** Cost ** |
Premium and Other Important Information |
$95.00 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). |
$3 250 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 |
$95.00 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). |
$3 250 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. |
No limit to the number of days covered by the plan each hospital stay. |
For Medicare-covered hospital stays: |
Days 1 - 5: $200 copay per day |
Days 6 - 90: $0 copay per day |
$0 copay for additional hospital days |
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: $200 copay per day |
Days 6 - 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: $0 copay per day |
Days 21 - 100: $100 copay per day |
Home Health Care |
15% of the cost for each Medicare-covered home health visit |
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. |
$5 copay for each primary care doctor visit for Medicare-covered benefits. |
$30 copay for each specialist visit for Medicare-covered benefits. |
Chiropractic Services |
50% of the cost 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 |
$35 copay for each Medicare-covered visit |
Medicare-covered podiatry benefits are for medically-necessary foot care. |
Outpatient Mental Health Care |
40% of the cost for each Medicare-covered individual therapy visit |
40% of the cost for each Medicare-covered group therapy visit |
40% of the cost for each Medicare-covered individual therapy visit with a psychiatrist |
40% of the cost for each Medicare-covered group therapy visit with a psychiatrist |
$200 copay for Medicare-covered partial hospitalization program services |
Outpatient Substance Abuse Care |
40% of the cost for Medicare-covered individual visits |
40% of the cost for Medicare-covered group visits |
Outpatient Services/Surgery |
$75 copay for each Medicare-covered ambulatory surgical center visit |
$150 copay for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
$150 copay for Medicare-covered ambulance benefits. |
Emergency Care |
$65 copay for Medicare-covered emergency room visits |
$20 000 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 |
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. |
$15 copay for Medicare-covered Occupational Therapy visits |
$15 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% to 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 $5 to $30 may apply |
'Diagnostic Tests, X-Rays, Lab Services, and Radiology Services' |
$0 copay for Medicare-covered lab services |
$0 copay for Medicare-covered diagnostic procedures and tests |
20% of the cost for Medicare-covered X-rays |
20% 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 $5 to $30 may apply |
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $5 to $30 may apply |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
$15 copay for Medicare-covered Cardiac Rehabilitation Services |
$15 copay for Medicare-covered Intensive Cardiac Rehabilitation Services |
$15 copay 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: Abdominal Aortic Aneurysm screening Bone Mass Measurement Cardiovascular Screening Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam) Colorectal Cancer Screening Diabetes Screening Influenza Vaccine Hepatitis B Vaccine HIV Screening Breast Cancer Screening (Mammogram) Medical Nutrition Therapy Services Personalized Prevention Plan Services (Annual Wellness Visits) Pneumococcal Vaccine Prostate Cancer Screening (Prostate Specific Antigen (PSA) test only) Smoking Cessation (Counseling to stop smoking) Welcome to Medicare Physical Exam (Initial Preventive Physical Exam) |
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: |
Written health education materials including Newsletters |
Nursing Hotline |
Kidney Disease and Conditions |
$30 copay 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 |
In general preventive dental benefits (such as cleaning) not covered. |
Hearing Services |
Hearing aids not covered. |
$20 copay for Medicare-covered diagnostic hearing exams |
$20 copay for up to 1 supplemental routine hearing exam(s) every year |
** Additional Benefits ** |
Vision Services |
$20 copay for one pair of eyeglasses or contact lenses after cataract surgery. |
$20 copay for exams to diagnose and treat diseases and conditions of the eye. |
$20 copay for up to 1 supplemental routine eye exam(s) every year |
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. |
No limit to the number of days covered by the plan each hospital stay. |
For Medicare-covered hospital stays: |
Days 1 - 5: $200 copay per day |
Days 6 - 90: $0 copay per day |
$0 copay for additional hospital days |
** Outpatient Care ** |
Doctor Office Visits |
You may go to any doctor specialist or hospital that accepts the plan's terms and conditions of payment. |
$5 copay for each primary care doctor visit for Medicare-covered benefits. |
$30 copay for each specialist visit for Medicare-covered benefits. |
Outpatient Services/Surgery |
$75 copay for each Medicare-covered ambulatory surgical center visit |
$150 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 lab services |
$0 copay for Medicare-covered diagnostic procedures and tests |
20% of the cost for Medicare-covered X-rays |
20% 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 $5 to $30 may apply |
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $5 to $30 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. |