2011 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Medicare Blue Saver (PPO) | ||||
Location: | Kershaw, South Carolina Click to see other locations | ||||
Plan ID: | H4209 - 008 - 0 Click to see other plans | ||||
Member Services: | 1-888-645-6025 TTY users 1-888-645-6023 | ||||
— 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 Medicare Blue Saver (PPO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $32.00 (see Plan Premium Details below) | ||||
Annual Deductible: | no drug coverage | ||||
Health Plan Type: | Local PPO * | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,400 | ||||
Number of Members enrolled in this plan in (H4209 - 008): | 71 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 | |||||
$32.00 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 covers all Medicare-covered preventive services with zero cost sharing. | |||||
$3 400 out-of-pocket limit. | |||||
All plan services included. | |||||
$1 250 yearly deductible. Contact the plan for services that apply. | |||||
$5 100 out-of-pocket limit. | |||||
All plan services included. | |||||
** Doctor and Hospital Choice ** | |||||
Doctor and Hospital Choice | |||||
No referral required for network doctors specialists and hospitals. | |||||
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. | |||||
Plan covers you when you travel in the U.S. | |||||
** Extra Benefits ** | |||||
Prescription Drugs | |||||
Most drugs not covered. | |||||
20% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. | |||||
30% of the cost for Part B drugs out-of-network. | |||||
This plan does not offer prescription drug coverage. | |||||
Physical Exams | |||||
$0 copay for routine exams. | |||||
Limited to 1 exam(s) every year. | |||||
$0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits. | |||||
Separate Office Visit cost sharing of $15 to $25 may apply. | |||||
30% of the cost for routine exams. | |||||
Vision Services | |||||
$125 plan coverage limit for eye wear every year. | |||||
0% to 50% of the cost for eye exams. | |||||
0% to 50% of the cost for eye wear. | |||||
Dental Services | |||||
20% of the cost for Medicare-covered dental benefits. | |||||
$10 copay for an office visit that includes: | |||||
50% of the cost for preventive dental benefits. | |||||
30% of the cost for comprehensive dental benefits. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$32.00 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 covers all Medicare-covered preventive services with zero cost sharing. | |||||
$3 400 out-of-pocket limit. | |||||
All plan services included. | |||||
$1 250 yearly deductible. Contact the plan for services that apply. | |||||
$5 100 out-of-pocket limit. | |||||
All plan services included. | |||||
Doctor and Hospital Choice | |||||
No referral required for network doctors specialists and hospitals. | |||||
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. | |||||
Plan covers you when you travel in the U.S. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care (Acute) | |||||
No limit to the number of days covered by the plan each benefit period. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 5: $275 copay per day | |||||
Days 6 - 90: $0 copay per day | |||||
$0 copay for additional hospital days | |||||
30% of the cost for each hospital stay. | |||||
Inpatient Mental Health Care | |||||
You get up to 190 days in a Psychiatric Hospital in a lifetime. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 5: $275 copay per day | |||||
Days 6 - 90: $0 copay per day | |||||
30% of the cost for each hospital stay. | |||||
Skilled Nursing Facility (SNF) | |||||
Plan covers up to 100 days each benefit period | |||||
3-day prior hospital stay is required. | |||||
For Medicare-covered SNF stays: | |||||
Days 1 - 20: $0 copay per day | |||||
Days 21 - 100: $128 copay per day | |||||
30% of the cost for each SNF stay. | |||||
Home Health Care | |||||
10% of the cost for each Medicare-covered home health visit. | |||||
30% for home health visits. | |||||
Hospice | |||||
You must get care from a Medicare-certified hospice. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
See 'Welcome to Medicare; and Annual Wellness Visit' for more information. | |||||
$15 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$15 to $25 copay for each in-area network urgent care Medicare-covered visit. | |||||
$25 copay for each specialist visit for Medicare-covered benefits. | |||||
$35 copay for each primary care doctor visit. | |||||
30% for each specialist visit. | |||||
Chiropractic Services | |||||
$25 copay 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. | |||||
30% of the cost for chiropractic benefits. | |||||
Podiatry Services | |||||
$25 copay for each Medicare-covered visit. | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
30% of the cost for podiatry benefits. | |||||
Outpatient Mental Health Care | |||||
$25 copay for each Medicare-covered individual or group therapy visit. | |||||
30% of the cost for Mental Health benefits. | |||||
30% of the cost for Mental Health benefits with a psychiatrist. | |||||
Outpatient Substance Abuse Care | |||||
$25 copay for Medicare-covered individual or group visits. | |||||
30% of the cost for outpatient substance abuse benefits. | |||||
Outpatient Hospital Services | |||||
$100 copay for each Medicare-covered ambulatory surgical center visit. | |||||
$200 copay for each Medicare-covered outpatient hospital facility visit. | |||||
30% of the cost for ambulatory surgical center benefits. | |||||
30% of the cost for outpatient hospital facility benefits. | |||||
Emergency Care | |||||
$50 copay for Medicare-covered emergency room visits. | |||||
This amount applies toward your out-of-network plan deductible. | |||||
$25 000 plan coverage limit for emergency services outside the U.S. every year. | |||||
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. | |||||
$25 copay for Medicare-covered Occupational Therapy visits. | |||||
$25 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. | |||||
$25 copay for Medicare-covered Cardiac Rehab services. | |||||
30% of the cost for Occupational Therapy benefits. | |||||
30% of the cost for Physical and/or Speech and Language Therapy visits. | |||||
30% of the cost for Cardiac Rehab services. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
25% of the cost for Medicare-covered items. | |||||
30% of the cost for durable medical equipment. | |||||
Prosthetic Devices | |||||
25% of the cost for Medicare-covered items. | |||||
30% of the cost for prosthetic devices. | |||||
Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies | |||||
$0 copay for Diabetes self-monitoring training. | |||||
$0 copay for Nutrition Therapy for Diabetes. | |||||
$0 copay for Diabetes supplies. | |||||
Separate Office Visit cost sharing of $15 to $25 may apply. | |||||
30% of the cost for Diabetes self-monitoring training. | |||||
30% of the cost for Nutrition Therapy for Diabetes. | |||||
30% of the cost for Diabetes supplies. | |||||
** Preventive Services ** | |||||
Bone Mass Measurement | |||||
$0 copay for Medicare-covered bone mass measurement | |||||
Separate Office Visit cost sharing of $15 to $25 may apply. | |||||
30% of the cost for Medicare-covered bone mass measurement. | |||||
Colorectal Screening Exams | |||||
$0 copay for Medicare-covered colorectal screenings. | |||||
Separate Office Visit cost sharing of $15 to $25 may apply. | |||||
30% of the cost for colorectal screenings. | |||||
Immunizations | |||||
$0 copay for Flu and Pneumonia vaccines. | |||||
$0 copay for Hepatitis B vaccine. | |||||
No referral needed for Flu and pneumonia vaccines. | |||||
30% of the cost for immunizations. | |||||
Pap Smears and Pelvic Exams | |||||
$0 copay for Medicare-covered pap smears and pelvic exams. | |||||
Separate Office Visit cost sharing of $15 to $25 may apply. | |||||
30% of the cost for pap smears and pelvic exams. | |||||
Prostate Cancer Screening Exams | |||||
$0 copay for
| |||||
Separate Office Visit cost sharing of $15 to $25 may apply. | |||||
30% of the cost for prostate cancer screening. | |||||
** Additional Benefits ** | |||||
Dialysis | |||||
20% of the cost for renal dialysis | |||||
$0 copay for Nutrition Therapy for End-Stage Renal Disease | |||||
30% of the cost for renal dialysis. | |||||
30% 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. | |||||
30% of the cost for Part B drugs out-of-network. | |||||
This plan does not offer prescription drug coverage. | |||||
Dental Services | |||||
20% of the cost for Medicare-covered dental benefits. | |||||
$10 copay for an office visit that includes: | |||||
50% of the cost for preventive dental benefits. | |||||
30% of the cost for comprehensive dental benefits. | |||||
Hearing Services | |||||
In general routine hearing exams and hearing aids not covered. | |||||
30% of the cost for hearing exams. | |||||
Vision Services | |||||
$125 plan coverage limit for eye wear every year. | |||||
0% to 50% of the cost for eye exams. | |||||
0% to 50% of the cost for eye wear. | |||||
Physical Exams | |||||
$0 copay for routine exams. | |||||
Limited to 1 exam(s) every year. | |||||
$0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits. | |||||
Separate Office Visit cost sharing of $15 to $25 may apply. | |||||
30% of the cost for routine exams. | |||||
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. | |||||
30% of the cost for Health and Wellness services. | |||||
Transportation | |||||
This plan does not cover routine transportation. | |||||
Acupuncture | |||||
This plan does not cover Acupuncture. |