2015 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Health Alliance Medicare PPO Basic (PPO) | ||||
Location: | Saline, Illinois Click to see other locations | ||||
Plan ID: | H1417 - 011 - 0 Click to see other plans | ||||
Member Services: | 1-800-965-4022 TTY users 1-800-526-0844 | ||||
— 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 Health Alliance Medicare PPO Basic (PPO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $9.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | no drug coverage | ||||
Health Plan Type: | Local PPO * | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $6,700 | ||||
Number of Members enrolled in this plan in Saline, Illinois: | less than 10 members | ||||
Number of Members enrolled in this plan in Illinois: | less than 10 members | ||||
Number of Members enrolled in this plan in (H1417 - 011): | 32 members | ||||
Plan’s Summary Star Rating: | 4.5 out of 5 Stars. | ||||
• Customer Service Rating: | Insufficient data to rate this plan. | ||||
• 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 ** | |||||
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services | |||||
$9.00 per month. In addition you must keep paying your Medicare Part B premium. | |||||
This plan does not have a deductible. | |||||
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. | |||||
Your yearly limit(s) in this plan: | |||||
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Your limit for services received from in-network providers will count toward this limit. | |||||
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums. | |||||
No. There are no limits on how much our plan will pay. | |||||
** Doctor and Hospital Choice ** | |||||
Acupuncture and Other Alternative Therapies | |||||
Not covered | |||||
** Extra Benefits ** | |||||
Inpatient Mental Health Care | |||||
For inpatient mental health care see the "Mental Health Care" section. | |||||
Outpatient Prescription Drugs | |||||
For Part B drugs such as chemotherapy drugs:
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Other Part B drugs:
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Our plan does not cover Part D prescription drug. | |||||
** Important Information ** | |||||
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services | |||||
$9.00 per month. In addition you must keep paying your Medicare Part B premium. | |||||
This plan does not have a deductible. | |||||
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care. | |||||
Your yearly limit(s) in this plan: | |||||
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Your limit for services received from in-network providers will count toward this limit. | |||||
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Please note that you will still need to pay your monthly premiums. | |||||
No. There are no limits on how much our plan will pay. | |||||
** Outpatient Care and Services ** | |||||
Acupuncture and Other Alternative Therapies | |||||
Not covered | |||||
Ambulance Services | |||||
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Chiropractic Care | |||||
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):
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Dental Services | |||||
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):
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Preventive dental services: | |||||
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Diabetes Supplies and Services | |||||
Diabetes monitoring supplies:
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Diabetes self-management training:
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Therapeutic shoes or inserts:
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Diagnostic Tests, Lab and Radiology Services, and X-Rays | |||||
Diagnostic radiology services (such as MRIs CT scans):
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Diagnostic tests and procedures:
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Lab services:
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Outpatient x-rays:
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Therapeutic radiology services (such as radiation treatment for cancer):
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Doctor’s Office Visits | |||||
Primary care physician visit:
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Specialist visit:
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Durable Medical Equipment (wheelchairs, oxygen, etc.) | |||||
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Emergency Care | |||||
$65 copay | |||||
If you are immediately admitted to the hospital you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section for other costs. | |||||
Foot Care (podiatry services) | |||||
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
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Hearing Services | |||||
Exam to diagnose and treat hearing and balance issues:
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Routine hearing exam (for up to 1 every year):
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Home Health Care | |||||
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Mental Health Care | |||||
Inpatient visit: | |||||
Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital. | |||||
Our plan covers 90 days for an inpatient hospital stay. | |||||
Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days. | |||||
Outpatient group therapy visit:
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Outpatient individual therapy visit:
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Outpatient Rehabilitation Services | |||||
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):
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Occupational therapy visit:
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Physical therapy and speech and language therapy visit:
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Outpatient Substance Abuse | |||||
Group therapy visit:
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Individual therapy visit:
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Outpatient Surgery | |||||
Ambulatory surgical center:
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Outpatient hospital:
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Over-the-Counter Items | |||||
Not Covered | |||||
Prosthetic Devices (braces, artificial limbs, etc.) | |||||
Prosthetic devices:
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Related medical supplies:
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Renal Dialysis | |||||
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Transportation | |||||
Not covered | |||||
Urgently Needed Care | |||||
$65 copay | |||||
Vision Services | |||||
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):
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Routine eye exam (for up to 1 every year):
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Eyeglasses or contact lenses after cataract surgery:
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** Hospice ** | |||||
Hospice | |||||
You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care. | |||||
** Preventive Care ** | |||||
Preventive Care | |||||
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Our plan covers many preventive services including:
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** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
Our plan covers an unlimited number of days for an inpatient hospital stay. | |||||
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Inpatient Mental Health Care | |||||
For inpatient mental health care see the "Mental Health Care" section. | |||||
Skilled Nursing Facility (SNF) | |||||
Our plan covers up to 100 days in a SNF. | |||||
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Outpatient Prescription Drugs | |||||
For Part B drugs such as chemotherapy drugs:
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Other Part B drugs:
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Our plan does not cover Part D prescription drug. | |||||
** Outpatient Care ** | |||||
Diabetes Supplies and Services | |||||
Diabetes monitoring supplies:
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Diabetes self-management training:
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Therapeutic shoes or inserts:
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Foot Care (podiatry services) | |||||
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
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Hearing Services | |||||
Exam to diagnose and treat hearing and balance issues:
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Routine hearing exam (for up to 1 every year):
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** Outpatient Medical Services and Supplies ** | |||||
Outpatient Substance Abuse | |||||
Group therapy visit:
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Individual therapy visit:
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Prosthetic Devices (braces, artificial limbs, etc.) | |||||
Prosthetic devices:
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Related medical supplies:
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** Additional Benefits ** | |||||
Inpatient Mental Health Care | |||||
For inpatient mental health care see the "Mental Health Care" section. |