** Cost ** |
Premium and Other Important Information |
Balance billing means that a provider may charge and bill you more than the plan's payment amount for services. There is a limit on what providers may charge for Medicare-covered services. |
$20.00 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. |
Providers may balance bill 0% to 15% of the plan payment amount for the following services: - Inpatient Hospital Acute
- Inpatient Hospital Psychiatric
- Skilled Nursing Facility (SNF)
- Comprehensive Outpatient Rehabilitation Facility (CORF)
- Emergency Care
- Urgently Needed Care
- Partial Hospitalization
- Home Health Services
- Primary Care Physician Services
- Chiropractic Services
- Occupational Therapy Services
- Physician Specialist Services
- Mental Health Specialty Services
- Podiatry Services
- Other Health Care Professional
- Psychiatric Services
- Physical Therapy and Speech/Language Pathology Services
- Outpatient Diag Procs/Tests/Lab Services
- Outpatient Diag/Therapeutic Rad Services
- Outpatient Hospital Services
- Ambulatory Surgical Center (ASC) Services
- Out
|
$5 000 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. |
$0 copay for the required Medicare-covered initial preventive physical exam and annual wellness visits. |
Vision Services |
$0 copay for one pair of eyeglasses or contact lenses after cataract surgery. |
$0 to $35 copay for exams to diagnose and treat diseases and conditions of the eye. |
$35 copay for up to 1 routine eye exam(s) every year |
Dental Services |
In general preventive dental benefits (such as cleaning) not covered. |
$0 copay for Medicare-covered dental benefits. |
** Important Information ** |
Premium and Other Important Information |
Balance billing means that a provider may charge and bill you more than the plan's payment amount for services. There is a limit on what providers may charge for Medicare-covered services. |
$20.00 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. |
Providers may balance bill 0% to 15% of the plan payment amount for the following services: - Inpatient Hospital Acute
- Inpatient Hospital Psychiatric
- Skilled Nursing Facility (SNF)
- Comprehensive Outpatient Rehabilitation Facility (CORF)
- Emergency Care
- Urgently Needed Care
- Partial Hospitalization
- Home Health Services
- Primary Care Physician Services
- Chiropractic Services
- Occupational Therapy Services
- Physician Specialist Services
- Mental Health Specialty Services
- Podiatry Services
- Other Health Care Professional
- Psychiatric Services
- Physical Therapy and Speech/Language Pathology Services
- Outpatient Diag Procs/Tests/Lab Services
- Outpatient Diag/Therapeutic Rad Services
- Outpatient Hospital Services
- Ambulatory Surgical Center (ASC) Services
- Out
|
$5 000 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 - 7: $225 copay per day |
Days 8 - 90: $0 copay per day |
$0 copay for additional hospital days |
Inpatient Mental Health Care |
You get up to 190 days in a Psychiatric Hospital in a lifetime. |
For Medicare-covered hospital stays: |
Days 1 - 7: $225 copay per day |
Days 8 - 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 SNF stays: |
Days 1 - 20: $0 copay per day |
Days 21 - 100: $128 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 |
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. |
$20 copay for each primary care doctor visit for Medicare-covered benefits. |
$35 copay for each specialist visit for Medicare-covered benefits. |
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. |
Podiatry Services |
$35 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 |
20% of the cost for each Medicare-covered ambulatory surgical center visit. |
$35 copay [or 20% 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 72-hour(s) for the same condition you pay $0 for the emergency room visit |
Outpatient Rehabilitation Services |
$35 to $50 copay for Medicare-covered Occupational Therapy visits. |
$35 to $50 copay for Medicare-covered Physical and/or Speech and Language Therapy visits. |
$35 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. |
$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 |
$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 |
In general preventive dental benefits (such as cleaning) not covered. |
$0 copay for Medicare-covered dental benefits. |
Hearing Services |
Hearing aids not covered. |
$35 copay for Medicare-covered diagnostic hearing exams |
$35 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. |
$0 to $35 copay for exams to diagnose and treat diseases and conditions of the eye. |
$35 copay for up to 1 routine eye exam(s) every year |
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. |
Health/Wellness Education |
The plan covers the following health/wellness education benefits: |
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. |