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2013 Medicare Advantage Plan Benefit Details for the Coventry Vista Value (HMO)
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2013 Medicare Advantage Plan Details
Medicare Plan Name:Coventry Vista Value (HMO)
Location:Miami-Dade, Florida 33142     Click to see other locations
Plan ID:H1076 - 010 - 0     Click to see other plans
Member Services:1-800-847-3995 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 Coventry Vista Value (HMO) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 (see Plan Premium Details below)
Annual Deductible:no drug coverage
Health Plan Type:Local HMO *
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$6,700
Number of Members enrolled in this plan in (H1076 - 010):267 members
Plan’s Summary Star Rating: 3 out of 5 Stars.
• Customer Service Rating: 4 out of 5 Stars.
• Member Experience Rating: 4 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
$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.
Coventry Health Care of Florida will reduce your monthly Medicare Part B premium by up to $ 50.00.
$6 700 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.
Referral required for network specialists (for certain benefits).
Plan covers you when you travel in the U.S. or its territories.
** 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
$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.
Coventry Health Care of Florida will reduce your monthly Medicare Part B premium by up to $ 50.00.
$6 700 out-of-pocket limit. All plan services included.
Doctor and Hospital Choice
You must go to network doctors specialists and hospitals.
Referral required for network specialists (for certain benefits).
Plan covers you when you travel in the U.S. or its territories.
** Inpatient Care **
Inpatient Hospital Care
No limit to the number of days covered by the plan each hospital stay.
For Medicare-covered hospital stays:
  • Days 1 - 10: $150 copay per day
  • Days 11 - 90: $0 copay per day
    • $0 copay for additional hospital days
    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:
    • Days 1 - 7: $150 copay per day
  • Days 8 - 90: $0 copay per day
    • 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:
    • Days 1 - 20: $35 copay per day
  • Days 21 - 100: $100 copay per day
    • 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
    Authorization rules may apply.
    $0 copay for each Medicare-covered primary care doctor visit.
    $25 copay for each Medicare-covered specialist visit.
    Chiropractic Services
    $15 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
    $0 copay for Medicare-covered podiatry visits
    up to 6 supplemental routine podiatry visit(s) every year
    Medicare-covered podiatry visits are for medically-necessary foot care.
    Outpatient Mental Health Care
    Authorization rules may apply.
    $0 copay for:
    • each Medicare-covered individual therapy visit
  • each Medicare-covered group therapy visit
    • $0 copay for:
    • each Medicare-covered individual therapy visit with a psychiatrist
  • each Medicare-covered group therapy visit with a psychiatrist
    • $0 copay for Medicare-covered partial hospitalization program services
    Outpatient Substance Abuse Care
    Authorization rules may apply.
    $0 copay for:
    • each Medicare-covered individual substance abuse outpatient treatment visit
  • each Medicare-covered group substance abuse outpatient treatment visit
    • Outpatient Services
    Authorization rules may apply.
    $50 copay for each Medicare-covered ambulatory surgical center visit
    $150 copay for each Medicare-covered outpatient hospital facility visit
    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
    $50 000 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
    $0 copay for Medicare-covered urgently-needed-care visits
    Outpatient Rehabilitation Services
    Authorization rules may apply.
    $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
    Authorization rules may apply.
    $0 copay for Medicare-covered durable medical equipment
    Prosthetic Devices
    Authorization rules may apply.
    $0 copay for Medicare-covered prosthetic devices
    Diabetes Programs and Supplies
    Authorization rules may apply.
    $0 copay for Medicare-covered Diabetes self-management training
    $0 copay for Medicare-covered:
    • Diabetes monitoring supplies
  • Therapeutic shoes or inserts
    • Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
    Authorization rules may apply.
    $0 copay for Medicare-covered:
    • lab services
  • X-rays
    • $10 to $100 copay for Medicare-covered diagnostic procedures and tests
    $10 to $100 copay for Medicare-covered diagnostic radiology services (not including X-rays)
    20% of the cost for Medicare-covered therapeutic radiology services
    ** Preventive Services **
    Cardiac and Pulmonary Rehabilitation Services
    Authorization rules may apply.
    $0 copay for:
    • Medicare-covered Cardiac Rehabilitation Services
  • Medicare-covered Intensive Cardiac Rehabilitation Services
  • 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:
    • Health Education
  • Nutritional Education
  • Additional Smoking and Tobacco Use Cessation Visits
  • Health Club Membership/Fitness Classes
    • 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.
    0% to 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
    $0 copay for Medicare-covered dental benefits
    $0 copay for the following preventive dental benefits:
    • up to 1 oral exam(s)
  • up to 1 cleaning(s)
  • up to 1 dental x-ray(s)
    • Plan offers additional comprehensive dental benefits.
    Hearing Services
    $0 copay for Medicare-covered diagnostic hearing exams
    $0 copay for :
    • up to 1 supplemental routine hearing exam(s) every year
  • up to 1 fitting-evaluation(s) for a hearing aid every year
    • $0 copay for up to 2 hearing aid(s) every year
    $1 000 plan coverage limit for hearing aids every year.
    ** Additional Benefits **
    Vision Services
    $0 copay for Medicare-covered diagnosis and treatment for diseases and conditions of the eye
    $0 copay for up to 1 supplemental routine eye exam(s) every year
    $0 copay for
    • one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery
    • up to 1 pair(s) of glasses every year
  • contacts
    • $100 plan coverage limit for eye wear 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
    No limit to the number of days covered by the plan each hospital stay.
    For Medicare-covered hospital stays:
    • Days 1 - 10: $150 copay per day
  • Days 11 - 90: $0 copay per day
    • $0 copay for additional hospital days
    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
    Authorization rules may apply.
    $0 copay for each Medicare-covered primary care doctor visit.
    $25 copay for each Medicare-covered specialist visit.
    Outpatient Services
    Authorization rules may apply.
    $50 copay for each Medicare-covered ambulatory surgical center visit
    $150 copay for each Medicare-covered outpatient hospital facility visit
    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.
    $0 copay for Medicare-covered durable medical equipment
    Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
    Authorization rules may apply.
    $0 copay for Medicare-covered:
    • lab services
  • X-rays
    • $10 to $100 copay for Medicare-covered diagnostic procedures and tests
    $10 to $100 copay for Medicare-covered diagnostic radiology services (not including X-rays)
    20% of the cost for Medicare-covered therapeutic radiology services
    ** Additional Benefits **
    Over-the-Counter Items
    The plan does not cover Over-the-Counter items.
    Transportation
    This plan does not cover supplemental routine transportation.




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