2011 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | First+Plus Advantage (PPO) | ||||
Location: | Guayanilla, Puerto Rico Click to see other locations | ||||
Plan ID: | H4011 - 001 - 0 Click to see other plans | ||||
Member Services: | 1-888-767-7717 TTY users 1-877-672-4242 | ||||
— 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 First+Plus Advantage (PPO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 (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): | $6,700 | ||||
Number of Members enrolled in this plan in (H4011 - 001): | 168 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. | |||||
First Medical Health Plan Inc. will reduce your monthly Medicare Part B premium by up to $ 50.00. | |||||
$6 700 out-of-pocket limit. | |||||
All plan services included. | |||||
$10 000 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. | |||||
** Extra Benefits ** | |||||
Prescription Drugs | |||||
Most drugs not covered. | |||||
$0 copay for Part B-covered drugs. | |||||
20% of the cost for Part B drugs out-of-network. | |||||
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. | |||||
Vision Services | |||||
$0 copay for diagnosis and treatment for diseases and conditions of the eye | |||||
$0 copay for
| |||||
$100 plan coverage limit for eye wear every year. | |||||
20% of the cost for eye exams. | |||||
50% of the cost for eye wear. | |||||
Dental Services | |||||
$0 copay for Medicare-covered dental benefits. | |||||
$0 copay for the following preventive dental benefits: | |||||
20% of the cost for preventive dental benefits. | |||||
20% of the cost for comprehensive dental benefits. | |||||
** 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. | |||||
First Medical Health Plan Inc. will reduce your monthly Medicare Part B premium by up to $ 50.00. | |||||
$6 700 out-of-pocket limit. | |||||
All plan services included. | |||||
$10 000 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. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care (Acute) | |||||
No limit to the number of days covered by the plan each benefit period. | |||||
$0 copay | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
$0 copay for inpatient hospital services. | |||||
Inpatient Mental Health Care | |||||
You get up to 190 days in a Psychiatric Hospital in a lifetime. | |||||
$0 copay | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
$0 copay for inpatient hospital services. | |||||
Skilled Nursing Facility (SNF) | |||||
Authorization rules may apply. | |||||
Plan covers up to 100 days each benefit period | |||||
No prior hospital stay is required. | |||||
$0 copay for SNF services | |||||
$0 copay for each SNF stay. | |||||
Home Health Care | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered home health visits. | |||||
20% for home health visits. | |||||
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. | |||||
$5 copay for each specialist visit for Medicare-covered benefits. | |||||
20% for each primary care doctor visit. | |||||
20% for each specialist visit. | |||||
Chiropractic Services | |||||
$0 copay for: Medicare-covered chiropractic visits | |||||
up to 3 routine visit(s) every year | |||||
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. | |||||
20% of the cost for chiropractic benefits. | |||||
Podiatry Services | |||||
$0 copay for Medicare-covered podiatry visits | |||||
up to 3 routine visit(s) every year | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
20% of the cost for podiatry benefits. | |||||
Outpatient Mental Health Care | |||||
$0 copay for Medicare-covered Mental Health visits. | |||||
50% of the cost for Mental Health benefits. | |||||
50% of the cost for Mental Health benefits with a psychiatrist. | |||||
Outpatient Substance Abuse Care | |||||
$0 copay for Medicare-covered visits. | |||||
50% of the cost for outpatient substance abuse benefits. | |||||
Outpatient Hospital Services | |||||
Authorization rules may apply. | |||||
$0 copay for each Medicare-covered ambulatory surgical center visit. | |||||
$0 copay for each Medicare-covered outpatient hospital facility visit. | |||||
20% of the cost for ambulatory surgical center benefits. | |||||
20% of the cost for outpatient hospital facility benefits. | |||||
Emergency Care | |||||
$35 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. | |||||
$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. | |||||
20% of the cost for Occupational Therapy benefits. | |||||
20% of the cost for Physical and/or Speech and Language Therapy visits. | |||||
20% of the cost for Cardiac Rehab services. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
5% of the cost for Medicare-covered items. | |||||
20% of the cost for durable medical equipment. | |||||
Prosthetic Devices | |||||
Authorization rules may apply. | |||||
5% of the cost for Medicare-covered items. | |||||
20% of the cost for prosthetic devices. | |||||
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. | |||||
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 | |||||
$0 copay for Medicare-covered bone mass measurement | |||||
20% of the cost for Medicare-covered bone mass measurement. | |||||
Colorectal Screening Exams | |||||
$0 copay for Medicare-covered colorectal screenings. | |||||
20% 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. | |||||
20% of the cost for immunizations. | |||||
Pap Smears and Pelvic Exams | |||||
$0 copay for Medicare-covered pap smears and pelvic exams. | |||||
20% of the cost for pap smears and pelvic exams. | |||||
Prostate Cancer Screening Exams | |||||
$0 copay for
| |||||
20% of the cost for prostate cancer screening. | |||||
** Additional Benefits ** | |||||
Dialysis | |||||
$0 copay for renal dialysis | |||||
$0 copay for Nutrition Therapy for End-Stage Renal Disease | |||||
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. | |||||
$0 copay for Part B-covered drugs. | |||||
20% of the cost for Part B drugs out-of-network. | |||||
This plan does not offer prescription drug coverage. | |||||
Dental Services | |||||
$0 copay for Medicare-covered dental benefits. | |||||
$0 copay for the following preventive dental benefits: | |||||
20% of the cost for preventive dental benefits. | |||||
20% of the cost for comprehensive dental benefits. | |||||
Hearing Services | |||||
$0 copay for Medicare-covered diagnostic hearing exams | |||||
$0 copay for | |||||
$0 copay for hearing aids. | |||||
$300 plan coverage limit for hearing aids every three years. | |||||
20% of the cost for hearing exams. | |||||
0% of the cost for hearing aids. | |||||
Vision Services | |||||
$0 copay for diagnosis and treatment for diseases and conditions of the eye | |||||
$0 copay for
| |||||
$100 plan coverage limit for eye wear every year. | |||||
20% of the cost for eye exams. | |||||
50% of the cost for eye wear. | |||||
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. | |||||
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. | |||||
20% of the cost for Health and Wellness services. | |||||
Transportation | |||||
This plan does not cover routine transportation. | |||||
Acupuncture | |||||
This plan does not cover Acupuncture. |