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2011 Medicare Advantage Plan Benefit Details for the Any, Any, Any Gold MA Only (PFFS) - H5820-026-0
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2011 Medicare Advantage Plan Details
Medicare Plan Name:Any, Any, Any Gold MA Only (PFFS)
Location:Butts, Georgia     Click to see other locations
Plan ID:H5820 - 026 - 0     Click to see other plans
Member Services:1-866-690-4842 TTY users 1-800-617-0177
— 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
Email a copy of the Any, Any, Any Gold MA Only (PFFS) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 (see Plan Premium Details below)
Annual Deductible:no drug coverage
Health Plan Type:PFFS *
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$6,700
Number of Members enrolled in this plan in (H5820 - 026):3,582 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
$0.00 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.
This plan does not allow providers to balance bill (charging more than your cost share amount).
UNIVERSAL HEALTH CARE INSURANCE COMPANY INC. will reduce your monthly Medicare Part B premium by up to $ 45.00.
$6 700 out-of-pocket limit.
This limit includes only Medicare-covered services.
** Doctor and Hospital Choice **
Doctor and Hospital Choice
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment.
** 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
$0 copay for routine exams.
Limited to 1 exam(s) every year.
Vision Services
  • $10 copay for one pair of eyeglasses or contact lenses after cataract surgery.
  • $40 copay for exams to diagnose and treat diseases and conditions of the eye.
  • $0 copay for up to 1 routine eye exam(s) every year
  • $10 copay for up to 1 pair(s) of glasses every year
  • $10 copay for up to 1 pair(s) of contacts every year
    • $100 plan coverage limit for eye wear every year.
    Plan offers additional vision benefits.
    Dental Services
    $0 copay for Medicare-covered dental benefits.
  • $0 copay for up to 1 oral exam(s) every year
  • $0 copay for up to 2 cleaning(s) every year
  • $0 copay for up to 1 fluoride treatment(s) every year
  • $0 to $75 copay for up to 1 dental x-ray(s) every year
    • ** Important Information **
    Premium and Other Important Information
    $0.00 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.
    This plan does not allow providers to balance bill (charging more than your cost share amount).
    UNIVERSAL HEALTH CARE INSURANCE COMPANY INC. will reduce your monthly Medicare Part B premium by up to $ 45.00.
    $6 700 out-of-pocket limit.
    This limit includes only Medicare-covered services.
    Doctor and Hospital Choice
    You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment.
    ** Inpatient Care **
    Inpatient Hospital Care (Acute)
    You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment except in emergencies.
    No limit to the number of days covered by the plan each benefit period.
    For Medicare-covered hospital stays:
    Days 1 - 6: $268 copay per day
    Days 7 - 90: $0 copay per day
    $0 copay for additional hospital days
    Inpatient Mental Health Care
    Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days.
    For Medicare-covered hospital stays:
    Days 1 - 6: $299 copay per day
    Days 7 - 90: $0 copay per day
    $0 copay for additional hospital days
    Skilled Nursing Facility (SNF)
    Plan covers up to 100 days each benefit period
    No prior hospital stay is required.
    For SNF stays:
    Days 1 - 20: $50 copay per day
    Days 21 - 100: $128 copay per day
    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
    You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment.
    See 'Welcome to Medicare; and Annual Wellness Visit' for more information.
    $15 copay for each primary care doctor visit for Medicare-covered benefits.
    $40 copay for each specialist visit for Medicare-covered benefits.
    Chiropractic Services
    $20 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.
    Podiatry Services
    $40 copay for each Medicare-covered visit.
    Medicare-covered podiatry benefits are for medically-necessary foot care.
    Outpatient Mental Health Care
    $40 copay for each Medicare-covered individual or group therapy visit.
    Outpatient Substance Abuse Care
    $40 copay for Medicare-covered individual or group visits.
    Outpatient Hospital Services
    10% of the cost for each Medicare-covered ambulatory surgical center visit.
    25% of the cost for each Medicare-covered outpatient hospital facility visit.
    Emergency Care
    $50 copay for Medicare-covered emergency room visits.
    Worldwide coverage.
    If you are admitted to the hospital within 24-hour(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.
    $40 copay [or 25% of the cost] for Medicare-covered Occupational Therapy visits.
    $40 copay [or 25% of the cost] for Medicare-covered Physical and/or Speech and Language Therapy visits.
    $40 copay for Medicare-covered Cardiac Rehab services.
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    20% of the cost for Medicare-covered items.
    Prosthetic Devices
    20% of the cost for Medicare-covered items.
    Diabetes Self-Monitoring Training, Nutrition Therapy, and Supplies
    $0 copay for Diabetes self-monitoring training.
    $40 copay for Nutrition Therapy for Diabetes.
    20% of the cost for Diabetes supplies.
    ** Preventive Services **
    Bone Mass Measurement
    $0 copay for Medicare-covered bone mass measurement
    Colorectal Screening Exams
    $0 copay for Medicare-covered colorectal screenings.
    Immunizations
    $0 copay for Flu and Pneumonia vaccines.
    $0 copay for Hepatitis B vaccine.
    Pap Smears and Pelvic Exams
    $0 copay for Medicare-covered pap smears and pelvic exams.
    Prostate Cancer Screening Exams
    $0 copay for
    • Medicare-covered prostate cancer screening
    ** Additional Benefits **
    Dialysis
    20% of the cost for renal dialysis
    $40 copay 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
    $0 copay for Medicare-covered dental benefits.
  • $0 copay for up to 1 oral exam(s) every year
  • $0 copay for up to 2 cleaning(s) every year
  • $0 copay for up to 1 fluoride treatment(s) every year
  • $0 to $75 copay for up to 1 dental x-ray(s) every year
    • Hearing Services
    Hearing aids not covered.
  • $40 copay for Medicare-covered diagnostic hearing exams
  • $40 copay for up to 1 routine hearing test(s) every year
    • Vision Services
  • $10 copay for one pair of eyeglasses or contact lenses after cataract surgery.
  • $40 copay for exams to diagnose and treat diseases and conditions of the eye.
  • $0 copay for up to 1 routine eye exam(s) every year
  • $10 copay for up to 1 pair(s) of glasses every year
  • $10 copay for up to 1 pair(s) of contacts every year
    • $100 plan coverage limit for eye wear every year.
    Plan offers additional vision benefits.
    Physical Exams
    $0 copay for routine exams.
    Limited to 1 exam(s) every year.
    Health/Wellness Education
    The plan covers the following health/wellness education benefits:
  • Written health education materials including Newsletters
  • Nutritional Training
  • Nutritional benefit
  • Additional Smoking Cessation
  • Health Club Membership/Fitness Classes
  • Nursing Hotline
    • $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.




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    .