2011 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | AB Basic Plan (Cost) | ||||
Location: | Niobrara, Wyoming Click to see other locations | ||||
Plan ID: | H0602 - 026 - 0 Click to see other plans | ||||
Member Services: | 1-888-282-1420 TTY users 1-800-704-6370 | ||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the AB Basic Plan (Cost) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $25.00 (see Plan Premium Details below) | ||||
Annual Deductible: | no drug coverage | ||||
Health Plan Type: | Cost * | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $-1 | ||||
Number of Members enrolled in this plan in (H0602 - 026): | 1,112 members | ||||
— Plan Premium Details — | |||||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $0.00 | $0.00 | $0.00 | $0.00 | |
— Plan Health Benefits — | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
$25.00 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |||||
This plan does not cover all Medicare-covered preventive services with zero cost sharing. | |||||
** Doctor and Hospital Choice ** | |||||
Doctor and Hospital Choice | |||||
No referral required for network doctors specialists and hospitals. | |||||
You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services. When Medicare pays its share you pay the Medicare Part B deductible and coinsurance. | |||||
** Extra Benefits ** | |||||
Prescription Drugs | |||||
Most drugs not covered. | |||||
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. | |||||
This plan does not offer prescription drug coverage. | |||||
Physical Exams | |||||
When you get Medicare Part B you can get a one-time physical within the first 12 months of your new Part B coverage. The coverage does not include lab tests. | |||||
20% of the cost for the required Medicare-covered initial preventive physical exam and annual wellness visits. | |||||
Vision Services | |||||
Non-Medicare-covered eye exams and glasses not covered. | |||||
$0 copay for
| |||||
Dental Services | |||||
Authorization rules may apply. | |||||
In general preventive dental benefits (such as cleaning) not covered. | |||||
20% of the cost for Medicare-covered dental benefits. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$25.00 monthly plan premium in addition to your monthly Medicare Part B premium. | |||||
Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. | |||||
This plan does not cover all Medicare-covered preventive services with zero cost sharing. | |||||
Doctor and Hospital Choice | |||||
No referral required for network doctors specialists and hospitals. | |||||
You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services. When Medicare pays its share you pay the Medicare Part B deductible and coinsurance. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care (Acute) | |||||
Plan covers 90 days each benefit period. | |||||
You will not be charged additional cost sharing for professional services. | |||||
Inpatient Mental Health Care | |||||
You get up to 190 days in a Psychiatric Hospital in a lifetime. | |||||
Same deductible and copay as inpatient hospital care (see 'Inpatient Hospital Care') | |||||
Skilled Nursing Facility (SNF) | |||||
Plan covers up to 100 days each benefit period | |||||
You will not be charged additional cost sharing for professional services. | |||||
Home Health Care | |||||
$0 copay for Medicare-covered home health visits. | |||||
Hospice | |||||
You must get care from a Medicare-certified hospice. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
20% of the cost for each primary care doctor visit for Medicare-covered benefits. | |||||
20% of the cost for each in-area network urgent care Medicare-covered visit. | |||||
20% of the cost for each specialist visit for Medicare-covered benefits. | |||||
Chiropractic Services | |||||
20% of the cost for each Medicare-covered visit. | |||||
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers. | |||||
Podiatry Services | |||||
20% of the cost for each Medicare-covered visit. | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
Outpatient Mental Health Care | |||||
Authorization rules may apply. | |||||
45% of the cost for each Medicare-covered individual or group therapy visit. | |||||
20% of the cost for each Medicare-covered individual or group therapy visit with a psychiatrist. | |||||
Outpatient Substance Abuse Care | |||||
Authorization rules may apply. | |||||
20% of the cost for Medicare-covered individual or group visits. | |||||
Outpatient Hospital Services | |||||
Authorization rules may apply. | |||||
20% of the cost for each Medicare-covered ambulatory surgical center visit. | |||||
20% of the cost for each Medicare-covered outpatient hospital facility visit. | |||||
Emergency Care | |||||
20% of the cost for Medicare-covered emergency room visits. | |||||
Not covered outside the U.S. except under limited circumstances. Contact the plan for more details. | |||||
If you are admitted to the hospital within 3-day(s) for the same condition you pay $0 for the emergency room visit. | |||||
Outpatient Rehabilitation Services | |||||
There may be limits on physical therapy occupational therapy and speech and language pathology services. If so there may be exceptions to these limits. | |||||
20% of the cost for Medicare-covered Occupational Therapy visits. | |||||
20% of the cost for Medicare-covered Physical and/or Speech and Language Therapy visits. | |||||
20% of the cost for Medicare-covered Cardiac Rehab services. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
20% of the cost for Medicare-covered items. | |||||
Prosthetic Devices | |||||
Authorization rules may apply. | |||||
20% of the cost for Medicare-covered items. | |||||
Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies | |||||
20% of the cost for Diabetes self-monitoring training. | |||||
20% of the cost for Nutrition Therapy for Diabetes. | |||||
20% of the cost for Diabetes supplies. | |||||
** Preventive Services ** | |||||
Bone Mass Measurement | |||||
20% of the cost for Medicare-covered bone mass measurement. | |||||
Colorectal Screening Exams | |||||
20% of the cost for Medicare-covered colorectal screenings. | |||||
Immunizations | |||||
$0 copay for Flu and Pneumonia vaccines. | |||||
No referral needed for Flu and pneumonia vaccines. | |||||
20% of the cost for Hepatitis B vaccine. | |||||
Pap Smears and Pelvic Exams | |||||
0% of the cost for Medicare-covered pap smears. | |||||
20% of the cost for Medicare-covered pelvic exams. | |||||
Prostate Cancer Screening Exams | |||||
20% of the cost for Medicare-covered prostate cancer screening. | |||||
** Additional Benefits ** | |||||
Dialysis | |||||
Cost plan members pay Fee-for-Service cost sharing for out-of-area dialysis. | |||||
20% of the cost for renal dialysis | |||||
20% of the cost for Nutrition Therapy for End-Stage Renal Disease. | |||||
Prescription Drugs | |||||
Most drugs not covered. | |||||
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. | |||||
This plan does not offer prescription drug coverage. | |||||
Dental Services | |||||
Authorization rules may apply. | |||||
In general preventive dental benefits (such as cleaning) not covered. | |||||
20% of the cost for Medicare-covered dental benefits. | |||||
Hearing Services | |||||
In general routine hearing exams and hearing aids not covered. | |||||
Vision Services | |||||
Non-Medicare-covered eye exams and glasses not covered. | |||||
$0 copay for
| |||||
Physical Exams | |||||
When you get Medicare Part B you can get a one-time physical within the first 12 months of your new Part B coverage. The coverage does not include lab tests. | |||||
20% of the cost for the required Medicare-covered initial preventive physical exam and annual wellness visits. | |||||
Health/Wellness Education | |||||
The plan covers the following health/wellness education benefits: | |||||
$0 copay for each Medicare-covered smoking cessation counseling session. | |||||
$0 copay for each Medicare-covered HIV screening. | |||||
HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. | |||||
Transportation | |||||
This plan does not cover routine transportation. | |||||
Acupuncture | |||||
This plan does not cover Acupuncture. |