2012 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | HealthPartners Freedom Vital (Cost) | ||||
Location: | Carlton, Minnesota Click to see other locations | ||||
Plan ID: | H2462 - 018 - 0 Click to see other plans | ||||
Member Services: | 1-800-233-9645 TTY users 1-800-443-0156 | ||||
— 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 HealthPartners Freedom Vital (Cost) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $53.00 (see Plan Premium Details below) | ||||
Annual Deductible: | no drug coverage | ||||
Health Plan Type: | Cost * | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,000 | ||||
Number of Members enrolled in this plan in (H2462 - 018): | 173 members | ||||
Plan’s Summary Star Rating: | 4 out of 5 Stars. | ||||
• Customer Service Rating: | Insufficient data to rate this plan. | ||||
• Member Experience Rating: | 4 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 4 out of 5 Stars. | ||||
— 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 | |||||
$53.00 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. | |||||
$3 000 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 use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services When Medicare pays its share you pay the Medicare Part B deductible and coinsurance. | |||||
Plan covers you when you travel in the U.S. | |||||
** Extra Benefits ** | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$53.00 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. | |||||
$3 000 out-of-pocket limit. All plan services included. | |||||
Doctor and Hospital Choice | |||||
No referral required for network doctors specialists and hospitals. | |||||
You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services When Medicare pays its share you pay the Medicare Part B deductible and coinsurance. | |||||
Plan covers you when you travel in the U.S. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
$0 copay | |||||
$300 out-of-pocket limit every benefit period. | |||||
Inpatient Mental Health Care | |||||
$0 copay | |||||
Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days. | |||||
$300 out-of-pocket limit every benefit period. | |||||
Skilled Nursing Facility (SNF) | |||||
Plan covers up to 100 days each benefit period | |||||
For Medicare-covered SNF stays: | |||||
Days 1 - 20: $0 copay per day | |||||
Days 21 - 100: $100 copay per day | |||||
Home Health Care | |||||
$0 copay for Medicare-covered home health visits | |||||
Hospice | |||||
You must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
$15 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$15 to $40 copay for each in-area network urgent care Medicare-covered visit | |||||
$40 copay for each specialist visit for Medicare-covered benefits. | |||||
Chiropractic Services | |||||
$15 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 | |||||
$40 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 therapy visit | |||||
$20 copay for each Medicare-covered group therapy visit | |||||
$40 copay for each Medicare-covered individual therapy visit with a psychiatrist | |||||
$20 copay for each Medicare-covered group therapy visit with a psychiatrist | |||||
$0 copay for Medicare-covered partial hospitalization program services | |||||
Outpatient Substance Abuse Care | |||||
$40 copay for Medicare-covered individual visits | |||||
$40 copay for Medicare-covered group visits | |||||
Outpatient Services/Surgery | |||||
$150 copay for each Medicare-covered ambulatory surgical center visit | |||||
$0 copay for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
20% of the cost for Medicare-covered ambulance benefits. | |||||
Emergency Care | |||||
$75 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. | |||||
Urgently Needed Care | |||||
$40 copay for Medicare-covered urgently-needed-care visits | |||||
Outpatient Rehabilitation Services | |||||
$40 copay for Medicare-covered Occupational Therapy visits | |||||
$40 copay for Medicare-covered Physical and/or Speech and Language Therapy visits | |||||
** 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 Programs and Supplies | |||||
$0 copay for Diabetes self-management training | |||||
20% of the cost for Diabetes monitoring supplies | |||||
20% of the cost for Therapeutic shoes or inserts | |||||
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' | |||||
0% of the cost for Medicare-covered lab services | |||||
10% of the cost for Medicare-covered diagnostic procedures and tests | |||||
10% of the cost for Medicare-covered X-rays | |||||
20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
10% of the cost for Medicare-covered therapeutic radiology services | |||||
** Preventive Services ** | |||||
Cardiac and Pulmonary Rehabilitation Services | |||||
$0 copay for: | |||||
Preventive Services and Wellness/Education Programs | |||||
$0 copay for all preventive services covered under Original Medicare at zero cost sharing: | |||||
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. Please contact plan for details. | |||||
The plan covers the following supplemental education/wellness programs: | |||||
Kidney Disease and Conditions | |||||
Cost plan members pay Fee-for-Service cost sharing for out-of-area dialysis. | |||||
$0 copay for renal dialysis | |||||
$0 copay for kidney disease education services | |||||
Outpatient Prescription Drugs | |||||
Most drugs not covered. | |||||
0% to 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. However this plan covers preventive dental benefits for an extra cost (see 'Optional Benefits.') | |||||
0% of the cost for Medicare-covered dental benefits | |||||
Hearing Services | |||||
Hearing aids not covered. | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
$0 copay for | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. | |||||
Acupuncture | |||||
$35 copay per visit | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
$0 copay | |||||
$300 out-of-pocket limit every benefit period. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
$15 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$15 to $40 copay for each in-area network urgent care Medicare-covered visit | |||||
$40 copay for each specialist visit for Medicare-covered benefits. | |||||
Outpatient Services/Surgery | |||||
$150 copay for each Medicare-covered ambulatory surgical center visit | |||||
$0 copay for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
20% of the cost for Medicare-covered ambulance benefits. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
20% of the cost for Medicare-covered items | |||||
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' | |||||
0% of the cost for Medicare-covered lab services | |||||
10% of the cost for Medicare-covered diagnostic procedures and tests | |||||
10% of the cost for Medicare-covered X-rays | |||||
20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
10% of the cost for Medicare-covered therapeutic radiology services | |||||
** Additional Benefits ** | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
Package: 1 - Freedom Comprehensive Dental Benefit: | |||||
$38.37 monthly premium in addition to your $53 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
$1 100 plan coverage limit every year for these benefits. | |||||
** Important Information ** | |||||
Package: 1 - Freedom Comprehensive Dental Benefit: | |||||
$38.37 monthly premium in addition to your $53 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: | |||||
$1 100 plan coverage limit every year for these benefits. | |||||
** Preventive Services ** | |||||
Dental Services | |||||
Plan offers additional comprehensive dental benefits. | |||||
$0 copay for the following preventive dental benefits: | |||||