2013 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Rocky Mountain Standard Plan (Cost) | ||||
Location: | Moffat, Colorado Click to see other locations | ||||
Plan ID: | H0602 - 001 - 0 Click to see other plans | ||||
Member Services: | 1-888-282-1420 TTY users 711 | ||||
— 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 Rocky Mountain Standard Plan (Cost) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $64.00 (see Plan Premium Details below) | ||||
Annual Deductible: | no drug coverage | ||||
Health Plan Type: | Cost * | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $5,000 | ||||
Number of Members enrolled in this plan in (H0602 - 001): | 5,578 members | ||||
Plan’s Summary Star Rating: | 4.5 out of 5 Stars. | ||||
• Customer Service Rating: | 5 out of 5 Stars. | ||||
• Member Experience Rating: | 5 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 3 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 | |||||
$64.00 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 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. | |||||
$5 000 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 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. | |||||
** 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 | |||||
$64.00 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 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. | |||||
$5 000 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 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. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
Plan covers 90 days each benefit period. | |||||
$600 copay for each Medicare-covered hospital stay | |||||
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. | |||||
$600 copay for each Medicare-covered hospital stay. | |||||
Skilled Nursing Facility (SNF) | |||||
Plan covers up to 100 days each benefit period | |||||
For Medicare-covered SNF stays: | |||||
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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 | |||||
Authorization rules may apply. | |||||
$15 copay for each Medicare-covered primary care doctor visit. | |||||
$45 copay for each Medicare-covered specialist visit. | |||||
Chiropractic Services | |||||
20% of the cost for each Medicare-covered chiropractic 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. | |||||
Podiatry Services | |||||
$45 copay for each Medicare-covered podiatry visit | |||||
Medicare-covered podiatry visits are for medically-necessary foot care. | |||||
Outpatient Mental Health Care | |||||
Authorization rules may apply. | |||||
$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 | |||||
$40 copay for Medicare-covered partial hospitalization program services | |||||
Outpatient Substance Abuse Care | |||||
Authorization rules may apply. | |||||
$40 copay for Medicare-covered individual substance abuse outpatient treatment visits | |||||
$40 copay for Medicare-covered group substance abuse outpatient treatment visits | |||||
Outpatient Services | |||||
Authorization rules may apply. | |||||
$350 copay for each Medicare-covered ambulatory surgical center visit | |||||
$350 copay for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
Authorization rules may apply. | |||||
$100 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 | |||||
$45 copay for Medicare-covered urgently-needed-care visits | |||||
Outpatient Rehabilitation Services | |||||
There may be limits on physical therapy occupational therapy and speech and language pathology visits. If so there may be exceptions to these limits. | |||||
$15 copay for Medicare-covered Occupational Therapy visits | |||||
$15 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
20% of the cost for Medicare-covered durable medical equipment | |||||
Prosthetic Devices | |||||
Authorization rules may apply. | |||||
20% of the cost for Medicare-covered prosthetic devices | |||||
Diabetes Programs and Supplies | |||||
$0 copay for Medicare-covered Diabetes self-management training | |||||
20% of the cost for Medicare-covered Diabetes monitoring supplies | |||||
20% of the cost for Medicare-covered Therapeutic shoes or inserts | |||||
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered: | |||||
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$0 to $350 copay for Medicare-covered diagnostic procedures and tests | |||||
$75 to $150 copay 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 $45 may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $15 to $45 may apply | |||||
** Preventive Services ** | |||||
Cardiac and Pulmonary Rehabilitation Services | |||||
$0 copay for: | |||||
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Preventive Services and Wellness/Education Programs | |||||
$0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare. | |||||
This plan does not cover supplemental education/wellness programs. | |||||
$0 copay for Annual Cervical and Vaginal Cancer Screening. Contact plan for details. | |||||
Kidney Disease and Conditions | |||||
Cost plan members pay Original Medicare cost sharing for out-of-area dialysis. | |||||
20% of the cost for Medicare-covered renal dialysis | |||||
$0 copay for Medicare-covered kidney disease education services | |||||
Outpatient Prescription Drugs | |||||
Most drugs not covered. | |||||
20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs. | |||||
This plan does not offer prescription drug coverage. | |||||
Dental Services | |||||
Authorization rules may apply. | |||||
This plan covers some preventive dental benefits for an extra cost (see "Optional Supplemental Benefits.") | |||||
$0 to $600 copay [or 0% to 20% of the cost] for Medicare-covered dental benefits | |||||
Hearing Services | |||||
Hearing aids not covered. | |||||
$15 to $45 copay for Medicare-covered diagnostic hearing exams | |||||
$20 copay for up to 1 supplemental routine hearing exam(s) every year | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
This plan covers some vision benefits for an extra cost (see "Optional Supplemental Benefits"). | |||||
$0 copay for
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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 | |||||
Plan covers 90 days each benefit period. | |||||
$600 copay for each Medicare-covered hospital stay | |||||
Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
Authorization rules may apply. | |||||
$15 copay for each Medicare-covered primary care doctor visit. | |||||
$45 copay for each Medicare-covered specialist visit. | |||||
Outpatient Services | |||||
Authorization rules may apply. | |||||
$350 copay for each Medicare-covered ambulatory surgical center visit | |||||
$350 copay for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
Authorization rules may apply. | |||||
$100 copay for Medicare-covered ambulance benefits. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
Authorization rules may apply. | |||||
20% of the cost for Medicare-covered durable medical equipment | |||||
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered: | |||||
| |||||
$0 to $350 copay for Medicare-covered diagnostic procedures and tests | |||||
$75 to $150 copay 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 $45 may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $15 to $45 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. | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
Package: 1 - Dental Services: | |||||
$18 monthly premium in addition to your $64 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
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$1 500 plan coverage limit every year for these benefits. | |||||
** Important Information ** | |||||
Package: 1 - Dental Services: | |||||
$18 monthly premium in addition to your $64 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
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$1 500 plan coverage limit every year for these benefits. | |||||
** Preventive Services ** | |||||
Dental Services | |||||
Plan offers additional comprehensive dental benefits. | |||||
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$1 500 plan coverage limit for dental benefits every year | |||||
** Cost ** | |||||
Premium and Other Important Information | |||||
Package: 2 - Vision Services: | |||||
$12 monthly premium in addition to your $64 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
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** Important Information ** | |||||
Package: 2 - Vision Services: | |||||
$12 monthly premium in addition to your $64 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits:
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** Additional Benefits ** | |||||
Vision Services | |||||
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$0 copay for | |||||
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$130 plan coverage limit for eye wear every year. |