2012 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Any, Any, Any Gold MA Only (PFFS) | ||||
Location: | Jim Hogg, Texas Click to see other locations | ||||
Plan ID: | H5820 - 026 - 0 Click to see other plans | ||||
Member Services: | 1-866-690-4842 TTY users 1-800-617-0177 | ||||
— 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 Any, Any, Any Gold MA Only (PFFS) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | no drug coverage | ||||
Health Plan Type: | PFFS * | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $6,700 | ||||
Number of Members enrolled in this plan in (H5820 - 026): | 6,883 members | ||||
Plan’s Summary Star Rating: | 2.5 out of 5 Stars. | ||||
• Customer Service Rating: | 3 out of 5 Stars. | ||||
• Member Experience Rating: | 4 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 2 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 | |||||
$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 does not allow providers to balance bill (charging more than your cost share amount). | |||||
UNIVERSAL HEALTH CARE INSURANCE COMPANY INC. will reduce your monthly Medicare Part B premium by up to $ 10.00. | |||||
$6 700 out-of-pocket limit for 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 ** | |||||
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 | |||||
$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 does not allow providers to balance bill (charging more than your cost share amount). | |||||
UNIVERSAL HEALTH CARE INSURANCE COMPANY INC. will reduce your monthly Medicare Part B premium by up to $ 10.00. | |||||
$6 700 out-of-pocket limit for 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 | |||||
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment except in emergencies. | |||||
Plan covers 90 days each benefit period. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 6: $268 copay per day | |||||
Days 7 - 90: $0 copay per day | |||||
Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day. | |||||
Inpatient Mental Health Care | |||||
You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 6: $239 copay per day | |||||
Days 7 - 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: $50 copay per day | |||||
Days 21 - 100: $146 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 | |||||
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. | |||||
$15 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$40 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 | |||||
$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 | |||||
$40 copay for each Medicare-covered group therapy visit | |||||
$40 copay for each Medicare-covered individual therapy visit with a psychiatrist | |||||
$40 copay for each Medicare-covered group therapy visit with a psychiatrist | |||||
$268 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 | |||||
10% of the cost for each Medicare-covered ambulatory surgical center visit | |||||
30% of the cost for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
$125 copay for Medicare-covered ambulance benefits. | |||||
If you are admitted to the hospital you pay $0 for Medicare-covered ambulance benefits. | |||||
Emergency Care | |||||
$60 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 | |||||
Cost sharing is the same as Doctor Office Visit cost sharing. | |||||
Outpatient Rehabilitation Services | |||||
There may be limits on physical therapy occupational therapy and speech and language pathology services If so there may be exceptions to these limits. | |||||
$40 copay [or 30% of the cost] for Medicare-covered Occupational Therapy visits | |||||
$40 copay [or 30% of the cost] 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 | |||||
If the doctor provides you services in addition to Diabetes self-management training separate cost sharing of $15 to $40 may apply | |||||
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' | |||||
$15 copay for Medicare-covered lab services | |||||
$0 to $100 copay [or 0% to 30% of the cost] for Medicare-covered diagnostic procedures and tests | |||||
$5 copay [or 30% of the cost] for Medicare-covered X-rays | |||||
$0 to $100 copay [or 0% to 30% of the cost] for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
20% of the cost for Medicare-covered therapeutic radiology services | |||||
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $15 to $40 may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $15 to $40 may apply | |||||
** Preventive Services ** | |||||
Cardiac and Pulmonary Rehabilitation Services | |||||
$40 copay [or 30% of the cost] for Medicare-covered Cardiac Rehabilitation Services | |||||
$40 copay [or 30% of the cost] for Medicare-covered Intensive Cardiac Rehabilitation Services | |||||
$40 copay [or 30% of the cost] for Medicare-covered Pulmonary Rehabilitation Services | |||||
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 | |||||
20% of the cost for renal dialysis | |||||
$0 copay for kidney disease education services | |||||
Outpatient 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 | |||||
$0 copay for Medicare-covered dental benefits | |||||
Hearing Services | |||||
Hearing aids not covered. | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
$100 plan coverage limit for eye wear every year. | |||||
If the doctor provides you services in addition to eye exams separate cost sharing of $40 may apply | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. | |||||
Acupuncture | |||||
This plan does not cover Acupuncture. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment except in emergencies. | |||||
Plan covers 90 days each benefit period. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 6: $268 copay per day | |||||
Days 7 - 90: $0 copay per day | |||||
Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. | |||||
$15 copay for each primary care doctor visit for Medicare-covered benefits. | |||||
$40 copay for each specialist visit for Medicare-covered benefits. | |||||
Outpatient Services/Surgery | |||||
10% of the cost for each Medicare-covered ambulatory surgical center visit | |||||
30% of the cost for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
$125 copay for Medicare-covered ambulance benefits. | |||||
If you are admitted to the hospital you pay $0 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' | |||||
$15 copay for Medicare-covered lab services | |||||
$0 to $100 copay [or 0% to 30% of the cost] for Medicare-covered diagnostic procedures and tests | |||||
$5 copay [or 30% of the cost] for Medicare-covered X-rays | |||||
$0 to $100 copay [or 0% to 30% of the cost] for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
20% of the cost for Medicare-covered therapeutic radiology services | |||||
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $15 to $40 may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $15 to $40 may apply | |||||
** Additional Benefits ** | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. |