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This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2011 Blue Medicare HMO Medical Only (HMO) in Stokes, North Carolina

Medicare Advantage Plan Benefit Details in Plain Text
The following Medicare Advantage plan benefits apply to the Blue Medicare HMO Medical Only (HMO) (H3449 - 012) in Stokes, North Carolina .

This plan is administered by .  To switch to a different Medicare Advantage plan or to change your location, click here.
Click here to see the Blue Medicare HMO Medical Only (HMO) health benefit details in chart format or email and view benefits chart

Plan Premium
This plan has a $0.00 monthly premium. Although you pay no additional monthly premium, you must continue to pay your Medicare Part B premium. If you have a premium penalty, your premium will be higher. Or if you have a higher income you would be subject to the Income Related Adjustment Amount (IRMAA).

This Medicare Advantage Plan without Prescription Drug Coverage is a Local HMO * plan.

Please be aware that this plan does NOT include Prescription Drug Coverage!
The Blue Medicare HMO Medical Only (HMO) offers many Health Coverage Benefits. The following section will describe these benefits in detail.

** 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.
$3 400 out-of-pocket limit.
This limit includes only Medicare-covered services.
** Doctor and Hospital Choice **
Doctor and Hospital Choice
You must go to network doctors specialists and hospitals.
No referral required for network doctors specialists and hospitals.
** Extra Benefits **
Prescription Drugs
Most drugs not covered.
10% 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).
Vision Services
  • 10% of the cost for one pair of eyeglasses or contact lenses after cataract surgery.
  • $0 to $20 copay for exams to diagnose and treat diseases and conditions of the eye.
  • $20 copay for up to 1 routine eye exam(s)
  • $100 plan coverage limit for eye exams.
    Dental Services
    Authorization rules may apply.
    In general preventive dental benefits (such as cleaning) not covered.
    $20 copay for Medicare-covered 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.
    $3 400 out-of-pocket limit.
    This limit includes only Medicare-covered services.
    Doctor and Hospital Choice
    You must go to network doctors specialists and hospitals.
    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 - 6: $195 copay per day
    Days 7 - 90: $0 copay per day
    $0 copay for each additional hospital day.
    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.
    For Medicare-covered hospital stays:
    Days 1 - 6: $195 copay per day
    Days 7 - 90: $0 copay per day
    Plan covers 60 lifetime reserve days. Cost per lifetime reserve day:
    Days 1 - 60: $0 copay per day
    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 Medicare-covered SNF stays:
    Days 1 - 10: $0 copay per day
    Days 11 - 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.
    $10 copay for each primary care doctor visit for Medicare-covered benefits.
    $20 copay for each in-area network urgent care Medicare-covered visit.
    $20 copay for each specialist visit for Medicare-covered benefits.
    Chiropractic Services
    $20 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
    $20 copay for each Medicare-covered visit.
    Medicare-covered podiatry benefits are for medically-necessary foot care.
    Outpatient Mental Health Care
    Authorization rules may apply.
    $20 copay for each Medicare-covered individual or group therapy visit.
    Outpatient Substance Abuse Care
    Authorization rules may apply.
    $20 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.
    $0 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 48-hour(s) for the same condition you pay $0 for the emergency room visit
    Outpatient Rehabilitation Services
    Authorization rules may apply.
    $20 copay for Medicare-covered Occupational Therapy visits.
    $20 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.
    10% of the cost for Medicare-covered items.
    Prosthetic Devices
    Authorization rules may apply.
    10% 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.
    10% 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.
    No referral needed for Flu and pneumonia vaccines.
    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)
  • 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.
    10% 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.
    In general preventive dental benefits (such as cleaning) not covered.
    $20 copay for Medicare-covered dental benefits.
    Hearing Services
    In general routine hearing exams and hearing aids not covered.
  • $20 copay for Medicare-covered diagnostic hearing exams
  • Vision Services
  • 10% of the cost for one pair of eyeglasses or contact lenses after cataract surgery.
  • $0 to $20 copay for exams to diagnose and treat diseases and conditions of the eye.
  • $20 copay for up to 1 routine eye exam(s)
  • $100 plan coverage limit for eye exams.
    Physical Exams
    $0 copay for routine exams.
    Limited to 1 exam(s).
    Health/Wellness Education
    The plan covers the following health/wellness education benefits:
  • Health Club Membership/Fitness Classes
  • Nursing Hotline
  • Other Wellness 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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    • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
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    • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
    • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.