AgeWell New York – Feel Well, Live Well with …
|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 |
|Acupuncture |No |Covered services include 10 acupuncture treatments per year when provided by certified network providers |
|Ambulance Services - Air |No | |
| | |Covered emergency ambulance services include air ambulance and ground ambulance services, to the nearest appropriate facility that can|
| |(Prior Authorization is |provide care if they are furnished to a member whose medical condition is such that other means of transportation could endanger the |
| |required for non-emergency air |person’s health or if authorized by the plan |
| |ambulance services) | |
| | |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 |
|Ambulance services - Ground |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 months |
|Bone mass measurement |No |Once every 24 months or more frequently if medically necessary |
|Breast cancer screening |No |One baseline mammogram between ages 35-39/ One screening mammogram every 12 months for women 40 and older/ Clinical breast exams once |
|Screening mammogram | |every 24 months |
|Breast cancer |Yes |Once a year or as many times as medically necessary |
|Diagnostic mammogram | | |
|Cardiac rehabilitation services |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|
|(Includes exercise, education, counselling)- Initial | |period of time if approved based on medical necessity/ Intensive cardiac rehab limited to 72, 1-hour sessions, up to 6 sessions per |
|course treatment | |day, over a period of up to 18 weeks |
|Cardiovascular disease risk reduction visit (therapy for |No |One visit per year |
|cardiovascular disease) | | |
|Cardiovascular disease testing |No |Tests for detection once every 5 years (60 months) |
|Cervical and vaginal cancer screening |No |For all women: Pap tests and pelvic exams once every 24 months |
|Pelvic Exam | |At high risk or have had an abnormal pap test and are of childbearing age and have had an abnormal Pap test within the past 3 years: |
|Pap Test | |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 | |For people 50 and older: Flexible sigmoidoscopy (or screening barium enema as an alternative) every 48 months; |
|Colonoscopy (screening/preventive) |Yes |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 sigmoidoscopy |
| | | |
| | |IMPORTANT: 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 (diagnostic/surgical) |Yes | |
| | | |
| | | |
|Dental services (Optional Supplemental Benefit) |Contact HealthPlex |Optional Dental Benefit: Diagnostic and restorative services, oral exams, cleaning, fluoride treatment, dental x-rays, endodontics, |
|Preventive services |1-800-468-9868 for coverage and|periodontics, extractions, prosthodontics, oral surgery, and other services. |
|Comprehensive services |authorization |Preventive dental: Oral exams one every 6 months; Prophylaxis (cleaning) one every 6 months; Fluoride treatment one every 6 months; |
| | |Dental x-ray(s) one every 6 months |
| | |Comprehensive dental: Diagnostic services one every 6 months, Restorative Services, endodontics/periodontics extractions, |
| | |prosthodontics, oral/maxillofacial surgery |
|Depression screening |No |One screening for depression per year |
|Diabetes 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 |
|Diabetic services and supplies |No |Supplies to monitor your blood glucose |
|Diabetic therapeutic shoes and inserts |Yes |One pair per calendar year of therapeutic custom molded shoes (including inserts provided with such shoe).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, hospital bed, IV infusion pump, oxygen equipment, nebulizer, and|
| | |walker. Please refer to Medicare limitations |
|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. |
|Fitness Program |Registration is required | |
| |contact Silver Sneakers | |
| |1-888-423-4632 | |
|Hearing services |No |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 provider |
| |(Contact EPIC Hearing |1 Routine Hearing Exam per year |
| |1-877-606-3742 for coverage) | |
| | | |
|Hearing aids |Yes |We cover $1,000 towards the purchase of hearing aids once every 2 years |
| | |Includes fitting and evaluation for hearing aids. |
| |(Contact EPIC Hearing | |
| |1-877-606-3742 for coverage) | |
|HIV screening |No |Increased risk: one screening exam every 12 months or for women who are pregnant: up to 3 screening exams during pregnancy |
|Home health agency care |Yes |Services must total fewer than 8 hours per day & 35 hours per week; Medicare 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 ) |
|Immunizations |No |Flu shots once a year in the fall or winter with additional flu shots, if medically necessary |
| | |Pneumonia vaccines, Hepatitis B, and other vaccines if you are at risk and meet Medicare Part B coverage rules |
|Inpatient hospital care |Yes |Our plan covers an unlimited number of days for an inpatient hospital stay |
|Inpatient mental health care |Yes |Our plan covers an unlimited number of days for an inpatient hospital stay |
|Medical 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 |Consult Formulary for PA requirements on certain drugs EnvisionRx 1-800-361-4542 |
| | |Tier 1 and 2 are excluded from the $275 Part D deductible |
| | |Additional Gap Coverage provided for Tier 1 in the Gap Coverage Stage |
|Obesity screening and therapy to promote sustained weight |No |If you have body mass index 30 or more |
|loss | | |
|Other Health Care Professional Services |Yes |We cover services provided by other health providers, such as physician Assistants, nurse practitioners, social workers, and |
| | |psychologists. Coverage can also include a health educator, a registered dietitian, or nutrition professional, or other licensed |
| |(Prior Authorization is not |practitioner or a team of such medical professionals, working under the direct supervision of a Physician. |
| |required for Nurse Practitioner| |
| |and Physician Assistant) | |
|Outpatient diagnostic tests and therapeutic services and |No |Preventive Diagnostic procedures and tests |
|supplies (Part 1)* | |X-Rays |
| |(Prior Authorization is needed |Lab services |
| |for tests that require |Diagnostic procedures and tests such as: |
| |contrasts or Anesthesia) |-Echocardiogram |
| | |-EKG |
| | |-Sonogram |
| | |-Ultrasound |
|Outpatient diagnostic tests and therapeutic services and |Yes |Surgical and medical supplies |
|supplies (Part 2)* | |Blood Services- Coverage begins with the first pint (3-pint deductible is waived) |
| | |Therapeutic radiological services |
| | |Diagnostic radiological services (CT, MRI, PET scan, MRA, etc) |
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|Outpatient hospital services |Yes |We cover medically-necessary services you get in the outpatient department of a hospital for diagnosis or treatment of an illness or |
| | |injury |
| |(Prior Authorization is not |Covered services include, but are not limited to: |
| |required for tests such as |Services in an emergency department or outpatient clinic, such as observation services or outpatient surgery |
| |Sonogram/ |Laboratory and diagnostic tests billed by the hospital |
| |Ultrasound, Electrocardiogram, |Mental health care, including care in a partial-hospitalization program, if a doctor certifies that inpatient treatment would be |
| |X-Ray and Lab) |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 - for tests that require |Cover individual or group outpatient mental health care |
| |Anesthesia | |
| |(Prior Authorization is not | |
| |required for tests such as | |
| |cognitive skills testing, | |
| |psychological and neurological | |
| |testing. Also psychiatrist, | |
| |nurse practitioner, & physician| |
| |assistant) | |
|Outpatient rehabilitation services |Yes |Occupational therapy |
| | |Physical therapy |
| | |Speech-language pathology (Speech therapy) |
|Outpatient substance abuse services |Yes |Cover individual and group outpatient substance abuse services |
|Outpatient surgery, including services provided at |Yes |Outpatient Surgery includes services provided at hospital outpatient facilities and ambulatory surgical centers. |
|hospital outpatient facilities and ambulatory surgical | | |
|centers | | |
|Over-The-Counter benefit |Not Covered | |
|Partial hospitalization services |Yes | |
|Physician/Practitioner services, including doctor’s office|No |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 |
| |(Prior Authorization is needed |any lab or diagnostic testing performed during your visit. |
| |for tests that require | |
| |Contrasts or Anesthesia) | |
|Podiatry services |No |Nail debridement and clipping |
| | |Must 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 | |
|Pulmonary rehabilitation services |Yes |Limited to up to 36 sessions, no more than two sessions per day |
|Screening and counseling to reduce alcohol misuse |No |One alcohol misuse screening for adults who misuse alcohol but aren’t alcohol dependent but 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 |No |Covered once every 12 months for people 55-77 years who have a history of tobacco smoking |
|tomography | | |
|Screening for sexually transmitted infections (STIs) and |No |Cover tests once every 12 months or at certain times during pregnancy |
|counseling to prevent STIs | |Cover 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 |Yes |We cover 100 days in a SNF during each benefit period. |
| | |The 3 day inpatient hospital stay prior to SNF admission is waived. |
|Smoking and tobacco use cessation (counseling to stop |No |If you use tobacco but do not have signs of tobacco related disease we cover two counseling sessions within a 12 month period (Each |
|smoking or tobacco use) | |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. |
|Telemonitoring Services |Yes (referral may also be |Model of care intended to reduce avoidable hospital admissions for members living with chronic conditions and transitioning from home |
| |required) |health services to community with no formal support. Telemonitoring is provided through structured electronic contact between members |
| | |and health care providers (with or without home visits) and includes reporting of symptoms and physiological data to physicians. The |
| | |tele monitoring benefit does not include blood glucose monitors. |
| | | |
| | |If a member calls for this benefit: |
| | | |
| | |“This benefit is offered to qualified members based on certain criteria; if you wish to know if you qualify, let me put you in contact|
| | |with one of our Wellness Coaches to determine if the service is appropriate for you” (number will be posted on intranet). You can also|
| | |call the Navigator line 718.696.0203 to be transferred. Thank you for your call”. |
|Transportation |Not Covered | |
|Urgently needed services |No |If you are admitted to the hospital within 24 hours for the same condition, you do not pay the copay |
|(US + Territories Only) | | |
|Vision Care |(Contact National Vision | |
|Eye exams |Associates 1-844-344-1250 for |High risk of Glaucoma 1 screening per year |
|Glaucoma screening |coverage and authorization) |For people with diabetes one screening for diabetic retinopathy per year |
| | |One pair of eyeglasses with standard frames (or one set of contact lenses) after cataract surgery that implants an intraocular lens. |
|Vision Care (Optional Supplemental Benefit) |Yes (Contact National Vision |Optional Vision Benefit: |
| |Associates 1-844-344-1250 for |1 Routine Eye Exam per Year |
|Eye exam |coverage and authorization) | |
|Eye wear | |Up to $275 for eyeglasses |
|“Welcome to Medicare” Preventive visit |No |One time visit only within the first 12 months you have Medicare Part B. |
| | | |
| | |Medicare-covered EKG following Welcome Visit Preventive Services at no additional cost. |
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