2013 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | DeanCare Gold Basic (Cost) | ||||
Location: | Iowa, Wisconsin Click to see other locations | ||||
Plan ID: | H5264 - 003 - 0 Click to see other plans | ||||
Member Services: | 1-888-422-3326 TTY users 1-877-733-6456 | ||||
— 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 DeanCare Gold Basic (Cost) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $108.00 (see Plan Premium Details below) | ||||
Annual Deductible: | no drug coverage | ||||
Health Plan Type: | Cost * | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $0 | ||||
Number of Members enrolled in this plan in (H5264 - 003): | 101 members | ||||
Plan’s Summary Star Rating: | Does not apply. | ||||
• Customer Service Rating: | Does not apply. | ||||
• Member Experience Rating: | Does not apply. | ||||
• Drug Cost Accuracy Rating: | Does not apply. | ||||
— 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 | |||||
$108.00 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. | |||||
** 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 | |||||
$108.00 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. | |||||
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. | |||||
$0 copay | |||||
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. | |||||
$0 copay | |||||
Skilled Nursing Facility (SNF) | |||||
Plan covers up to 100 days each benefit period | |||||
$0 copay for SNF services | |||||
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 Medicare-covered primary care doctor visit. | |||||
$0 copay for each Medicare-covered specialist visit. | |||||
Chiropractic Services | |||||
$0 copay for Medicare-covered chiropractic visits | |||||
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 | |||||
$0 copay for Medicare-covered podiatry visits | |||||
Medicare-covered podiatry visits are for medically-necessary foot care. | |||||
Outpatient Mental Health Care | |||||
$0 copay for: | |||||
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$0 copay for: | |||||
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$0 copay for Medicare-covered partial hospitalization program services | |||||
Outpatient Substance Abuse Care | |||||
$0 copay for: | |||||
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Outpatient Services | |||||
$0 copay for each Medicare-covered ambulatory surgical center visit | |||||
$0 copay for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
$0 copay for Medicare-covered ambulance benefits. | |||||
Emergency Care | |||||
$0 copay for Medicare-covered emergency room visits | |||||
Not covered outside the U.S. and its territories except under limited circumstances. Contact plan for details. | |||||
Urgently Needed Care | |||||
$0 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 Therapy and/or Speech and Language Pathology visits | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
$0 copay for Medicare-covered durable medical equipment | |||||
Prosthetic Devices | |||||
$0 copay for Medicare-covered prosthetic devices | |||||
Diabetes Programs and Supplies | |||||
$0 copay for Medicare-covered Diabetes self-management training | |||||
$0 copay for Medicare-covered: | |||||
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Diagnostic Tests, X-Rays, Lab Services, and Radiology Services | |||||
$0 copay for Medicare-covered: | |||||
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** 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. | |||||
The plan covers the following supplemental education/wellness programs: | |||||
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Kidney Disease and Conditions | |||||
Cost plan members pay Original Medicare cost sharing for out-of-area dialysis. | |||||
$0 copay for Medicare-covered renal dialysis | |||||
$0 copay for Medicare-covered kidney disease education services | |||||
Outpatient Prescription Drugs | |||||
Most drugs not covered. | |||||
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 | |||||
In general supplemental routine hearing exams and hearing aids not covered. | |||||
$0 copay for Medicare-covered diagnostic hearing exams | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
This plan offers only Medicare-covered eye care and eye wear | |||||
$0 copay for Medicare-covered diagnosis and treatment for diseases and conditions of the eye | |||||
$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. | |||||
$0 copay | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
$0 copay for each Medicare-covered primary care doctor visit. | |||||
$0 copay for each Medicare-covered specialist visit. | |||||
Outpatient Services | |||||
$0 copay for each Medicare-covered ambulatory surgical center visit | |||||
$0 copay for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
$0 copay for Medicare-covered ambulance benefits. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
$0 copay for Medicare-covered durable medical equipment | |||||
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services | |||||
$0 copay for Medicare-covered: | |||||
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** Additional Benefits ** | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
Transportation | |||||
This plan does not cover supplemental routine transportation. |