2013 Medicare Advantage Plan Details | |||||
---|---|---|---|---|---|
Medicare Plan Name: | Windsor Medicare Extra Silver Plan (HMO) | ||||
Location: | Macon, Tennessee Click to see other locations | ||||
Plan ID: | H5698 - 035 - 0 Click to see other plans | ||||
Member Services: | 1-800-316-2273 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 |
||||
Email a copy of the Windsor Medicare Extra Silver Plan (HMO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||
Annual Rx 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 (H5698 - 035): | 1,211 members | ||||
Plan’s Summary Star Rating: | 2.5 out of 5 Stars. | ||||
• Customer Service Rating: | 4 out of 5 Stars. | ||||
• Member Experience Rating: | 3 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 2 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. | |||||
Windsor Medicare Extra will reduce your monthly Medicare Part B premium by up to $ 30.00. | |||||
$3 400 out-of-pocket limit. All plan services included. | |||||
** Doctor and Hospital Choice ** | |||||
Doctor and Hospital Choice | |||||
You must go to network doctors specialists and hospitals. | |||||
No referral required for network doctors specialists and hospitals. | |||||
** Extra Benefits ** | |||||
Over-the-Counter Items | |||||
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. | |||||
Transportation | |||||
Authorization rules may apply. | |||||
$0 copay for up to 50 one-way trip(s) to plan-approved location every year | |||||
** 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. | |||||
Windsor Medicare Extra will reduce your monthly Medicare Part B premium by up to $ 30.00. | |||||
$3 400 out-of-pocket limit. All plan services included. | |||||
Doctor and Hospital Choice | |||||
You must go to network doctors specialists and hospitals. | |||||
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 hospital stays: | |||||
| |||||
$100 copay for each additional hospital day. | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
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: | |||||
| |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
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: | |||||
| |||||
Home Health Care | |||||
Authorization rules may apply. | |||||
$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 | |||||
$20 copay for each Medicare-covered primary care doctor visit. | |||||
$30 copay for each Medicare-covered specialist visit. | |||||
Chiropractic Services | |||||
$20 copay 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 | |||||
$30 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. | |||||
$35 copay for each Medicare-covered individual therapy visit | |||||
$35 copay for each Medicare-covered group therapy visit | |||||
$35 copay for each Medicare-covered individual therapy visit with a psychiatrist | |||||
$35 copay for each Medicare-covered group therapy visit with a psychiatrist | |||||
$35 copay for Medicare-covered partial hospitalization program services | |||||
Outpatient Substance Abuse Care | |||||
Authorization rules may apply. | |||||
$35 copay for Medicare-covered individual substance abuse outpatient treatment visits | |||||
$35 copay for Medicare-covered group substance abuse outpatient treatment visits | |||||
Outpatient Services | |||||
Authorization rules may apply. | |||||
$200 copay for each Medicare-covered ambulatory surgical center visit | |||||
$0 to $300 copay [or 20% of the cost] for each Medicare-covered outpatient hospital facility visit | |||||
$300 out-of-pocket limit for outpatient hospital facility visits. | |||||
Ambulance Services | |||||
Authorization rules may apply. | |||||
$100 copay for Medicare-covered ambulance benefits. | |||||
If you are admitted to the hospital you pay $0 for Medicare-covered ambulance benefits. | |||||
Emergency Care | |||||
$65 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 | |||||
$25 copay for Medicare-covered urgently-needed-care visits | |||||
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the urgently-needed-care visit. | |||||
Outpatient Rehabilitation Services | |||||
Authorization rules may apply. | |||||
$30 copay for Medicare-covered Occupational Therapy visits | |||||
$30 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 | |||||
Authorization rules may apply. | |||||
$0 copay for Medicare-covered Diabetes self-management training | |||||
0% to 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: | |||||
| |||||
$0 copay for Medicare-covered X-rays | |||||
$0 to $75 copay for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
5% 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 $20 to $30 may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $20 to $30 may apply | |||||
** Preventive Services ** | |||||
Cardiac and Pulmonary Rehabilitation Services | |||||
Authorization rules may apply. | |||||
$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. 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: | |||||
| |||||
Kidney Disease and Conditions | |||||
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 | |||||
In general preventive dental benefits (such as cleaning) not covered. | |||||
$30 copay for Medicare-covered dental benefits | |||||
Hearing Services | |||||
Hearing aids not covered. | |||||
$20 to $30 copay for Medicare-covered diagnostic hearing exams | |||||
$30 copay for up to 1 supplemental routine hearing exam(s) every year | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
$0 copay for
| |||||
| |||||
Over-the-Counter Items | |||||
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. | |||||
Transportation | |||||
Authorization rules may apply. | |||||
$0 copay for up to 50 one-way trip(s) to plan-approved location every year | |||||
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. | |||||
For hospital stays: | |||||
| |||||
$100 copay for each additional hospital day. | |||||
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
$20 copay for each Medicare-covered primary care doctor visit. | |||||
$30 copay for each Medicare-covered specialist visit. | |||||
Outpatient Services | |||||
Authorization rules may apply. | |||||
$200 copay for each Medicare-covered ambulatory surgical center visit | |||||
$0 to $300 copay [or 20% of the cost] for each Medicare-covered outpatient hospital facility visit | |||||
$300 out-of-pocket limit for outpatient hospital facility visits. | |||||
Ambulance Services | |||||
Authorization rules may apply. | |||||
$100 copay for Medicare-covered ambulance benefits. | |||||
If you are admitted to the hospital you pay $0 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 copay for Medicare-covered X-rays | |||||
$0 to $75 copay for Medicare-covered diagnostic radiology services (not including X-rays) | |||||
5% 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 $20 to $30 may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $20 to $30 may apply | |||||
** Additional Benefits ** | |||||
Over-the-Counter Items | |||||
Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit. | |||||
Transportation | |||||
Authorization rules may apply. | |||||
$0 copay for up to 50 one-way trip(s) to plan-approved location every year |