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2011 Medicare Advantage Plan Benefit Details for the Mercy MedicareADVANTAGE (no drug) (HMO) - H2667-012-0
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:Mercy MedicareADVANTAGE (no drug) (HMO)
Location:Greene, Missouri     Click to see other locations
Plan ID:H2667 - 012 - 0     Click to see other plans
Member Services:1-800-481-4466 TTY users 1-800-446-1468
— 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 Mercy MedicareADVANTAGE (no drug) (HMO) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 (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):$3,000
Number of Members enrolled in this plan in (H2667 - 012):886 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 covers all Medicare-covered preventive services with zero cost sharing.
$3 000 out-of-pocket limit.
There is no limit on cost sharing for the following services: Supplemental Services:
  • Transportation Services
  • Acupuncture
  • Over The Counter (OTC) Items
  • Meal Benefit
** Doctor and Hospital Choice **
Doctor and Hospital Choice
You must go to network doctors specialists and hospitals.
Referral required for network hospitals and specialists (for certain benefits).
** 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.
$0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits.
Separate Office Visit cost sharing of $10 to $30 may apply.
Vision Services
$0 copay for
  • one pair of eyeglasses or contact lenses after cataract surgery
  • up to 1 pair(s) of glasses
  • up to 1 pair(s) of contacts
  • $0 to $30 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
    • $150 plan coverage limit for eye wear every two years.
    Dental Services
    Authorization rules may apply.
    $0 copay for the following preventive dental benefits:
  • oral exams
  • cleanings
  • fluoride treatments
  • dental x-rays
    • $30 copay for Medicare-covered dental benefits.
    Plan offers additional comprehensive dental benefits.
    $500 plan coverage limit for dental benefits 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 covers all Medicare-covered preventive services with zero cost sharing.
    $3 000 out-of-pocket limit.
    There is no limit on cost sharing for the following services: Supplemental Services:
    • Transportation Services
    • Acupuncture
    • Over The Counter (OTC) Items
    • Meal Benefit
    Doctor and Hospital Choice
    You must go to network doctors specialists and hospitals.
    Referral required for network hospitals and specialists (for certain benefits).
    ** Inpatient Care **
    Inpatient Hospital Care (Acute)
    No limit to the number of days covered by the plan each benefit period.
    $0 copay
    $500 out-of-pocket limit every year.
    Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
    Inpatient Mental Health Care
    You get up to 190 days in a Psychiatric Hospital in a lifetime.
    $0 copay
    The maximum out-of-pocket limit is covered under 'Inpatient Hospital Care'.
    Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
    Skilled Nursing Facility (SNF)
    Authorization rules may apply.
    Plan covers up to 100 days each benefit period
    No prior hospital stay is required.
    For SNF stays:
    Days 1 - 30: $0 copay per day
    Days 31 - 100: $100 copay per day
    Home Health Care
    Authorization rules may apply.
    $0 copay for Medicare-covered 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.
    Authorization rules may apply.
    $10 copay for each primary care doctor visit for Medicare-covered benefits.
    $15 copay for each in-area network urgent care Medicare-covered visit.
    $30 copay for each specialist visit for Medicare-covered benefits.
    Chiropractic Services
    Authorization rules may apply.
    $30 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
    Authorization rules may apply.
    $10 copay for each Medicare-covered visit.
    $10 copay for up to 6 routine visit(s) every year
    Medicare-covered podiatry benefits are for medically-necessary foot care.
    Outpatient Mental Health Care
    Authorization rules may apply.
    $30 copay for each Medicare-covered individual or group therapy visit.
    Outpatient Substance Abuse Care
    Authorization rules may apply.
    $30 copay for Medicare-covered individual or group visits.
    Outpatient Hospital Services
    Authorization rules may apply.
    $100 copay for each Medicare-covered ambulatory surgical center visit.
    $100 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
    Authorization rules may apply.
    $30 copay for Medicare-covered Occupational Therapy visits.
    $30 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
    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
    Authorization rules may apply.
    $0 copay for Diabetes self-monitoring training.
    $0 copay for Nutrition Therapy for Diabetes.
    $0 copay for Diabetes supplies.
    ** Preventive Services **
    Bone Mass Measurement
    Authorization rules may apply.
    $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.
    Separate Office Visit cost sharing of $10 to $30 may apply.
    No referral needed for other immunizations.
    Pap Smears and Pelvic Exams
    $0 copay for Medicare-covered pap smears and pelvic exams
  • up to 1 additional pap smear(s) and pelvic exam(s) every two years
    • Separate Office Visit cost sharing of $10 to $30 may apply.
    Prostate Cancer Screening Exams
    $0 copay for
    • Medicare-covered prostate cancer screening
    ** Additional Benefits **
    Dialysis
    Authorization rules may apply.
    20% of the cost for renal dialysis
    $0 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
    Authorization rules may apply.
    $0 copay for the following preventive dental benefits:
  • oral exams
  • cleanings
  • fluoride treatments
  • dental x-rays
    • $30 copay for Medicare-covered dental benefits.
    Plan offers additional comprehensive dental benefits.
    $500 plan coverage limit for dental benefits every year.
    Hearing Services
    Authorization rules may apply.
    Hearing aids not covered.
  • $30 copay for Medicare-covered diagnostic hearing exams
  • $0 copay for up to 1 routine hearing test(s) every year
    • Vision Services
    $0 copay for
    • one pair of eyeglasses or contact lenses after cataract surgery
  • up to 1 pair(s) of glasses
  • up to 1 pair(s) of contacts
  • $0 to $30 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
    • $150 plan coverage limit for eye wear every two years.
    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 $10 to $30 may apply.
    Health/Wellness Education
    Authorization rules may apply.
    The plan covers the following health/wellness education benefits:
  • Nutritional Training
  • Additional Smoking Cessation
  • Health Club Membership/Fitness Classes
  • Nursing Hotline
    • Copays may apply for these 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.




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