2014 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Geisinger Gold Classic Plus (HMO-POS) | ||||
Location: | Union, Pennsylvania Click to see other locations | ||||
Plan ID: | H3954 - 140 - 0 Click to see other plans | ||||
Member Services: | 1-800-498-9731 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 |
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Email a copy of the Geisinger Gold Classic Plus (HMO-POS) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $70.00 (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): | $4,300 | ||||
Number of Members enrolled in this plan in (H3954 - 140): | 40 members | ||||
Plan’s Summary Star Rating: | 4.5 out of 5 Stars. | ||||
• Customer Service Rating: | 2 out of 5 Stars. | ||||
• Member Experience Rating: | 4 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 | |||||
$70.00 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. | |||||
$4 300 out-of-pocket limit for Medicare-covered services and select Non-Medicare Supplemental services. Contact plan for details regarding Non-Medicare Supplemental services covered under this limit. | |||||
** Doctor and Hospital Choice ** | |||||
Doctor and Hospital Choice | |||||
No referral required for network doctors specialists and hospitals. | |||||
** Extra Benefits ** | |||||
Wellness/Education and Other Supplemental Benefits & Services | |||||
The plan covers the following supplemental education/wellness programs: | |||||
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Acupuncture | |||||
This plan does not cover Acupuncture and other alternative therapies. | |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. | |||||
** Important Information ** | |||||
Premium and Other Important Information | |||||
$70.00 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. | |||||
$4 300 out-of-pocket limit for Medicare-covered services and select Non-Medicare Supplemental services. Contact plan for details regarding Non-Medicare Supplemental services covered under this limit. | |||||
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. | |||||
For Medicare-covered hospital stays: | |||||
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$0 copay for additional non-Medicare-covered 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: | |||||
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Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve 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: | |||||
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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. You must consult with your plan before you select hospice. | |||||
** Outpatient Care ** | |||||
Doctor Office Visits | |||||
$10 copay for each Medicare-covered primary care doctor visit. | |||||
$25 copay for each Medicare-covered specialist visit. | |||||
Chiropractic Services | |||||
$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). | |||||
Podiatry Services | |||||
$20 copay for each Medicare-covered podiatry visit | |||||
$0 copay for up to 4 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. | |||||
$25 copay for each Medicare-covered individual therapy visit | |||||
$10 copay for each Medicare-covered group therapy visit | |||||
$25 copay for each Medicare-covered individual therapy visit with a psychiatrist | |||||
$10 copay for each Medicare-covered group therapy visit with a psychiatrist | |||||
$55 copay for Medicare-covered partial hospitalization program services | |||||
Outpatient Substance Abuse Care | |||||
Authorization rules may apply. | |||||
$25 copay for Medicare-covered individual substance abuse outpatient treatment visits | |||||
$10 copay for Medicare-covered group substance abuse outpatient treatment visits | |||||
Outpatient Services | |||||
Authorization rules may apply. | |||||
$275 copay for each Medicare-covered ambulatory surgical center visit | |||||
$275 copay for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
$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 | |||||
Worldwide coverage. | |||||
If you are admitted to the hospital within 3-day(s) for the same condition you pay $0 for the emergency room visit. | |||||
Urgently Needed Care | |||||
$25 copay for Medicare-covered urgently-needed-care visits | |||||
If you are admitted to the hospital within 3-day(s) for the same condition you pay $0 for the urgently-needed-care visit. | |||||
Outpatient Rehabilitation Services | |||||
Authorization rules may apply. | |||||
Medically necessary physical therapy occupational therapy and speech and language pathology services are covered. | |||||
$10 copay for Medicare-covered Occupational Therapy visits | |||||
$10 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. | |||||
20% of the cost for Medicare-covered durable medical equipment | |||||
Prosthetic Devices | |||||
Authorization rules may apply. | |||||
20% of the cost for Medicare-covered prosthetic devices | |||||
20% of the cost for Medicare-covered medical supplies related to prosthetics splints and other devices | |||||
Diabetes Programs and Supplies | |||||
Authorization rules may apply. | |||||
$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 | |||||
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services | |||||
Authorization rules may apply. | |||||
$5 copay for Medicare-covered lab services | |||||
$5 copay for Medicare-covered diagnostic procedures and tests | |||||
$25 copay for Medicare-covered X-rays | |||||
$25 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. | |||||
$10 copay for Medicare-covered Cardiac Rehabilitation Services | |||||
$10 copay for Medicare-covered Intensive Cardiac Rehabilitation Services | |||||
$10 copay for Medicare-covered Pulmonary Rehabilitation Services | |||||
Preventive Services | |||||
$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. | |||||
$10 copay for a supplemental annual physical exam | |||||
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. | |||||
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 | |||||
$20 copay for a supplemental visit that includes: | |||||
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$20 to $30 copay for up to 1 supplemental dental x-ray(s) every year | |||||
Hearing Services | |||||
$0 copay for: | |||||
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$0 copay for up to 1 supplemental hearing aid(s) every three years | |||||
$20 copay for Medicare-covered diagnostic hearing exams | |||||
$20 copay for up to 1 supplemental routine hearing exam(s) every year | |||||
$800 plan coverage limit for supplemental hearing aids every three years. | |||||
** Additional Benefits ** | |||||
Vision Services | |||||
$0 to $20 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye including an annual glaucoma screening for people at risk | |||||
$20 copay for up to 1 supplemental routine eye exam(s) every year | |||||
$0 copay for
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$200 plan coverage limit for supplemental eyewear every two years | |||||
Wellness/Education and Other Supplemental Benefits & Services | |||||
The plan covers the following supplemental education/wellness programs: | |||||
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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 and other alternative therapies. | |||||
Point of Service | |||||
Authorization rules may apply. | |||||
Point of Service coverage is available for the following benefits: | |||||
Medicare-covered
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Supplemental
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20% of the cost per Medicare-covered inpatient acute hospital stay. | |||||
20% of the cost per Medicare-covered Inpatient Psychiatric Hospital stay. | |||||
20% of the cost for each Medicare-covered SNF stay. | |||||
20% of the cost for Medicare-covered
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$0 copay for Medicare-covered
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$0 copay for Supplemental
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$0 copay for Supplemental
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$15 copay for Medicare-covered
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$25 copay for Medicare-covered
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$30 copay for Medicare-covered
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** 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 copay for additional non-Medicare-covered 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 | |||||
$10 copay for each Medicare-covered primary care doctor visit. | |||||
$25 copay for each Medicare-covered specialist visit. | |||||
Outpatient Services | |||||
Authorization rules may apply. | |||||
$275 copay for each Medicare-covered ambulatory surgical center visit | |||||
$275 copay for each Medicare-covered outpatient hospital facility visit | |||||
Ambulance Services | |||||
$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. | |||||
20% of the cost for Medicare-covered durable medical equipment | |||||
Diagnostic Tests, X-Rays, Lab Services, and Radiology Services | |||||
Authorization rules may apply. | |||||
$5 copay for Medicare-covered lab services | |||||
$5 copay for Medicare-covered diagnostic procedures and tests | |||||
$25 copay for Medicare-covered X-rays | |||||
$25 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 ** | |||||
Wellness/Education and Other Supplemental Benefits & Services | |||||
The plan covers the following supplemental education/wellness programs: | |||||
| |||||
Over-the-Counter Items | |||||
The plan does not cover Over-the-Counter items. |