2011 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Erickson Advantage Signature without Drugs (HMO-POS) | ||||
Location: | Plymouth, Massachusetts Click to see other locations | ||||
Plan ID: | H5652 - 002 - 0 Click to see other plans | ||||
Member Services: | 1-866-314-8188 TTY users 711 | ||||
— 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 Erickson Advantage Signature without Drugs (HMO-POS) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $121.00 (see Plan Premium Details below) | ||||
Annual Deductible: | no drug coverage | ||||
Health Plan Type: | Local HMO * | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $2,500 | ||||
Number of Members enrolled in this plan in (H5652 - 002): | 245 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 | |||||
$121.00 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. | |||||
$2 500 out-of-pocket limit. | |||||
This limit includes only Medicare-covered services. | |||||
** Doctor and Hospital Choice ** | |||||
Doctor and Hospital Choice | |||||
No referral required for network doctors specialists and hospitals. | |||||
** Extra Benefits ** | |||||
Prescription Drugs | |||||
Most drugs not covered. | |||||
$0 copay 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. | |||||
$0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits. | |||||
Vision Services | |||||
$100 plan coverage limit for eye wear every two years. | |||||
Dental Services | |||||
$30 copay for Medicare-covered dental benefits. | |||||
$30 copay for an office visit that includes: | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$121.00 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. | |||||
$2 500 out-of-pocket limit. | |||||
This limit includes only Medicare-covered services. | |||||
Doctor and Hospital Choice | |||||
No referral required for network doctors specialists and hospitals. | |||||
** 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 - 90: $0 copay per day | |||||
$0 copay for each additional hospital day. | |||||
Inpatient Mental Health Care | |||||
You get up to 190 days in a Psychiatric Hospital in a lifetime. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 90: $0 copay per day | |||||
Skilled Nursing Facility (SNF) | |||||
Plan covers up to 100 days each benefit period | |||||
No prior hospital stay is required. | |||||
For Medicare-covered SNF stays: | |||||
Days 1 - 20: $0 copay per day | |||||
Days 21 - 54: $75 copay per day | |||||
Days 55 - 100: $0 copay per day | |||||
Home Health Care | |||||
$0 copay for each Medicare-covered home health visit. | |||||
Hospice | |||||
You must get care from a Medicare-certified hospice. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
$0 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$30 copay for each in-area network urgent care Medicare-covered visit. | |||||
$30 copay for each specialist visit for Medicare-covered benefits. | |||||
Chiropractic Services | |||||
50% 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 | |||||
$0 copay for each Medicare-covered visit. | |||||
$0 copay for up to 6 routine visit(s) every year | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
Outpatient Mental Health Care | |||||
$0 copay for each Medicare-covered individual or group therapy visit. | |||||
$30 copay for each Medicare-covered individual or group therapy visit with a psychiatrist. | |||||
Outpatient Substance Abuse Care | |||||
$30 copay for Medicare-covered individual or group visits. | |||||
Outpatient Hospital Services | |||||
$50 copay for each Medicare-covered ambulatory surgical center visit. | |||||
$50 copay 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 | |||||
$0 copay for Medicare-covered Occupational Therapy visits. | |||||
$0 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. | |||||
$0 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. | |||||
$0 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. | |||||
No referral needed 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 | |||||
$0 copay for renal dialysis | |||||
$0 copay for Nutrition Therapy for End-Stage Renal Disease. | |||||
Prescription Drugs | |||||
Most drugs not covered. | |||||
$0 copay for Part B-covered chemotherapy drugs and other Part B-covered drugs. | |||||
This plan does not offer prescription drug coverage. | |||||
Dental Services | |||||
$30 copay for Medicare-covered dental benefits. | |||||
$30 copay for an office visit that includes: | |||||
Hearing Services | |||||
$160 plan coverage limit for hearing aids every two years. | |||||
Vision Services | |||||
$100 plan coverage limit for eye wear every two years. | |||||
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. | |||||
$0 copay 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 | |||||
$0 copay for up to 24 one-way trip(s) to plan approved location every year. | |||||
Acupuncture | |||||
This plan does not cover Acupuncture. | |||||
Point of Service | |||||
Point of Service coverage is available for the following benefits:
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30% of the cost per hospital stay. | |||||
30% of the cost per Inpatient Psychiatric Hospital stay. | |||||
30% of the cost for each SNF stay. | |||||
30% of the cost for
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0% to 30% of the cost for
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$0 copay for
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50% of the cost for
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