2018 Summary of Benefits Kansas Health Advantage (HMO-SNP) H2392 001January 1, 2018-December 31, 2018

For more information, contact Kansas Health Advantage (HMO-SNP) from 8:00 a.m. to 8:00 p.m., 7 days a week at 1-800-399-7524 (TTY users call 711) or visit www.kansashealthadvantage.com.

H2392_SB_1117 Accepted

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This is a summary of drug and health services covered by Kansas Health Advantage (HMO-SNP),

January 1, 2018 - December 31, 2018

Kansas Health Advantage (HMO-SNP) is a Medicare Advantage HMO plan with a Medicare contract. Enrollment in the Plan depends on contract renewal.

The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, please request the “Evidence of Coverage” by calling Member Services at 1-800-399-7524. Hours are seven (7) days a week from 8:00 a. m. to 8:00 p. m. TTY users call711, or visit our website at www.kansashealthadvantage.com.

To join Kansas Health Advantage (HMO-SNP), you must be entitled to Medicare Part A, be enrolled in Medicare Part B and live in our service area. You must live in one of our network nursing homes. Our service area includes the following Kansas Counties: Allen, Atchison, Bourbon, Butler, Chautauqua, Cherokee, Clay, Cowley, Crawford, Edwards, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Miami, Nemaha, Neosho, Osage, Pottawatomie, Reno, Russell, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson and Wyandotte.

Kansas Health Advantage (HMO-SNP) has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services.

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Premiums and Benefits Kansas Health Advantage (HMO-SNP)

What you should know

Monthly Plan Premium You pay $27. 60 You must continue to pay your Medicare Part B premium.

Deductible $183.00 This is the 2017 amount which may change for 2018. The Plan will provide updated rates as soon as Medicare releases them.

Maximum Out-of-Pocket Responsibility (does not include prescription drugs)

$6,700 annually The most you pay for copays, coinsurance and other costs for medical services in a year.

Inpatient Hospital You pay a $1,316 deductible for days 1-60 of each benefit period

You pay $329 coinsurance per day for days 61 – 90

You pay $658 coinsurance per lifetime reserve day after day 90 up to 60 days over your lifetime

These are 2017 amounts which may change for 2018. The Plan will provide updated rates as soon as Medicare releases them.

Prior authorization is required.

Cost sharing is applied starting on the first day of admission and does not include the date of discharge.

Outpatient Hospital 20% of the cost of Medicare-covered services

Prior authorization is required.

Doctor Visits• Primary Care• Specialists

You pay 20% per visitYou pay 20% per visit

Preventive Care(e.g. flu vaccine, diabetic screenings)

You pay nothing Other preventive services are available. There are some covered services that have a cost.

Emergency Care 20% of the cost of Medicare-covered services up to $80

If you are admitted to the hospital within one (1) day, then you do not have to pay $80.

Urgently Needed Services 20% of the cost for Medicare-covered services up to $65

If you are admitted to the hospital within three (3) days, then you do not have to pay $65.

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Premiums and Benefits Kansas Health Advantage (HMO-SNP)

What you should know

Diagnostic Services/Labs/Imaging

• Diagnostic radiologyservice (e.g., MRI)

• Lab services

• Diagnostic tests andprocedures

• Outpatient x-rays

• 20% of the cost for Medicare-covered Diagnostic Radiologyservices (e.g., MRI)• You pay nothing for Medicare-covered Lab services• 20% of the cost for Medicare-covered Diagnostic tests andprocedures• 20% of the cost for Medicare-covered Outpatient x-rayservices

Prior authorization is required for some services.

Hearing Services 20% of the cost for Medicare-covered services

Dental Services 20% of the cost for Medicare-covered services

In general, preventive dental services (such as cleaning, routine dental exams and dental x-rays) are not covered byOriginal Medicare.

Vision Services 20% of the cost for Medicare-covered services

Our plan pays up to $50 every year for routine eye exams and $150 every year for eyeglasses (frames and lenses).

Mental Health Services 20% of the cost for Outpatient Medicare-covered services

Skilled Nursing Facility (SNF) You pay nothing for the first 20 days of each benefit period.

You pay $164.50 per day for days 21-100.

You pay all costs for each day after 100.

These are 2017 amounts which may change for 2018. The Plan will provide updated rates as soon as Medicare releases them.

Prior authorization is required.

Zero hospital days required prior to SNF admission. The Plan covers 100 days per benefit period.

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Premiums and Benefits Kansas Health Advantage (HMO-SNP)

What you should know

Rehabilitation Services • Occupational therapy visit• Physical therapy andspeech and languagetherapy visit

20% of the cost for Medicare-covered services

Prior authorization is required.

Ambulance 20% of the cost for Medicare-covered services

Transportation (Non-emergent, Routine)

$0.00 copay for up to 36 one-way trip (s) to plan-approved locations every year.

Prior authorization may be required.

Foot Care (podiatry services) • Foot exams and treatment• Routine foot care

20% of the cost for Medicare-covered services

Medical Equipment/Supplies• Durable Medical

Equipment(e.g., wheelchairs, oxygen)

• Prosthetics (e.g., braces,artificial limbs)

• Diabetes supplies

20% of the cost for Medicare-covered services

Prior authorization is required for charges greater than $500.

Medicare Part B Drugs 20% of the cost for Medicare-covered services

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Outpatient Prescription Drugs

Stage 1Yearly

DeductibleStage

Stage 2Initial

CoverageStage

Stage 3Coverage

GapStage

Stage 4Catastrophic

CoverageStage

What you should know

You begin in this payment stage when you fill your first prescription of the year.

During this stage, you pay the full cost of your drugs.

You stay in this stage until you have paid $405 for your drugs ($405 is the amount of your deductible).

During this stage, the plan pays its share of the cost of your drugs and you pay your share of the cost.

You stay in this stage until your year-to-date “total drug costs” (your payments plus any Part D plan’s payments) total $3,750.

During this stage, you pay 35% of the price for brand name drugs plus a portion of the dispensing fee) and 44% of the price for generic drugs.

You stay in this stage until your year-to-date “out-of-pocket costs” (your payments) reach a total of $5,000. This amount and rules for counting costs toward this amount have been set by Medicare.

During this stage, the plan will pay most of the cost of your drugsfor the rest of the calendar year (through December 31,2018).

Cost-Sharing may change when you enter another phase of the Part D benefit.

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Anti-Discrimination NoticeEnglish

Kansas Health Advantage (HMO-SNP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Kansas Health Advantage (HMO-SNP) does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.Kansas Health Advantage (HMO-SNP):

• Provides free aids and services to people with disabilities to communicate effectively with us,such as:

• Qualified sign language interpreters• Written information in other formats (large print, audio, accessible electronic formats,

other formats)• Provides free language services to people whose primary language is not English, such as:

• Qualified interpreters• Information written in other languages

If you need these services, contact Raquel Chapman. If you believe that Kansas Health Advantage (HMO-SNP) has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with:Raquel Chapman, Corporate Compliance Director, 909 S. Meridian Avenue, Suite 425; Oklahoma City, OK 73108, or 1-800-399-7524, (TTY users call 711), Fax-1-866-819-4774, or email rchapman@tributehealthplans.com. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, Raquel Chapman, Corporate Compliance Director, is available to help you.You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office of Civil Rights, electronically through the Office of Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services200 Independence Avenue, SW

Room 509F, HHH BuildingWashington, D.C. 20201

1-800-368-1019, 800-537-7697 (TDD)Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html

Multi-Language Insert

English If you, or someone you’re helping, has questions about Kansas Health Advantage (HMO-SNP), you have the right to get help and information in your language at no cost. To talk to an interpreter, call 1-800-399-7524 (TTY: 711).

Español (Spanish) Si usted, o alguien a quien usted está ayudando, tiene preguntas acerca de Kansas Health Advantage (HMO-SNP), tiene derecho a obtener ayuda e información en su idioma sin costo alguno. Para hablar con un intérprete, llame a l -800-399-7524 (TTY: 711).

Tiếng Việt (Vietnamese) Nếu quý vị, hay người mà quý vị đang giúp đỡ, có câu hỏi về Kansas Health Advantage (HMO-SNP), quý vị sẽ có quyền được giúp và có thêm thông tin bằng ngôn ngữ của mình miễn phí. Để nói chuyện với một thông dịch viên, xin gọi 1-800-399-7524 (TTY: 711).

繁體中文 (Chinese) 如果您，或是您正在協助的對象，有關於[插入 SBM 項目的名稱 Kansas Health Advantage (HMO-SNP) 方面的問題，您有權利免費以您的母語得到幫助和訊息。洽詢一位翻譯員，請撥電話[在此插入數字1-800-399-7524 (TTY: 711)

Deutsch (German) Falls Sie oder jemand, dem Sie helfen, Fragen zum Kansas Health Advantage (HMO-SNP) haben, haben Sie das Recht, kostenlose Hilfe und Informationen in Ihrer Sprache zu erhalten. Um mit einem Dolmetscher zu sprechen, rufen Sie bitte die Nummer 1-800-399-7524 (TTY: 711) an.

한국어 (Korean)

만약 귀하 또는 귀하가 돕고 있는 어떤 사람이 Kansas Health Advantage (HMO-SNP) 에 관해서 질문이 있다면 귀하는 그러한 도움과 정보를 귀하의 언어로 비용 부담없이 얻을 수 있는 권리가 있습니다. 그렇게 통역사와 얘기하기 위해서는 1-800-399-7524 (TTY: 711)로 전화하십시오.

ພາສາລາວ (Lao) ຖ້ າທ່ ານ, ຫຼື ຄົ ນ ່ທທ່ ານກໍ າລັ ງຊ່ ວຍເຫຼື ອ, ມ ຄໍາຖາມກ່ ຽວກັ ບ Kansas Health Advantage

(HMO-SNP), ທ່ ານ ມ ສິດ ່ທຈະໄດ້ ຮັ ບການຊ່ ວຍເຫຼື ອແລະຂໍ້ ມູ ນຂ່ າວສານ ່ທເປັ ນພາສາຂອງທ່ານ່ໍບ ມ ຄ່ າໃຊ້ ຈ່ າຍ. ການໂອ້ ລົ ມກັ ບນາຍພາສາ, ໃຫ້ ໂທຫາ 1-800-399-7524 (TTY: 711). (Arabic) لعربیة

بخصوص أسئلة تساعده شخص لدى أو لدیك كان إن Kansas Health Advantage (HMO-SNP)، المساعدة على الحصول في الحق فلدیك والمعلومات

- الضروریة بلغتك من دون ایة تكلفة .للتحدث مع مترجم اتصل (TTY:711) 7524 399-800-1

Tagalog (Tagalog – Filipino) Kung ikaw, o ang iyong tinutulangan, ay may mga katanungan tungkol sa Kansas Health Advantage (HMO-SNP) may karapatan ka na makakuha ng tulong at impormasyon sa iyong wika ng walang gastos. Upang makausap ang isang tagasalin, tumawag sa 1-800-399-7524 (TTY: 711).

Burmese

Français (French) Si vous, ou quelqu'un que vous êtes en train d’aider, a des questions à propos de Kansas Health Advantage

(HMO-SNP), vous avez le droit d'obtenir de l'aide et l'information dans votre langue à aucun cot. Pour parler à un interprte, appelez 1-800-399-7524 (TTY: 711).

日本語 (Japanese) ご本人様、またはお客様の身の回りの方でも、Kansas Health Advantage (HMO-SNP)についてご質問

がございましたら、ご希望の言語でサポートを受けたり、情報を入手したりすることができます。料金はかかりません。通訳とお話される場合、1-800-399-7524 (TTY: 711) までお電話ください。

Русский (Russian) Если у вас или лица, которому вы помогаете, имеются вопросы по поводу Kansas Health Advantage (HMO-SNP), то вы имеете право на бесплатное получение помощи и информации на вашем языке. Для разговора с переводчиком позвоните по телефону Звоните 1-800-399-7524 (телетайп: 711).

Hmong Yog koj, los yog tej tus neeg uas koj pab ntawd, muaj lus nug txog Kansas Health Advantage (HMO-SNP), koj muaj cai kom lawv muab cov ntshiab lus qhia uas tau muab sau ua koj hom lus pub dawb rau koj. Yog koj xav nrog ib tug neeg txhais lus tham, hu rau 1-800-399-7524 (TTY: 711).

Persian-Farsi داشتھ باشید حق این را دارید کە کمک ، Kansas Health Advantage (HMO-SNP) گر شما، یا کسی کھ شما بە او کمک میکنید ، سوال در مورد

7524-399-800-1 دیينما تدریاف نارایگ رطو بھ را خود انبز بھ تالعاطا و (TTY: 711) یدنماي صلحا تماس .

Swahili Kama wewe, au mtu unaye mpa usaidizi ana maswali kuhusu Kansas Health Advantage (HMO-SNP), Una haki ya kupata habari hii na msaada kwa lugha yako bila gharama. Kuzungumza na mkalimani, piga nambari hii: 1-800-399-7524 (TTY: 711).

Kansas Health Advantage (HMO-SNP),

For more information, contact Kansas Health Advantage (HMO-SNP) from 8:00 a.m. to 8:00 p.m., 7 days a week at 1-800-399-7524 (TTY user’s call 711) or visit www.kansashealthadvantage.com.

You can access Kansas Health Advantage (HMO-SNP) provider or pharmacy directory on our website at www.kansashealthadvantage.com.

For coverage and costs of Original Medicare look in your current “Medicare & You” handbook. View it online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

Kansas Health Advantage (HMO-SNP) is a Health Plan with a Medicare Contract. Enrollment in Kansas Health Advantage (HMO-SNP) depends on contract renewal.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premium and/or copayments/co- insurance may change on January 1 of each year.

You must continue to pay your Medicare Part B premium.

This information is available for free in other languages. Please call Member Services at 1-800-399-7524 (TTY user’s call 711) from 8 a.m. to 8 p.m., 7 days a week.

This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home. Kansas Health Advantage (HMO-SNP) has been approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) until 2020 based on a review of Kansas Health Advantage (HMO-SNP)’s Model of Care.

The pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

Member Services: 1-800-399-7524 (TTY users call 711)8:00 a.m. to 8:00 p.m., 7 days a week

kansashealthadvantage.com