** Cost ** |
Premium and Other Important Information |
* Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services |
$0 monthly plan premium in addition to your monthly Medicare Part B premium.* |
$6 700 out-of-pocket limit for Medicare-covered services.* |
** 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 |
The plan does not cover Over-the-Counter items. |
Transportation |
Authorization rules may apply. |
$0 copay for up to 36 one-way trip(s) to plan-approved location every year |
** Important Information ** |
Premium and Other Important Information |
* Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services |
$0 monthly plan premium in addition to your monthly Medicare Part B premium.* |
$6 700 out-of-pocket limit for Medicare-covered services.* |
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 Medicare-covered hospital stays $0 or |
- Days 1 - 15: $175 copay per day*
|
Days 16 - 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. |
0% or 10% of the cost for each Medicare-covered hospital stay* |
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 Medicare-covered SNF stays $0 or |
- Days 1 - 10: $0 copay per day*
|
Days 11 - 20: $50 copay per day* |
Days 21 - 100: $120 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 |
$0 or $10 copay for each Medicare-covered primary care doctor visit.* |
$0 or $25 copay for each Medicare-covered specialist visit.* |
Chiropractic Services |
Authorization rules may apply. |
$0 or $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 |
$0 or $20 copay for each Medicare-covered podiatry visit* |
$20 copay for each supplemental routine podiatry visit |
Medicare-covered podiatry visits are for medically-necessary foot care. |
Outpatient Mental Health Care |
Authorization rules may apply. |
$0 or $20 copay for each Medicare-covered individual therapy visit* |
$0 or $20 copay for each Medicare-covered group therapy visit* |
$0 or $20 copay for each Medicare-covered individual therapy visit with a psychiatrist* |
$0 or $20 copay for each Medicare-covered group therapy visit with a psychiatrist* |
0% or 20% of the cost for Medicare-covered partial hospitalization program services* |
Outpatient Substance Abuse Care |
Authorization rules may apply. |
0% or 20% of the cost for Medicare-covered individual substance abuse outpatient treatment visits* |
0% or 20% of the cost for Medicare-covered group substance abuse outpatient treatment visits* |
Outpatient Services |
$0 or $175 copay for each Medicare-covered ambulatory surgical center visit* |
$0 or $175 copay for each Medicare-covered outpatient hospital facility visit* |
Ambulance Services |
Authorization rules may apply. |
$0 or $125 copay for Medicare-covered ambulance benefits.* |
Emergency Care |
0% or 20% of the cost (up to $65) for Medicare-covered emergency room visits* |
Not covered outside the U.S. and its territories except under limited circumstances. Contact plan for details. |
Urgently Needed Care |
$0 or $35 copay for Medicare-covered urgently-needed-care visits* |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
0% or 20% of the cost for Medicare-covered Occupational Therapy visits* |
0% or 20% of the cost 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% or 20% of the cost for Medicare-covered durable medical equipment* |
Prosthetic Devices |
Authorization rules may apply. |
0% or 20% of the cost 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 or $10 to $25 may apply* |
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
Authorization rules may apply. |
$0 copay for Medicare-covered lab services* |
$0 copay for Medicare-covered diagnostic procedures and tests* |
$0 or $20 copay for Medicare-covered X-rays* |
0% or 20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)* |
0% or 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 $0 or $10 to $25 may apply* |
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $0 or $10 to $25 may apply* |
** Preventive Services ** |
Cardiac and Pulmonary Rehabilitation Services |
Authorization rules may apply. |
0% or 20% of the cost for Medicare-covered Cardiac Rehabilitation Services* |
0% or 20% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services* |
0% or 20% of the cost 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. |
This plan does not cover supplemental education/wellness programs. |
$0 copay for Bathroom Safety Products. Contact plan for details. |
Kidney Disease and Conditions |
0% or 20% of the cost for Medicare-covered renal dialysis* |
$0 copay for Medicare-covered kidney disease education services* |
Outpatient Prescription Drugs |
$0 yearly deductible for Medicare Part B drugs.* |
0% or 20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.* |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at www.MedicareAssured.com on the web. |
Different out-of-pocket costs may apply for people who - have limited incomes
- live in long term care facilities or
- have access to Indian/Tribal/Urban (Indian Health Service) providers.
|
Your in-network prescription coverage may be limited to the plan’s service area. This means that if you travel outside the service area you may have to pay the full cost of your prescription. In certain emergencies your drugs will be covered if you get them at an out-of-network-pharmacy although you may have to pay additional charges. Contact the plan for details. |
Total yearly drug costs are the total drug costs paid by you the plan and Medicare. |
The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition. |
Some drugs have quantity limits. |
Your provider must get prior authorization from Gateway Health Plan Medicare Assured 3 (HMO SNP) for certain drugs. |
You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan’s website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov. |
If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount. |
You pay a $0 annual deductible. |
Depending on your income and institutional status you pay the following: For generic drugs (including brand drugs treated as generic) either: - A $0 copay or
- A $1.15 copay or
- A $2.65 copay
For all other drugs either: - A $0 copay or
- A $3.50 copay or
- A $6.60 copay.
|
You can get drugs the following way(s): |
- one-month (30-day) supply
|
You can get drugs the following way(s): |
- one-month (31-day) supply of generic drugs
|
31-day supply of brand drugs. |
Please note that brand drugs must be dispensed incrementally in long-term care facilities. Generic drugs may be dispensed incrementally. Contact your plan about cost-sharing billing/collection when less than a one-month supply is dispensed. |
After your yearly out-of-pocket drug costs reach $4 750 you pay a $0 copay. |
Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan’s service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy’s full charge for the drug and submit documentation to receive reimbursement from Gateway Health Plan Medicare Assured 3 (HMO SNP). |
You can get out-of-network drugs the following way: |
- one-month (30-day) supply
|
Depending on your income and institutional status you will be reimbursed by Gateway Health Plan Medicare Assured 3 (HMO SNP) up to the plan’s cost of the drug minus the following: For generic drugs purchased out-of-network (including brand drugs treated as generic) either: A $0 copay or A $1.15 copay or A $2.65 copay For all other drugs purchased out-of-network either: - A $0 copay or
- A $3.50 copay or
- A $6.60 copay.
|
After your yearly out-of-pocket drug costs reach $4 750 you will be reimbursed in full for drugs purchased out-of-network. |
Dental Services |
$0 copay for Medicare-covered dental benefits* |
$0 copay for the following preventive dental benefits: |
- up to 1 oral exam(s) every six months
|
up to 1 cleaning(s) every six months |
up to 1 dental x-ray(s) every six months |
Hearing Services |
$0 copay for Medicare-covered diagnostic hearing exams* |
$0 copay for : |
- supplemental routine hearing exams
|
fitting-evaluations for a hearing aid |
$0 copay for hearing aids. |
$1 000 plan coverage limit for hearing aids every two years. |
** 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 three months |
$0 copay for - one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery *
|
- up to 1 pair(s) of glasses every year
|
up to 1 pair(s) of contacts every year |
$150 plan coverage limit for eye wear every year. |
Over-the-Counter Items |
The plan does not cover Over-the-Counter items. |
Transportation |
Authorization rules may apply. |
$0 copay for up to 36 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 Medicare-covered hospital stays $0 or |
- Days 1 - 15: $175 copay per day*
|
Days 16 - 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 |
$0 or $10 copay for each Medicare-covered primary care doctor visit.* |
$0 or $25 copay for each Medicare-covered specialist visit.* |
Outpatient Services |
$0 or $175 copay for each Medicare-covered ambulatory surgical center visit* |
$0 or $175 copay for each Medicare-covered outpatient hospital facility visit* |
Ambulance Services |
Authorization rules may apply. |
$0 or $125 copay for Medicare-covered ambulance benefits.* |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
Authorization rules may apply. |
0% or 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 lab services* |
$0 copay for Medicare-covered diagnostic procedures and tests* |
$0 or $20 copay for Medicare-covered X-rays* |
0% or 20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)* |
0% or 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 $0 or $10 to $25 may apply* |
If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $0 or $10 to $25 may apply* |
** Additional Benefits ** |
Over-the-Counter Items |
The plan does not cover Over-the-Counter items. |
Transportation |
Authorization rules may apply. |
$0 copay for up to 36 one-way trip(s) to plan-approved location every year |