2011 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Network PlatinumPremier (PPO) | ||||
Location: | Green Lake, Wisconsin Click to see other locations | ||||
Plan ID: | H5215 - 006 - 0 Click to see other plans | ||||
Member Services: | 1-800-378-5234 TTY users 1-800-947-3529 | ||||
— 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 Network PlatinumPremier (PPO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $72.00 (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): | $1,250 | ||||
Number of Members enrolled in this plan in (H5215 - 006): | 3,298 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 | |||||
$72.00 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. | |||||
$1 250 out-of-pocket limit. | |||||
There is no limit on cost sharing for the following services: Supplemental Services:
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$2 500 out-of-pocket limit. | |||||
There is no limit on cost sharing for the following services: | |||||
In-Network: Supplemental Services:
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Out-of-Network: Supplemental Services:
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** 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. | |||||
10% of the cost for Part B-covered chemotherapy drugs and other 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 | |||||
$0 copay for routine exams. | |||||
Limited to 1 exam(s) every year. | |||||
$35 copay for routine exams. | |||||
Vision Services | |||||
$0 copay for diagnosis and treatment for diseases and conditions of the eye | |||||
$0 copay for
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$125 plan coverage limit for eye wear every year. | |||||
Plan offers additional vision benefits. | |||||
$35 copay for eye exams. | |||||
$35 copay for eye wear. | |||||
Dental Services | |||||
$0 copay for Medicare-covered dental benefits. | |||||
In general preventive dental benefits (such as cleaning) not covered. | |||||
$30 copay for comprehensive dental benefits. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$72.00 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. | |||||
$1 250 out-of-pocket limit. | |||||
There is no limit on cost sharing for the following services: Supplemental Services:
| |||||
$2 500 out-of-pocket limit. | |||||
There is no limit on cost sharing for the following services: | |||||
In-Network: Supplemental Services:
| |||||
Out-of-Network: Supplemental Services:
| |||||
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. | |||||
$0 copay | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
For hospital stays: | |||||
Days 1 - 7: $100 copay per day | |||||
Days 8 and beyond: $0 copay per day | |||||
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. | |||||
For hospital stays: | |||||
Days 1 - 7: $150 copay per day | |||||
Days 8 - 190: $0 copay per day | |||||
Skilled Nursing Facility (SNF) | |||||
Authorization rules may apply. | |||||
Plan covers up to 100 days each benefit period | |||||
3-day prior hospital stay is required. | |||||
For Medicare-covered SNF stays: | |||||
Days 1 - 100: $25 copay per day | |||||
For each SNF stay: | |||||
Days 1 - 100: $100 copay per SNF day | |||||
Home Health Care | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered home health visits. | |||||
$40 copay 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. | |||||
$0 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$0 copay for the cost of each in-area network urgent care Medicare-covered visit. | |||||
$10 copay for each specialist visit for Medicare-covered benefits. | |||||
$30 copay for each primary care doctor visit. | |||||
$35 copay for each specialist visit. | |||||
Chiropractic Services | |||||
$10 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. | |||||
$35 copay for chiropractic benefits. | |||||
Podiatry Services | |||||
$0 copay for Medicare-covered podiatry benefits. | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
$35 copay for podiatry benefits. | |||||
Outpatient Mental Health Care | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered Mental Health visits. | |||||
$35 copay for Mental Health benefits. | |||||
$35 copay for Mental Health benefits with a psychiatrist. | |||||
Outpatient Substance Abuse Care | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered visits. | |||||
$35 copay 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. | |||||
$100 copay for ambulatory surgical center benefits. | |||||
$100 copay for outpatient hospital facility benefits. | |||||
Emergency Care | |||||
$50 copay for Medicare-covered emergency room visits. | |||||
$100 000 plan coverage limit for emergency services outside the U.S. every year. | |||||
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. | |||||
$35 copay for Occupational Therapy benefits. | |||||
$35 copay for Physical and/or Speech and Language Therapy visits. | |||||
$35 copay for Cardiac Rehab services. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
0% of the cost for Medicare-covered items. | |||||
20% of the cost for durable medical equipment. | |||||
Prosthetic Devices | |||||
Authorization rules may apply. | |||||
0% 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. | |||||
$35 copay for Diabetes self-monitoring training. | |||||
$35 copay for Nutrition Therapy for Diabetes. | |||||
10% of the cost for Diabetes supplies. | |||||
** Preventive Services ** | |||||
Bone Mass Measurement | |||||
$0 copay for Medicare-covered bone mass measurement | |||||
$35 copay for Medicare-covered bone mass measurement. | |||||
Colorectal Screening Exams | |||||
$0 copay for Medicare-covered colorectal screenings. | |||||
$35 copay 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. | |||||
$0 copay for immunizations. | |||||
Pap Smears and Pelvic Exams | |||||
$0 copay for Medicare-covered pap smears and pelvic exams | |||||
$35 copay for pap smears and pelvic exams. | |||||
Prostate Cancer Screening Exams | |||||
$0 copay for
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$35 copay for prostate cancer screening. | |||||
** Additional Benefits ** | |||||
Dialysis | |||||
Authorization rules may apply. | |||||
$0 copay for renal dialysis | |||||
$0 copay for Nutrition Therapy for End-Stage Renal Disease | |||||
$35 copay for renal dialysis. | |||||
$35 copay for Nutrition Therapy for End-Stage Renal Disease. | |||||
Prescription Drugs | |||||
Most drugs not covered. | |||||
10% of the cost for Part B-covered chemotherapy drugs and other 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. | |||||
In general preventive dental benefits (such as cleaning) not covered. | |||||
$30 copay for comprehensive dental benefits. | |||||
Hearing Services | |||||
$0 copay for Medicare-covered diagnostic hearing exams | |||||
$0 copay for up to 1 hearing aid(s) every year. | |||||
$100 plan coverage limit for hearing aids every year. | |||||
$35 copay for hearing exams. | |||||
$0 copay for hearing aids. | |||||
Vision Services | |||||
$0 copay for diagnosis and treatment for diseases and conditions of the eye | |||||
$0 copay for
| |||||
$125 plan coverage limit for eye wear every year. | |||||
Plan offers additional vision benefits. | |||||
$35 copay for eye exams. | |||||
$35 copay for eye wear. | |||||
Physical Exams | |||||
$0 copay for routine exams. | |||||
Limited to 1 exam(s) every year. | |||||
$35 copay 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. | |||||
50% of the cost for Health and Wellness services. | |||||
Transportation | |||||
This plan does not cover routine transportation. | |||||
Acupuncture | |||||
This plan does not cover Acupuncture. |