2012 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Network PlatinumPremier (PPO) | ||||
Location: | Dodge, 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: | $77.00 (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): | $2,000 | ||||
Number of Members enrolled in this plan in (H5215 - 006): | 2,813 members | ||||
Plan’s Summary Star Rating: | 4.5 out of 5 Stars. | ||||
• Customer Service Rating: | 4 out of 5 Stars. | ||||
• 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 | |||||
$77.00 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. | |||||
Some physicians providers and suppliers that are out of a plan's network (i.e. out-of-network) accept 'assignment' from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare 'assignment ' your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare 'limiting charge.' If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare 'limiting charge' does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to 'assignment' and 'limiting charges' that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.gov/physician or www.medicare.gov/supplier. You can also call 1-800 | |||||
$2 000 out-of-pocket limit for Medicare-covered services and select Non-Medicare Supplemental Services. Contact plan for details regarding Non-Medicare Supplemental Services covered under this limit. | |||||
$2 000 out-of-pocket limit for Medicare-covered services and select Non-Medicare Supplemental Services. Contact plan for details regarding Non-Medicare Supplemental Services covered under this limit. | |||||
** 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 ** | |||||
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 | |||||
$77.00 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. | |||||
Some physicians providers and suppliers that are out of a plan's network (i.e. out-of-network) accept 'assignment' from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare 'assignment ' your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare 'limiting charge.' If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare 'limiting charge' does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to 'assignment' and 'limiting charges' that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.gov/physician or www.medicare.gov/supplier. You can also call 1-800 | |||||
$2 000 out-of-pocket limit for Medicare-covered services and select Non-Medicare Supplemental Services. Contact plan for details regarding Non-Medicare Supplemental Services covered under this limit. | |||||
$2 000 out-of-pocket limit for Medicare-covered services and select Non-Medicare Supplemental Services. Contact plan for details regarding Non-Medicare Supplemental Services covered under this limit. | |||||
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 | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
$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 | |||||
$0 copay | |||||
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. | |||||
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: $35 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. Your plan will pay for a consultative visit before you select hospice. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
$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. | |||||
$15 copay for each specialist visit for Medicare-covered benefits. | |||||
$20 copay for each primary care doctor visit | |||||
$25 copay for each specialist visit | |||||
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. | |||||
$35 copay for chiropractic benefits. | |||||
Podiatry Services | |||||
$15 copay for each Medicare-covered visit | |||||
Medicare-covered podiatry benefits are for medically-necessary foot care. | |||||
$25 copay for podiatry benefits. | |||||
Outpatient Mental Health Care | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered Mental Health visits | |||||
$0 copay for Medicare-covered partial hospitalization program services | |||||
$35 copay for Mental Health benefits with a psychiatrist | |||||
$35 copay for Mental Health benefits | |||||
$35 copay for partial hospitalization program services | |||||
Outpatient Substance Abuse Care | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered visits | |||||
$35 copay for outpatient substance abuse benefits. | |||||
Outpatient Services/Surgery | |||||
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 outpatient hospital facility benefits. | |||||
$100 copay for ambulatory surgical center benefits. | |||||
Ambulance Services | |||||
$65 copay for Medicare-covered ambulance benefits. | |||||
$65 copay for ambulance benefits. | |||||
Emergency Care | |||||
$65 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. | |||||
Urgently Needed Care | |||||
$40 copay for Medicare-covered urgently-needed-care visits | |||||
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 | |||||
$25 copay for Physical and/or Speech and Language Therapy visits | |||||
$25 copay for Occupational Therapy benefits. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
$20 copay [or 0% to 10% of the cost] for Medicare-covered items | |||||
$30 copay for durable medical equipment | |||||
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 Programs and Supplies | |||||
Authorization rules may apply. | |||||
$0 copay for Diabetes self-management training | |||||
$0 copay for: | |||||
$35 copay for Diabetes self-management training | |||||
10% of the cost for Diabetes monitoring supplies | |||||
10% of the cost for Therapeutic shoes or inserts | |||||
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered: | |||||
$35 copay for therapeutic radiology services | |||||
$30 copay for outpatient X-rays | |||||
$50 copay for diagnostic radiology services | |||||
$25 copay for diagnostic procedures tests and lab services | |||||
** Preventive Services ** | |||||
Cardiac and Pulmonary Rehabilitation Services | |||||
Authorization rules may apply. | |||||
$0 copay for: | |||||
$35 copay for Cardiac Rehabilitation Services | |||||
$35 copay for Intensive Cardiac Rehabilitation Services | |||||
$35 copay for 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: | |||||
$35 copay for Medicare-covered preventive services | |||||
$35 copay for supplemental education/wellness programs | |||||
50% of the cost for supplemental education/wellness programs | |||||
Kidney Disease and Conditions | |||||
Authorization rules may apply. | |||||
$0 copay for renal dialysis | |||||
$0 copay for kidney disease education services | |||||
$35 copay for kidney disease education services | |||||
$35 copay for renal dialysis | |||||
Outpatient Prescription Drugs | |||||
Most drugs not covered. | |||||
12% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs. | |||||
30% 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 | |||||
$35 copay for hearing exams. | |||||
$0 copay for hearing aids. | |||||
$100 plan coverage limit for supplemental routine hearing aids every year. This limit applies to both in-network and out-of-network benefits. | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
$0 copay for diagnosis and treatment for diseases and conditions of the eye | |||||
$0 copay for | |||||
Plan offers additional vision benefits. Contact plan for details. | |||||
$35 copay for eye exams. | |||||
$35 copay for eye wear. | |||||
$125 plan coverage limit for eye wear every year. This limit applies to both in-network and out-of-network benefits. | |||||
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 | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
$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 | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
$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. | |||||
$15 copay for each specialist visit for Medicare-covered benefits. | |||||
$20 copay for each primary care doctor visit | |||||
$25 copay for each specialist visit | |||||
Outpatient Services/Surgery | |||||
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 outpatient hospital facility benefits. | |||||
$100 copay for ambulatory surgical center benefits. | |||||
Ambulance Services | |||||
$65 copay for Medicare-covered ambulance benefits. | |||||
$65 copay for ambulance benefits. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
$20 copay [or 0% to 10% of the cost] for Medicare-covered items | |||||
$30 copay for durable medical equipment | |||||
20% of the cost for durable medical equipment | |||||
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered: | |||||
$35 copay for therapeutic radiology services | |||||
$30 copay for outpatient X-rays | |||||
$50 copay for diagnostic radiology services | |||||
$25 copay for diagnostic procedures tests and lab 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. |