Member

• The Enrollment/Disenrollment Process
• Member ID Cards
• Determining Eligibility
• Primary Care Practitioner’s Role in Determining Eligibility
• Benefits
  • Medical Benefits
  • Summary of Benefits
  • Prescription Drug Benefits
  • Drugs Covered
  • Self-Referred Services
• Members’ Rights and Responsibilities
  • Member Responsibilities

The Enrollment/Disenrollment Process

Gateway Health Plan Medicare Assured^® HMO Medicare Advantage Prescription Drug Plan (MA-PD) is for people with Medicare Part A, Medicare Part B and Medicaid (Full and QMB). The Centers for Medicare and Medicaid (CMS) have periods when beneficiaries can enroll or disenroll with/from Medicare plans throughout the year. These times are known as election periods. There are multiple election periods when beneficiaries are entitled to enroll with Gateway Health Plan Medicare Assured^® HMO which is a Special Needs Plan (SNP).This means that all of our members have both Medicare and Medicaid and because of this, they qualify for the Special Election Period (SEP) every month. The SEP permits our members to enroll and disenroll at any time throughout the year.

Members can enroll into our plan by using any of these methods:

• A paper enrollment form
• On-line forms through Medicare's website
• Gateway’s website at www.gatewayhealthplan.com - click on the link for Medicare Assured^® HMO
• By calling Gateway Health Plan Medicare Assured^® HMO at 1-877-GATEWAY (TTY users should call 1-800-654-5988); 8:00am – 6:00pm, 7 days a week.
• By contacting Medicare at: 1-800-MEDICARE or www.medicare.com.

Members can disenroll from our plan by completing a paper disenrollment form or sending a letter/fax to Gateway Health Plan Medicare Assured^® HMO. Members may also contact Medicare at 1-800-MEDICARE (TTY: 1-877-486-2048) or www.medicare.com. Members may also disenroll from Gateway Health Plan Medicare Assured^® HMO by simply enrolling in another HMO or Part D plan. Members should call Gateway Health Plan^® or visit www.GatewayHealthPlan.com for additional information.

Member enrollments are made effective the first day of the calendar month, and member disenrollments are made effective the last day of the calendar month.

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Member ID Cards

Each Medicare Assured^® HMO member will receive an ID card. Each card is issued once, unless cards are requested or reissued due to a demographic or PCP change. ID Cards are good for as long as the person is a member of Gateway Health Plan Medicare Assured^® HMO.

Members age 21 and over will need to use their Gateway Health Plan Medicare Assured^® HMO ID card and keep their Medicaid Access card to use for services covered under Medical Assistance and to cover Medicare deductibles and coinsurance, as long as the provider also participates with Medicaid.

Members under the age of 21 will use their Gateway Health Plan Medicare Assured^® HMO ID card and their Medicaid HMO plan ID card. These members will need to keep their Medicaid Access card for non-Medical assistance services, such as transportation through the Medical Assistance Transportation Program (MATP) or cash assistance.

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Determining Eligibility

Because of potential changes in a member’s eligibility, each participating practitioner is responsible to verify a member’s eligibility with Gateway Health Plan Medicare Assured^® HMO BEFORE providing services. Verifying a member’s eligibility will ensure proper reimbursement for services. To verify a member’s eligibility, the following methods are available to all practitioners:

1. Gateway Health Plan Medicare Assured^® HMO Identification Card
   • The card itself does NOT guarantee that a person is currently enrolled in Gateway Health Plan Medicare Assured^® HMO.    Members are NOT required to return their identification cards when they are no longer eligible for Gateway Health Plan Medicare Assured^® HMO.
2. Gateway Digital Voice Assistant (DIVA)
   • The Gateway DIVA System (1-800-642-3515) is available 24 hours a day, 7 days a week.  To verify member eligibility at each visit, practitioners follow a few simple steps, which are listed below:

Press 1 if calling for a member who resides in Pennsylvania

Press 1 to verify eligibility

Member Identification Number?

Press 1 to verify eligibility using the patient’s social security number, when prompted enter the patient’s 9-digit social security number

Press 2 to verify eligibility using the patient’s Gateway member identification number, when prompted enter the patient’s 8-digit Gateway Health Plan Medicare Assured^® HMO identification number

Press 3 to verify eligibility using the patient’s Medical Assistance recipient identification number, when prompted enter the patient’s Medical Assistance recipient number  (Note: This option can not be used for Gateway Health Plan Medicare Assured^® HMO members.)

Press 4 to verify eligibility using the patient’s Medicare Health Insurance Claim (HIC) number, when prompted enter the patient’s HIC number, followed by the # sign.  (For letters press the corresponding key on your touch tone phone.  For example:  To enter an A, B, or C, press the 2 key.  For Q, press the 7 key.  For Z, press the 9 key.)

Press 0 to speak to a Provider Services Representative

Press 9 to repeat the menu

Verification of Date?

Press 1 to verify whether the patient is eligible TODAY

Press 2 to verify whether the patient is eligible on a specific date (enter date)

Press 9 to listen to the instructions again

Press 0 to speak to a Provider Services Representative

Additional Instructions:

Press 1 to receive additional information about the patient/member

Press 2 to receive the patient’s primary care practitioner name and telephone number

Press 3 to fax information regarding the patient whose eligibility is being verified

Press 4 to verify eligibility for another patient/member

Press 5 to exit

Press 6 to return to the menu of Automated Services

Press 9 to listen to the menu again

Press 0 to speak to a Provider Services Representative

Primary Care Practitioner’s Role in Determining Eligibility

Primary care practitioners verify eligibility by consulting their panel listing in order to confirm that the member is a part of the practitioner’s panel.  The panel list is distributed on or about the first of every month.  The primary care practitioner should check the panel list each time a member is seen in the office. If a member’s name is on the panel list, the member is eligible with Gateway for that month.

If members insist they are effective, but do not appear on the panel list, the practitioner should call the Gateway Health Plan Medicare Assured^® HMO Provider Services Department for help in determining eligibility at 1-800-685-5205.

Benefits

Gateway Health Plan Medicare Assured^® HMO members are eligible for all the benefits covered under the Original (Fee-for-service) Medicare Program. In addition, Gateway Health Plan Medicare Assured^® HMO offers additional benefits for vision, hearing and health and wellness services. For a complete list of covered benefits, please refer to the Benefits Chart below, which is an excerpt from the member’s Evidence of Coverage. A complete copy of the Pennsylvania Evidence of Coverage booklet is located on our website at www.GatewayHealthPlan.com. Click on the link for Medicare Assured^® HMO. Members obtain most of their healthcare services either directly from or upon referral (approval in advance) by their primary care practitioner, except for services available on a self-referral basis, such as OB/GYN services and routine vision services. The primary care practitioner is responsible for the coordination of a member’s healthcare needs and access to services provided by hospitals, specialty care practitioners, ancillary providers, and other healthcare providers as needed.

The covered services listed in the Benefits Chart in this section are covered only when all requirements listed below are met:

• Services must be provided according to the Original Medicare coverage guidelines established by the Medicare Program.
• The medical care, services, supplies, and equipment that are listed as covered services must be medically necessary. Medically necessary refers to services or supplies that: are proper and needed for the diagnosis or treatment of the member’s medical condition; are used for the diagnosis, direct care, and treatment of the member’s medical condition; meet the standards of good medical practice in the local community; and are not mainly for the convenience of the member or the member’s doctor. Certain preventive care and screening tests are also covered.
• With few exceptions, covered services must be provided by plan providers, be approved in advance by plan providers, and some services may need to be authorized by our Plan.

In addition, some covered services require “prior authorization” by the Plan in order to be covered. Some of the covered services listed in the Benefits Chart in this section are covered only if the member’s doctor or other plan provider gets “prior authorization” (approval in advance) from our Plan. Covered services that need prior authorization (approval ahead of time) are marked in the Benefits Chart with an asterisk (*).

NOTE: The chart on the following page provides the Gateway Health Plan Medicare Assured^® HMO cost-sharing, NOT the original Medicare cost sharing. Medicare cost-sharing is paid by Medicaid depending upon the member’s Medicaid eligibility.

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Dental Services
Gateway Health Plan Medicare Assured^® HMO recognizes the importance of good dental health. Members are eligible to receive the following:

• One (1) oral exam every six (6) months,
• One (1) cleaning every six (6) months
• One (1) dental x-ray every six (6) months, and
• One (1) panoramic x-ray every five (5) years.

• Up to $500 every two (2) years toward minor restorations (such as fillings), simple extractions and denture repair.

Transportation Services
Gateway Health Plan Medicare Assured^® HMO members are eligible to receive at no cost:

• 36 one-way trip(s) to Plan-approved locations every calendar year
• Includes non-emergent transportation to doctor visits; dental, vision, hearing, and behavioral health services; and to pharmacies and fitness centers.
• Authorization and scheduling rules may apply.

Health Management Programs
Gateway Health Plan Medicare Assured^® HMO cares about members health and well-being. We believe good service means doing our best to help members stay healthy, lead an active lifestyle, and improve members quality of life.

Gateway Health Plan Medicare Assured^® HMO has special programs available for members to address heart disease, diabetes, and asthma and can provide information about health education and wellness services such as smoking cessation. Nurse care managers are available to help members stay on top of things (qualifications apply).

Hearing Services
In addition to routine hearing exams, Gateway Health Plan Medicare Assured^® HMO members will receive fittings and evaluations for hearing aids. In addition, members are covered up to $1,000 for hearing aids every two (2) years.

Vision Services
Gateway Health Plan Medicare Assured^® HMO members are eligible to receive four (4) routine eye exams every calendar year. In addition, Gateway Health Plan Medicare Assured^® HMO also provides:

• One (1) pair of eyeglasses every calendar year.
• Members may receive vendor frames and standard lenses, or
• Receive up to $90 toward non-vendor frames

• One (1) pair of standard contact lenses every calendar year, or
• Up to $150 toward specialty contact lenses every calendar year.

If members wish to purchase eyewear that totals more than $150, members will be responsible for the difference in price.
No referral is needed to take advantage of this benefit; simply members select a vision care provider in our participating provider network.

Yearly Physical Exam
Gateway Health Plan Medicare Assured^® HMO members are eligible to receive a physical exam each year.

Fitness Assured^® Wellness Program
Members of Gateway Health Plan Medicare Assured^® HMO, are automatically eligible for our Fitness Assured^® program. Designed to help keep members feeling fit, Fitness Assured^® offers members the opportunity to enjoy a membership to a network fitness center and access to resources that promote exercise and a healthy diet.

We understand that sometimes going to a Fitness Center isn’t an option for our members. To help members stay fit while at home, Gateway Health Plan Medicare Assured^® HMO can provide members with home fitness products.

Bathroom Safety Items
Gateway Health Plan Medicare Assured^® HMO can help members make their bathroom a safer place. Gateway Health Plan Medicare Assured^® HMO members may receive up to $100 a calendar year for bathroom safety products (such as bath/shower chairs, bathtub rails and bathtub stool or bench).

ADDITIONAL INFORMATION ON PLAN BENEFITS

Skilled Nursing Facility
There is a 100 day limit for each skilled nursing facility admission. Members must work with their provider to get authorization from Gateway Health Plan Medicare Assured^® HMO before they are admitted to a skilled nursing facility. If members do not get authorization, members may be responsible for charges incurred.

General Exclusions
In addition to any exclusions or limitations described in the Benefits Chart or anywhere else in the Evidence of Coverage booklet, the following items and services aren’t covered except as indicated by Gateway Health Plan Medicare Assured^® HMO:

1. Services not considered reasonable and necessary, according to the standards of Original Medicare, unless these services are otherwise listed by our Plan as a covered service.
2. Experimental medical and surgical procedures, equipment and medications, unless covered by the Original Medicare. However certain services may be covered under a Medicare-approved clinical research study.
3. Surgical treatment of morbid obesity, except when it is considered medically necessary and covered under the Original Medicare plan.
4. Private room in a hospital, except when it is considered medically necessary.
5. Private duty nurses.
6. Personal items in member’s rooms at a hospital or skilled nursing facility, such as a telephone or a television.
7. Full-time nursing care in member’s homes.
8. Custodial care, unless it is provided with covered skilled nursing care and/or skilled rehabilitation services. Custodial care, or non-skilled care, is care that helps members with activities of daily living, such as bathing or dressing.
9. Homemaker services include basic household assistance, including light housekeeping or light meal preparation.
10. Fees charged by member’s immediate relatives or household members.
11. Meals delivered to members homes.
12. Elective or voluntary enhancement procedures, services (including weight loss, hair growth, sexual performance, athletic performance, cosmetic purposes, anti-aging and mental performance), except when medically necessary.
13. Cosmetic surgery or procedures because of an accidental injury or to improve a malformed part of the body. However, all stages of reconstruction are covered for a breast after a mastectomy, as well as for the unaffected breast to produce a symmetrical appearance.
14. Chiropractic care, other than manual manipulation of the spine consistent with Medicare coverage guidelines.
15. Routine foot care, except for the limited coverage provided according to Medicare guidelines.
16. Orthopedic shoes, unless they are part of a leg brace and are included in the cost of the brace or the shoes are form a person with diabetic foot disease.
17. Supportive devices for the feet, except for orthopedic or therapeutic shoes for people with diabetic foot disease.
18. Radial keratotomy, LASIK surgery, vision therapy and other low vision aids.
19. Outpatient prescription drugs including drugs for the treatment of sexual dysfunction, including erectile dysfunction, impotence, and anorgasmy or hyporgasmy.
20. Reversal of sterilization procedures, sex change operations, and non-prescription contraceptive supplies.
21. Acupuncture.
22. Naturopath services (uses natural or alternative treatments).
23. Counseling or referral services that Medicare Assured^® HMO objects to based on moral or religious grounds. In the case of Medicare Assured^® HMO, we won’t give counseling or referral services related to contraceptive services, female sterilization services, male sterilization services and abortion services. To the extent these services are covered by Medicare, they will be covered through an alternative process.
24. Services provided to veterans in Veterans Affairs (VA) facilities. However, in the case of emergency services received at a VA hospital, if the VA cost-sharing is more than the cost-sharing required under our Plan, we will reimburse veterans for the difference. Members are still responsible for cost-sharing amount.

Any of the services listed above that aren’t covered will remain not covered even if received at an emergency facility.

At any time during the year, the Medicare program can change its national coverage. Since Gateway covers what Original Medicare covers, we would have to make any change that the Medicare program makes. These changes could be to increase or decrease benefits, depending on the Medicare program changes.

Prescription Drug Benefits
Full prescription drug benefits are available to all members. Prescriptions must be filled by a Gateway participating pharmacy in order to be covered by Gateway. When a member travels outside of the Gateway service area and must access a non-participating pharmacy, the member should utilize any Argus contracted Pharmacy and the claims should be billed to Gateway via the Argus Network.

Gateway contracts with Argus to develop a network of chain, independent, home infusion and long-term care pharmacies in order to provide pharmaceuticals to Gateway members. A list of participating pharmacies can be obtained by contacting Gateway’s Member Services Department at 1-800-685-5209.

Prescriptions are available to members who are eligible for pharmacy coverage when written by a Gateway practitioner. As long as a member’s Medical Assistance coverage is in effect, Gateway Health Plan Medicare Assured^® HMO will pay for the first $2,800 in covered prescription drug costs. Members are not responsible for any deductible. There is $0 co-payment for generic prescription drugs and $3.30 or $6.30 co-payment for brand name prescription drugs, depending on their income level. After a member’s total yearly prescription drug costs exceed $2,800 in costs, members are responsible for a $1.10 or $2.50 co-payment for each covered generic prescription drug or preferred drug that is a multi-source drug and $3.30 or $6.30 for each covered brand name prescription drug, depending on their income level. Once a member’s yearly prescription drugs costs exceed $6,440.00, they pay nothing for their prescription drugs.

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Formulary
Visit www.GatewayHealthPlan.com for the most recent version of the formulary.

Please Note:The Plan may place limits on the amount of medication a member may receive. Members can receive up to a 31-day supply of medication for prescriptions filled at an in-network pharmacy.

Gateway utilizes a closed formulary. Practitioners are requested to prescribe medications included in the formulary whenever possible.

Some formulary medications may have additional requirements or limits on coverage. These requirements and limits may include: prior authorization, quantity limits or step therapy. If use of a formulary medication is not medically advisable for a member, you must complete a Non-Formulary Drug Exception Form. Please refer to the Forms and Reference Materials Section of this manual for a copy of this form. Please refer to the Referral and Authorization Section of this manual for information regarding requesting non-formulary drugs.

• Legend drugs listed in the closed formulary
• Non-formulary drugs which have been granted a formulary exception for an individual member
• Insulin/disposable syringes/needles
• Compounded medication of which at least one ingredient is a covered prescription drug
• Contraceptives

Gateway Health Plan Medicare Assured^® HMO places a limit on the amount of medication a member can receive at the pharmacy. The limit is an amount normally prescribed by the practitioner, but must not exceed a 31-day supply. Prescriptions can be refilled up to 12 months from the original prescription date as authorized by the practitioner.

• A Medicare Prescription Drug Plan can’t cover a drug that would be covered under Medicare Part A or Part B.
• A Medicare Prescription Drug Plan can’t cover a drug purchased outside the United States and its territories.
• A Medicare Prescription Drug Plan can cover off-label uses (meaning for uses other than those indicated on a drug’s label as approved by the Food and Drug Administration) of a prescription drug only in cases where the use is supported by certain reference-book citations. Congress specifically listed the reference books that list whether the off-label use would be permitted. (These reference books are: American Hospital Formulary Service Drug Information, the DRUGDEX Information System, and USPDI or its successor.) If the use is not supported by one of these reference books, known as compendia, then the drug is considered a non-Part D drug and cannot be covered by our Plan.

In addition, by law, certain types of drugs or categories of drugs are not normally covered by Medicare Prescription Drug Plans. These drugs are not considered Part D drugs and may be referred to as “exclusions” or “non-Part D drugs.”

Self-Referred Services
Members may refer themselves for the following types of care:

• Routine Women’s Health Care
• Pap Smears
• Pelvic Exams
• Mammograms
• Flu Shots
• Pneumonia Vaccinations
• Specialists Visits
• Prostate Screening
• Colorectal Screening
• Bone Mass Measurements (Bone densitometry requires authorization by NIA)
• Diabetes Monitoring Training
• Dialysis
• Vision Exams
• Hearing Exams

Members’ Rights and Responsibilities

All Gateway members have rights and responsibilities.  They are as follows:

Gateway Health Plan Medicare Assured^® HMO
Members’ Rights and Responsibilities

Member Rights

• Provide information in a way that works for the member (in languages other than English that are spoken in the Plan service area, in Braille, in large print, or other alternate formats, etc.)
• Right to be treated with fairness and respect
• Right to the privacy of member medical records and personal health information
• Right to see plan providers and get covered services and drugs within a reasonable period of time
• Right to know his/her treatment choices and participate in decisions about his/her health care
• Right to use advance directives (such as a living will or a power of attorney)
• Right to make complaints and ask to have decisions made reconsidered
• Right to get information about his/her health care coverage and costs
• Right to get information about Gateway Health Plan^®, Gateway Health Plan Medicare Assured^® HMO, and plan providers

• To get familiar with his/her coverage and the rules he/she must follow to get care as a member.
• To give his/her doctor and other providers the information they need to care for him/her, and to follow the treatment plans and instructions that he/she and his/her doctors agree upon.
• To act in a way that supports the care given to other patients and helps the smooth running of his/her doctor’s office, hospitals, and other offices.
• To pay his/her plan premiums and any co-payments he/she may owe for the covered services you get.
• To let Gateway Health Plan Medicare Assured^® HMO know if he/she has any questions, concerns, problems, or suggestions.

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