2013 Advocare Vitality (HMO-POS) - H5211-006-0 in WI Plan Benefits Details

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2013 Medicare Advantage Plan Benefit Details for the Advocare Vitality (HMO-POS) - H5211-006-0

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:	Advocare Vitality (HMO-POS)
Location:	Price, Wisconsin Click to see other locations
Plan ID:	H5211 - 006 - 0 Click to see other plans
Member Services:	1-877-998-0998 TTY users 1-877-727-2232
— 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 Advocare Vitality (HMO-POS) benefit details
— Medicare Plan Features —
Monthly Premium:	$215.00 (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):	$500
Number of Members enrolled in this plan in (H5211 - 006):		1,266 members
Plan’s Summary Star Rating:		4.5 out of 5 Stars.
• Customer Service Rating:		4 out of 5 Stars.
• Member Experience Rating:		5 out of 5 Stars.
• Drug Cost Accuracy Rating:		4 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
$215.00 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.
$500 out-of-pocket limit. All plan services included.
$1 500 annual deductible. Contact the plan for services that apply.
$3 500 out-of-pocket limit. All plan services included.
Doctor and Hospital Choice
Doctor and Hospital Choice
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.
Point of Service
Point of Service coverage is available for the following benefits:
Medicare-covered Inpatient Hospital Acute Inpatient Hospital Psychiatric Skilled Nursing Facility (SNF) Cardiac Rehabilitation Services Intensive Cardiac Rehabilitation Services Pulmonary Rehabilitation Services Partial Hospitalization Home Health Services Primary Care Physician Services Chiropractic Services Occupational Therapy Services Physician Specialist Services Mental Health Specialty Services Podiatry Services Other Health Care Professional Psychiatric Services Physical Therapy and Speech-Language Pathology Services Outpatient Diagnostic Procedures/Tests/Lab Services Diagnostic Radiological Services Therapeutic Radiological Services Outpatient X-Rays Outpatient Hospital Services Ambulatory Surgical Center (ASC) Services
Supplemental Outpatient Blood Services Over-the-Counter (OTC) Items Eye Exams Hearing Exams
$1 500 annual deductible for POS benefits
$3 500 out-of-pocket limit every year for POS benefits
$1 500 annual service category deductible for both Inpatient Hospital and Inpatient Mental Health Care
20% of the cost per hospital stay.
$1 500 annual service category deductible for both Inpatient Hospital and Inpatient Mental Health Care
20% of the cost per Inpatient Psychiatric Hospital stay.
$1 500 annual service category deductible
$0 copay for each SNF stay.
20% of the cost for Medicare-covered Cardiac Rehabilitation Services Intensive Cardiac Rehabilitation Services Pulmonary Rehabilitation Services Partial Hospitalization Home Health Services Primary Care Physician Services Chiropractic Services Occupational Therapy Services Physician Specialist Services Mental Health Specialty Services Podiatry Services Other Health Care Professional Psychiatric Services Physical Therapy and Speech-Language Pathology Services Outpatient Diagnostic Procedures/Tests/Lab Services Diagnostic Radiological Services Therapeutic Radiological Services Outpatient X-Rays Outpatient Hospital Services Ambulatory Surgical Center (ASC) Services Outpatient Substance Abuse Outpatient Blood Services Durable Medical
Transportation
This plan does not cover supplemental routine transportation.
Important Information
Premium and Other Important Information
$215.00 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.
$500 out-of-pocket limit. All plan services included.
$1 500 annual deductible. Contact the plan for services that apply.
$3 500 out-of-pocket limit. All plan services included.
Doctor and Hospital Choice
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.
$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)
Authorization rules may apply.
Plan covers up to 100 days each benefit period
No prior hospital stay is required.
$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.
$10 copay for each Medicare-covered specialist visit.
Chiropractic Services
$10 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
$10 copay for each Medicare-covered podiatry visit
Medicare-covered podiatry visits are for medically-necessary foot care.
Outpatient Mental Health Care
$10 copay for each Medicare-covered individual therapy visit
$10 copay for each Medicare-covered group therapy visit
$10 copay for each Medicare-covered individual therapy visit with a psychiatrist
$10 copay for each Medicare-covered group therapy visit with a psychiatrist
$0 copay for Medicare-covered partial hospitalization program services
Outpatient Substance Abuse Care
$0 copay for:
each Medicare-covered individual substance abuse outpatient treatment visit
each Medicare-covered group substance abuse outpatient treatment visit
Outpatient Services
$0 copay for each Medicare-covered ambulatory surgical center visit
$0 to $100 copay for each Medicare-covered outpatient hospital facility visit
Ambulance Services
$0 copay 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
$0 to $10 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:
Diabetes monitoring supplies
Therapeutic shoes or inserts
If the doctor provides you services in addition to Diabetes self-management training separate cost sharing of $0 to $10 may apply
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
$0 copay for Medicare-covered:
lab services
diagnostic procedures and tests
X-rays
therapeutic radiology services
$100 copay for Medicare-covered diagnostic radiology services (not including X-rays)
Preventive Services
Cardiac and Pulmonary Rehabilitation Services
$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:
Additional Smoking and Tobacco Use Cessation Visits
Nursing Hotline
$0 copay for Enhanced Disease Management. Contact plan for details.
$0 copay for Re-admission Prevention. Contact plan for details.
Kidney Disease and Conditions
$0 copay for Medicare-covered renal dialysis
$0 copay for Medicare-covered kidney disease education services
Outpatient Prescription Drugs
Most drugs not covered.
$0 copay for Medicare Part B drugs.
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
Hearing aids not covered.
$10 copay for Medicare-covered diagnostic hearing exams
$10 copay for up to 1 supplemental routine hearing exam(s) every year
Additional Benefits
Vision Services
$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
$0 to $10 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye.
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
This plan does not cover supplemental routine transportation.
Acupuncture
This plan does not cover Acupuncture.
Point of Service
Point of Service coverage is available for the following benefits:
Medicare-covered Inpatient Hospital Acute Inpatient Hospital Psychiatric Skilled Nursing Facility (SNF) Cardiac Rehabilitation Services Intensive Cardiac Rehabilitation Services Pulmonary Rehabilitation Services Partial Hospitalization Home Health Services Primary Care Physician Services Chiropractic Services Occupational Therapy Services Physician Specialist Services Mental Health Specialty Services Podiatry Services Other Health Care Professional Psychiatric Services Physical Therapy and Speech-Language Pathology Services Outpatient Diagnostic Procedures/Tests/Lab Services Diagnostic Radiological Services Therapeutic Radiological Services Outpatient X-Rays Outpatient Hospital Services Ambulatory Surgical Center (ASC) Services
Supplemental Outpatient Blood Services Over-the-Counter (OTC) Items Eye Exams Hearing Exams
$1 500 annual deductible for POS benefits
$3 500 out-of-pocket limit every year for POS benefits
$1 500 annual service category deductible for both Inpatient Hospital and Inpatient Mental Health Care
20% of the cost per hospital stay.
$1 500 annual service category deductible for both Inpatient Hospital and Inpatient Mental Health Care
20% of the cost per Inpatient Psychiatric Hospital stay.
$1 500 annual service category deductible
$0 copay for each SNF stay.
20% of the cost for Medicare-covered Cardiac Rehabilitation Services Intensive Cardiac Rehabilitation Services Pulmonary Rehabilitation Services Partial Hospitalization Home Health Services Primary Care Physician Services Chiropractic Services Occupational Therapy Services Physician Specialist Services Mental Health Specialty Services Podiatry Services Other Health Care Professional Psychiatric Services Physical Therapy and Speech-Language Pathology Services Outpatient Diagnostic Procedures/Tests/Lab Services Diagnostic Radiological Services Therapeutic Radiological Services Outpatient X-Rays Outpatient Hospital Services Ambulatory Surgical Center (ASC) Services Outpatient Substance Abuse Outpatient Blood Services Durable Medical
Inpatient Care
Inpatient Hospital Care
No limit to the number of days covered by the plan each hospital stay.
$0 copay
Outpatient Care
Doctor Office Visits
$0 copay for each Medicare-covered primary care doctor visit.
$10 copay for each Medicare-covered specialist visit.
Outpatient Services
$0 copay for each Medicare-covered ambulatory surgical center visit
$0 to $100 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:
lab services
diagnostic procedures and tests
X-rays
therapeutic radiology services
$100 copay for Medicare-covered diagnostic radiology services (not including X-rays)
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
This plan does not cover supplemental routine transportation.

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