** 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: |
- Days 1 - 5: $200 copay per day
|
Days 6 - 90: $0 copay per day |
$0 copay for additional hospital days |
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 - 5: $200 copay per day
|
Days 6 - 90: $0 copay per day |
Skilled Nursing Facility (SNF) |
Plan covers up to 100 days each benefit period |
No prior hospital stay is required. |
For SNF stays: |
- Days 1 - 20: $0 copay per day
|
Days 21 - 100: $100 copay per day |
Home Health Care |
15% of the cost for each Medicare-covered home health visit |
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. |
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. |
Podiatry Services |
$35 copay for each Medicare-covered podiatry visit |
Medicare-covered podiatry visits are for medically-necessary foot care. |
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 |
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 |
Outpatient Services |
$75 copay for each Medicare-covered ambulatory surgical center visit |
$150 copay for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
$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 |
Cost sharing is the same as Doctor Office Visit cost sharing. |
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 |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
20% of the cost for Medicare-covered durable medical equipment |
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 |
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 |
** 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 |
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 |
$30 copay 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. |
$0 copay for Medicare-covered 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 |
** Additional Benefits ** |
Vision Services |
- $20 copay for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery.
|
$0 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye. |
$0 copay for up to 1 supplemental routine eye exam(s) every year |
If the doctor provides you services in addition to eye exams separate cost sharing of $5 to $35 may apply |
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: |
- Days 1 - 5: $200 copay per day
|
Days 6 - 90: $0 copay per day |
$0 copay for additional hospital days |
** 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. |
Outpatient Services |
$75 copay for each Medicare-covered ambulatory surgical center visit |
$150 copay for each Medicare-covered outpatient hospital facility visit |
Ambulance Services |
$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 |
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 |
** Additional Benefits ** |
Over-the-Counter Items |
The plan does not cover Over-the-Counter items. |
Transportation |
This plan does not cover supplemental routine transportation. |