicare批准的臨床研究或本計畫將其列入承保範圍。
有關臨床研究的更多資訊,請參閱《會員手冊》的第3章。實驗性治療和用品是指未被醫學界普遍接受的治療和用品。
病態肥胖症的手術治療,除非為醫療所需且Medicare負責付費。
醫院的私人病房,除非為醫療所需。
私人值班護士
醫院或護理設施病房內的個人用品,如電話或電視。
在家中進行的全職護理
您的直系親屬或您的家庭成員所收取的費用。
[Plans should delete this if the state allows:]送到您家中的餐食
選擇性或自願性增強程式或服務(包括減肥、生髮、性能力、運動能力、美容目的、抗衰老和心智表現),除非為醫療所需。
整容手術或其他整容工作,除非因意外傷害或為了改善外形不正常的身體部位而需要。但是,我們會支付乳房切除術後乳房的重建費用以及對另一側乳房進行治療以與之匹配的費用
整脊護理,除非按照承保指南對脊柱進行手動推拿。
矯形鞋,除非鞋子是腿支架的一部分並包含在支架的費用中或鞋子是為患有糖尿病足病患者準備的。
足部支撐裝置,除非為糖尿病足病患者的矯形鞋或治療鞋
[Plans delete this if supplemental:]定期聽力檢查、助聽器或助聽器安裝檢查
[Plans delete this if supplemental:]放射狀角膜切開術、LASIK手術和其他低視力輔助設備
逆轉絕育手術和非處方避孕用品。
自然療法服務(使用自然療法或替代療法)。
退伍軍人事務 (VA) 設施為退伍軍人提供的服務。[Zero cost-sharing plans may adjust this language as applicable]但是,當退伍軍人在VA醫院接受急診服務且VA分攤費用超過本計畫下的分攤費用時,我們將為退伍軍人補償差額。您仍需承擔您的分攤費用部分的金額。
如果您有任何疑問,請致電<plan
name>,電話:<toll-free
phone and TTY/TDD numbers>,<白天工作時間>。通話是免費的。如需瞭解更多資訊,請造訪<web
address>。
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