2013 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Today's Options Premier 300 (PFFS) | ||||
Location: | Rock, Wisconsin Click to see other locations | ||||
Plan ID: | H6169 - 051 - 0 Click to see other plans | ||||
Member Services: | 1-866-568-8921 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 Today's Options Premier 300 (PFFS) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $80.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | no drug coverage | ||||
Health Plan Type: | PFFS * | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $0 | ||||
Number of Members enrolled in this plan in (H6169 - 051): | 65 members | ||||
Plan’s Summary Star Rating: | 2.5 out of 5 Stars. | ||||
• Customer Service Rating: | 4 out of 5 Stars. | ||||
• Member Experience Rating: | Insufficient data to rate this plan. | ||||
• 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 | |||||
$80.00 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 | |||||
$80.00 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 or hospital that accepts the plan’s terms and conditions of payment. In emergencies you may go to any doctor or hospital even those that do not participate with the plan. | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
For Medicare-covered hospital stays: | |||||
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$0 copay for additional hospital days | |||||
For hospital stays: | |||||
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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: | |||||
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For hospital stays: | |||||
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Skilled Nursing Facility (SNF) | |||||
Plan covers up to 100 days each benefit period | |||||
No prior hospital stay is required. | |||||
For SNF stays: | |||||
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For each SNF stay: | |||||
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Home Health Care | |||||
15% of the cost for each Medicare-covered home health visit | |||||
15% of the cost 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 | |||||
You may go to any doctor that accepts the plan’s terms and conditions of payment. | |||||
$5 copay for each Medicare-covered primary care doctor visit. | |||||
$30 copay for each Medicare-covered specialist visit. | |||||
$10 copay for each Medicare-covered primary care doctor visit | |||||
$40 copay for each Medicare-covered specialist visit | |||||
Chiropractic Services | |||||
50% 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. | |||||
50% of the cost for Medicare-covered chiropractic visits. | |||||
Podiatry Services | |||||
$35 copay for each Medicare-covered podiatry visit | |||||
Medicare-covered podiatry visits are for medically-necessary foot care. | |||||
$35 copay for Medicare-covered podiatry visits | |||||
Outpatient Mental Health Care | |||||
35% of the cost for each Medicare-covered individual therapy visit | |||||
35% of the cost for each Medicare-covered group therapy visit | |||||
35% of the cost for each Medicare-covered individual therapy visit with a psychiatrist | |||||
35% of the cost for each Medicare-covered group therapy visit with a psychiatrist | |||||
$110 copay for Medicare-covered partial hospitalization program services | |||||
35% of the cost for Medicare-covered Mental Health visits with a psychiatrist | |||||
35% of the cost for Medicare-covered Mental Health visits | |||||
$110 copay for Medicare-covered partial hospitalization program services | |||||
Outpatient Substance Abuse Care | |||||
35% of the cost for Medicare-covered individual substance abuse outpatient treatment visits | |||||
35% of the cost for Medicare-covered group substance abuse outpatient treatment visits | |||||
35% of the cost Medicare-covered substance abuse outpatient treatment visits | |||||
Outpatient Services | |||||
$75 copay for each Medicare-covered ambulatory surgical center visit | |||||
$150 copay for each Medicare-covered outpatient hospital facility visit | |||||
$150 copay for Medicare-covered outpatient hospital facility visits | |||||
$75 copay for Medicare-covered ambulatory surgical center visits | |||||
Ambulance Services | |||||
$150 copay for Medicare-covered ambulance benefits. | |||||
$150 copay for Medicare-covered ambulance benefits. | |||||
Emergency Care | |||||
$65 copay for Medicare-covered emergency room visits | |||||
$20 000 plan coverage limit for supplemental emergency services outside the U.S. and its territories 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 | |||||
$35 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 | |||||
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 | |||||
$15 to $20 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits | |||||
$15 to $20 copay for Medicare-covered Occupational Therapy visits. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
20% of the cost for Medicare-covered durable medical equipment | |||||
20% of the cost for Medicare-covered durable medical equipment | |||||
Prosthetic Devices | |||||
20% of the cost for Medicare-covered prosthetic devices | |||||
20% of the cost for Medicare-covered prosthetic devices. | |||||
Diabetes Programs and Supplies | |||||
$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 | |||||
If the doctor provides you services in addition to Diabetes self-management training separate cost sharing of $5 to $35 may apply | |||||
$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 | |||||
If the doctor provides you services in addition to (Outpatient Diagnostic Procedures/Tests/Lab Services Diabetes Self-Management Training Eye Exams) separate cost sharing of $10 to $40 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 $35 may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $5 to $35 may apply | |||||
20% of the cost for Medicare-covered therapeutic radiology services | |||||
20% of the cost for Medicare-covered outpatient X-rays | |||||
20% of the cost for Medicare-covered diagnostic radiology services | |||||
$0 copay for Medicare-covered diagnostic procedures tests and lab services | |||||
If the doctor provides you services in addition to (Diagnostic Radiological Services Therapeutic Radiological Services Outpatient X-Rays) separate cost sharing of $10 to $40 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 | |||||
$15 to $20 copay for Medicare-covered Cardiac Rehabilitation Services | |||||
$15 to $20 copay for Medicare-covered Intensive Cardiac Rehabilitation Services | |||||
$15 to $20 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: | |||||
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$0 copay for Medicare-covered preventive services | |||||
Kidney Disease and Conditions | |||||
$30 copay for Medicare-covered renal dialysis | |||||
$0 copay for Medicare-covered kidney disease education services | |||||
$0 copay for Medicare-covered kidney disease education services | |||||
$30 copay for Medicare-covered renal dialysis | |||||
Outpatient Prescription Drugs | |||||
20% of the cost for Medicare Part B drugs out-of-network. | |||||
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. | |||||
$0 copay for Medicare-covered dental benefits | |||||
$0 copay for Medicare-covered comprehensive dental benefits | |||||
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 | |||||
$15 to $20 copay for Medicare-covered diagnostic hearing exams. | |||||
$15 to $20 copay for supplemental hearing exams. | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
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If the doctor provides you services in addition to eye exams separate cost sharing of $5 to $35 may apply | |||||
$0 copay for Medicare-covered eye exams | |||||
$0 copay for supplemental eye exams | |||||
$15 to $20 copay for Medicare-covered eye wear | |||||
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 or hospital that accepts the plan’s terms and conditions of payment. In emergencies you may go to any doctor or hospital even those that do not participate with the plan. | |||||
No limit to the number of days covered by the plan each hospital stay. | |||||
For Medicare-covered hospital stays: | |||||
| |||||
$0 copay for additional hospital days | |||||
For hospital stays: | |||||
| |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
You may go to any doctor that accepts the plan’s terms and conditions of payment. | |||||
$5 copay for each Medicare-covered primary care doctor visit. | |||||
$30 copay for each Medicare-covered specialist visit. | |||||
$10 copay for each Medicare-covered primary care doctor visit | |||||
$40 copay for each Medicare-covered specialist visit | |||||
Outpatient Services | |||||
$75 copay for each Medicare-covered ambulatory surgical center visit | |||||
$150 copay for each Medicare-covered outpatient hospital facility visit | |||||
$150 copay for Medicare-covered outpatient hospital facility visits | |||||
$75 copay for Medicare-covered ambulatory surgical center visits | |||||
Ambulance Services | |||||
$150 copay for Medicare-covered ambulance benefits. | |||||
$150 copay for Medicare-covered ambulance benefits. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Durable Medical Equipment | |||||
20% of the cost for Medicare-covered durable medical equipment | |||||
20% of the cost for Medicare-covered durable medical equipment | |||||
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 $35 may apply | |||||
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $5 to $35 may apply | |||||
20% of the cost for Medicare-covered therapeutic radiology services | |||||
20% of the cost for Medicare-covered outpatient X-rays | |||||
20% of the cost for Medicare-covered diagnostic radiology services | |||||
$0 copay for Medicare-covered diagnostic procedures tests and lab services | |||||
If the doctor provides you services in addition to (Diagnostic Radiological Services Therapeutic Radiological Services Outpatient X-Rays) separate cost sharing of $10 to $40 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. |