** 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 |
** Please consult with your plan about cost sharing when receiving services from out-of-network providers. |
$0 monthly plan premium* |
Some physicians providers and suppliers that are out of a plan’s network (i.e. out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare "assignment " your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare "limiting charge." If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare "limiting charge" does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to "assignment" and "limiting charges" that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.go |
$0 annual deductible.* |
$6 700 out-of-pocket limit for Medicare-covered services. However in this plan you will have no cost sharing responsibility for Medicare-covered services based on your level of Medicaid eligibility. |
$0 annual deductible.** |
$0 annual deductible.* |
Any annual service category deductible may count towards the plan level deductible if there is one. |
$6 700 out-of-pocket limit for Medicare-covered services. However in this plan you will have no cost sharing responsibility for Medicare-covered services based on your level of Medicaid eligibility. |
** Doctor and Hospital Choice ** |
Doctor and Hospital Choice |
No referral required for network doctors specialists and hospitals. |
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. |
** 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. |
Transportation |
Authorization rules may apply. |
$0 copay for up to 12 one-way trip(s) to plan approved location every year |
$0 copay for transportation. |
** 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 |
** Please consult with your plan about cost sharing when receiving services from out-of-network providers. |
$0 monthly plan premium* |
Some physicians providers and suppliers that are out of a plan’s network (i.e. out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept Medicare "assignment " your coinsurance can be based on the Medicare-approved amount plus an additional amount up to a higher Medicare "limiting charge." If you are a member of a plan that charges a copay for out-of-network physician services the higher Medicare "limiting charge" does not apply. See the publications Medicare You or Your Medicare Benefits available on www.medicare.gov for a full listing of benefits under Original Medicare as well as for explanations of the rules related to "assignment" and "limiting charges" that apply by benefit type. To find out if physicians and DME suppliers accept assignment or participate in Medicare visit www.medicare.go |
$0 annual deductible.* |
$6 700 out-of-pocket limit for Medicare-covered services. However in this plan you will have no cost sharing responsibility for Medicare-covered services based on your level of Medicaid eligibility. |
$0 annual deductible.** |
$0 annual deductible.* |
Any annual service category deductible may count towards the plan level deductible if there is one. |
$6 700 out-of-pocket limit for Medicare-covered services. However in this plan you will have no cost sharing responsibility for Medicare-covered services based on your level of Medicaid eligibility. |
Doctor and Hospital Choice |
No referral required for network doctors specialists and hospitals. |
You can go to doctors specialists and hospitals in or out of the network. It will cost more to get out of network benefits. |
** Inpatient Care ** |
Inpatient Hospital Care |
Plan covers 90 days each benefit period. |
You will not be charged additional cost sharing for professional services. |
$0 annual service category deductible* |
$0 copay* |
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 annual service category deductible* |
$0 copay* |
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital. |
Same deductible and copay as inpatient hospital care (see "Inpatient Hospital Care") |
Skilled Nursing Facility (SNF) |
Authorization rules may apply. |
Plan covers up to 100 days each benefit period |
No prior hospital stay is required. |
$0 annual service category deductible* |
$0 copay for SNF services* |
You will not be charged additional cost sharing for professional services |
Home Health Care |
Authorization rules may apply. |
$0 copay for Medicare-covered home health visits* |
$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.* |
$0 copay for each Medicare-covered specialist visit.* |
20% of the cost for each Medicare-covered primary care doctor visit** |
20% of the cost for each Medicare-covered specialist visit** |
Chiropractic Services |
$0 copay for Medicare-covered chiropractic visits* |
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. |
20% of the cost for Medicare-covered chiropractic visits.** |
Podiatry Services |
$0 copay for Medicare-covered podiatry visits* |
Medicare-covered podiatry visits are for medically-necessary foot care. |
20% of the cost for Medicare-covered podiatry visits** |
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* |
40% of the cost for Medicare-covered Mental Health visits with a psychiatrist** |
40% of the cost for Medicare-covered Mental Health visits** |
20% of the cost 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* |
40% of the cost Medicare-covered substance abuse outpatient treatment visits** |
Outpatient Services |
Authorization rules may apply. |
$0 copay for each Medicare-covered ambulatory surgical center visit* |
$0 copay for each Medicare-covered outpatient hospital facility visit* |
20% of the cost for Medicare-covered outpatient hospital facility visits** |
20% of the cost for Medicare-covered ambulatory surgical center visits** |
Ambulance Services |
$0 copay for Medicare-covered ambulance benefits.* |
20% of the cost for Medicare-covered ambulance benefits.** |
Emergency Care |
$0 annual service category deductible* |
$0 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 copay for Medicare-covered urgently-needed-care visits* |
Outpatient Rehabilitation Services |
Authorization rules may apply. |
There may be limits on physical therapy occupational therapy and speech and language pathology visits. If so there may be exceptions to these limits. |
$0 copay for Medicare-covered Occupational Therapy visits* |
$0 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits* |
20% of the cost for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits** |
20% of the cost for Medicare-covered Occupational Therapy visits.** |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
$0 annual service category deductible* |
Authorization rules may apply. |
$0 copay for Medicare-covered durable medical equipment* |
20% of the cost for Medicare-covered durable medical equipment** |
Prosthetic Devices |
Authorization rules may apply. |
$0 copay 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 copay for Medicare-covered: |
- Diabetes monitoring supplies*
|
Therapeutic shoes or inserts* |
$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** |
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services |
Authorization rules may apply. |
$0 copay for Medicare-covered: |
|
diagnostic procedures and tests* |
X-rays* |
diagnostic radiology services (not including X-rays)* |
therapeutic radiology services* |
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** |
20% of the cost for Medicare-covered diagnostic procedures tests and lab 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* |
20% of the cost for Medicare-covered Cardiac Rehabilitation Services** |
20% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services** |
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. |
The plan covers the following supplemental education/wellness programs: |
|
Additional Smoking and Tobacco Use Cessation Visits |
Nursing Hotline |
$0 copay for Medicare-covered preventive services** |
$0 copay for supplemental education/wellness programs |
Kidney Disease and Conditions |
$0 copay for Medicare-covered renal dialysis* |
$0 copay for Medicare-covered kidney disease education services* |
$0 copay for Medicare-covered kidney disease education services** |
20% of the cost for Medicare-covered renal dialysis** |
Outpatient Prescription Drugs |
$0 yearly deductible for Medicare Part B drugs.* |
$0 copay for Part B chemotherapy drugs and other Part-B drugs.* |
20% of the cost for Medicare Part B drugs out-of-network.** |
This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.careimprovementplus.com/members/formulary--medicare-drug-plan-coverage.aspx 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.
|
The plan offers national in-network prescription coverage (i.e. this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan’s service area (for instance when you travel). |
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 Care Improvement Plus Dual Advantage (Regional PPO 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
|
two-month (60-day) supply |
three-month (90-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. |
You can get drugs the following way(s): |
- one-month (30-day) supply
|
two-month (60-day) supply |
three-month (90-day) supply |
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 Care Improvement Plus Dual Advantage (Regional PPO 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 Care Improvement Plus Dual Advantage (Regional PPO 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.
|
You will be reimbursed in full for drugs purchased out-of-network. |
Dental Services |
Authorization rules may apply. |
$0 copay for Medicare-covered dental benefits* |
$0 copay for a visit that includes: |
- up to 1 oral exam(s) every year
|
up to 1 cleaning(s) every year |
up to 1 dental x-ray(s) every year |
20% of the cost for Medicare-covered comprehensive dental benefits** |
$0 copay for supplemental comprehensive dental benefits** |
$0 copay for supplemental preventive dental benefits |
Contact the plan for availability of additional in-network and out-of-network comprehensive dental benefits. |
Hearing Services |
$0 annual service category deductible for Medicare-covered diagnostic hearing exams* |
$0 copay for Medicare-covered diagnostic hearing exams* |
$0 copay for: |
$380 copay for up to 2 inner-ear hearing aid(s) every year |
$330 copay for up to 2 over-the-ear hearing aid(s) every year |
20% of the cost for Medicare-covered diagnostic hearing exams.** |
$330 to $380 copay for supplemental hearing aids. |
** Additional Benefits ** |
Vision Services |
$0 copay for Medicare-covered diagnosis and treatment for diseases and conditions of the eye* |
$0 copay for - one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery *
|
- $0 copay for up to 1 supplemental routine eye exam(s) every year
|
$0 copay for glasses |
$0 copay for contacts |
0% to 20% of the cost for Medicare-covered eye exams** |
$0 copay for supplemental eye exams** |
20% of the cost for Medicare-covered eye wear** |
$0 copay for supplemental eye wear** |
$200 plan coverage limit for eye wear every year. This limit applies to both in-network and out-of-network 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 |
Authorization rules may apply. |
$0 copay for up to 12 one-way trip(s) to plan approved location every year |
$0 copay for transportation. |
Acupuncture |
This plan does not cover Acupuncture. |
** Inpatient Care ** |
Inpatient Hospital Care |
Plan covers 90 days each benefit period. |
You will not be charged additional cost sharing for professional services. |
$0 annual service category deductible* |
$0 copay* |
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 copay for each Medicare-covered primary care doctor visit.* |
$0 copay for each Medicare-covered specialist visit.* |
20% of the cost for each Medicare-covered primary care doctor visit** |
20% of the cost for each Medicare-covered specialist visit** |
Outpatient Services |
Authorization rules may apply. |
$0 copay for each Medicare-covered ambulatory surgical center visit* |
$0 copay for each Medicare-covered outpatient hospital facility visit* |
20% of the cost for Medicare-covered outpatient hospital facility visits** |
20% of the cost for Medicare-covered ambulatory surgical center visits** |
Ambulance Services |
$0 copay for Medicare-covered ambulance benefits.* |
20% of the cost for Medicare-covered ambulance benefits.** |
** Outpatient Medical Services and Supplies ** |
Durable Medical Equipment |
$0 annual service category deductible* |
Authorization rules may apply. |
$0 copay 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 |
Authorization rules may apply. |
$0 copay for Medicare-covered: |
|
diagnostic procedures and tests* |
X-rays* |
diagnostic radiology services (not including X-rays)* |
therapeutic radiology services* |
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** |
20% of the cost for Medicare-covered diagnostic procedures tests and lab services** |
** 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 |
Authorization rules may apply. |
$0 copay for up to 12 one-way trip(s) to plan approved location every year |
$0 copay for transportation. |