2012 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Advocare Essence (HMO-POS) | ||||
Location: | Washburn, Wisconsin Click to see other locations | ||||
Plan ID: | H5211 - 003 - 0 Click to see other plans | ||||
Member Services: | 1-877-998-0998 TTY users 1-877-727-2232 | ||||
— 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 Advocare Essence (HMO-POS) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||
Annual Deductible: | no drug coverage | ||||
Health Plan Type: | Local HMO * | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,400 | ||||
Number of Members enrolled in this plan in (H5211 - 003): | 6,203 members | ||||
Plan’s Summary Star Rating: | 4.5 out of 5 Stars. | ||||
• Customer Service Rating: | 4 out of 5 Stars. | ||||
• Member Experience Rating: | 5 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 | |||||
$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. | |||||
$3 400 out-of-pocket limit. All plan services included. | |||||
$5 000 annual deductible. Contact the plan for services that apply. | |||||
$5 000 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. | |||||
** Extra Benefits ** | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Point of Service | |||||
Point of Service coverage is available for the following benefits: | |||||
$5 000 annual deductible for POS benefits | |||||
$5 000 out-of-pocket limit every year for POS benefits | |||||
$0 copay for inpatient hospital benefits. | |||||
$0 copay for Inpatient Psychiatric Hospital benefits. | |||||
$0 copay for each SNF stay. | |||||
$0 copay for | |||||
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. | |||||
$3 400 out-of-pocket limit. All plan services included. | |||||
$5 000 annual deductible. Contact the plan for services that apply. | |||||
$5 000 out-of-pocket limit. All plan services included. | |||||
Doctor and Hospital Choice | |||||
No referral required for network doctors specialists and hospitals. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 5: $300 copay per day | |||||
Days 6 - 90: $0 copay per day | |||||
$0 copay for additional hospital days | |||||
$1 500 out-of-pocket limit every stay. | |||||
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 - 5: $300 copay per day | |||||
Days 6 - 90: $0 copay per day | |||||
$1 500 out-of-pocket limit every stay. | |||||
Skilled Nursing Facility (SNF) | |||||
Authorization rules may apply. | |||||
Plan covers up to 100 days each benefit period | |||||
No prior hospital stay is required. | |||||
For SNF stays: | |||||
Days 1 - 14: $0 copay per day | |||||
Days 15 - 45: $100 copay per day | |||||
Days 46 - 100: $0 copay per day | |||||
$3 100 out-of-pocket limit every stay. | |||||
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 | |||||
$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. | |||||
$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 | |||||
$20 copay for each Medicare-covered individual therapy visit | |||||
$20 copay for each Medicare-covered group therapy visit | |||||
$20 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 | |||||
$0 copay for Medicare-covered visits | |||||
Outpatient Services/Surgery | |||||
$0 to $250 copay for each Medicare-covered ambulatory surgical center visit | |||||
$0 to $250 copay for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
$150 copay for Medicare-covered ambulance benefits. | |||||
Emergency Care | |||||
$50 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 | |||||
$0 to $20 copay for Medicare-covered urgently-needed-care visits | |||||
Outpatient Rehabilitation Services | |||||
$0 copay for Medicare-covered Occupational Therapy visits | |||||
$0 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 | |||||
$0 copay for: | |||||
If the doctor provides you services in addition to Diabetes self-management training separate cost sharing of $0 to $20 may apply | |||||
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' | |||||
$0 copay for Medicare-covered: | |||||
$0 copay for Medicare-covered X-rays | |||||
$0 to $100 copay for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
$0 copay 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 $0 to $20 may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $0 to $20 may apply | |||||
** 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 | |||||
$0 copay for renal dialysis | |||||
$0 copay for kidney disease education services | |||||
Outpatient Prescription Drugs | |||||
Most drugs not covered. | |||||
$0 copay for Part B-covered drugs. | |||||
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. | |||||
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 | |||||
This plan does not cover Acupuncture. | |||||
Point of Service | |||||
Point of Service coverage is available for the following benefits: | |||||
$5 000 annual deductible for POS benefits | |||||
$5 000 out-of-pocket limit every year for POS benefits | |||||
$0 copay for inpatient hospital benefits. | |||||
$0 copay for Inpatient Psychiatric Hospital benefits. | |||||
$0 copay for each SNF stay. | |||||
$0 copay for | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
For Medicare-covered hospital stays: | |||||
Days 1 - 5: $300 copay per day | |||||
Days 6 - 90: $0 copay per day | |||||
$0 copay for additional hospital days | |||||
$1 500 out-of-pocket limit every stay. | |||||
** 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. | |||||
$20 copay for each specialist visit for Medicare-covered benefits. | |||||
Outpatient Services/Surgery | |||||
$0 to $250 copay for each Medicare-covered ambulatory surgical center visit | |||||
$0 to $250 copay for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
$150 copay 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 copay for Medicare-covered: | |||||
$0 copay for Medicare-covered X-rays | |||||
$0 to $100 copay for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
$0 copay 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 $0 to $20 may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $0 to $20 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. |