2015 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Platinum Blue Choice Plan (Cost) | ||||
Location: | Stevens, Minnesota Click to see other locations | ||||
Plan ID: | H2461 - 006 - 0 Click to see other plans | ||||
Member Services: | 1-866-340-8654 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 Platinum Blue Choice Plan (Cost) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $74.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | no drug coverage | ||||
Health Plan Type: | Cost * | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,000 | ||||
Number of Members enrolled in this plan in Stevens, Minnesota: | 46 members | ||||
Number of Members enrolled in this plan in Minnesota: | 34,915 members | ||||
Number of Members enrolled in this plan in (H2461 - 006): | 35,069 members | ||||
Plan’s Summary Star Rating: | Insufficient data to rate this plan. | ||||
• Customer Service Rating: | Insufficient data to rate this plan. | ||||
• Member Experience Rating: | Insufficient data to rate this plan. | ||||
• Drug Cost Accuracy Rating: | Insufficient data to rate this plan. | ||||
— 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 | |||||
$74.00 per month. In addition you must keep paying your Medicare Part B premium. | |||||
This plan does not have a deductible. | |||||
Yes. 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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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. | |||||
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. | |||||
** 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: 20% of the cost | |||||
Other Part B drugs: 20% of the cost | |||||
Our plan does not cover Part D prescription drug. | |||||
** Important Information ** | |||||
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services | |||||
$74.00 per month. In addition you must keep paying your Medicare Part B premium. | |||||
This plan does not have a deductible. | |||||
Yes. 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: | |||||
| |||||
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. | |||||
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply. | |||||
** Outpatient Care and Services ** | |||||
Acupuncture and Other Alternative Therapies | |||||
Not covered | |||||
Ambulance Services | |||||
$25 copay | |||||
Chiropractic Care | |||||
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $15 copay | |||||
Dental Services | |||||
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): $15 copay | |||||
Diabetes Supplies and Services | |||||
Diabetes monitoring supplies: 20% of the cost | |||||
Diabetes self-management training: You pay nothing | |||||
Therapeutic shoes or inserts: 20% of the cost | |||||
Diagnostic Tests, Lab and Radiology Services, and X-Rays | |||||
Diagnostic radiology services (such as MRIs CT scans): You pay nothing | |||||
Diagnostic tests and procedures: You pay nothing | |||||
Lab services: You pay nothing | |||||
Outpatient x-rays: You pay nothing | |||||
Therapeutic radiology services (such as radiation treatment for cancer): You pay nothing | |||||
Doctor’s Office Visits | |||||
Primary care physician visit: $15 copay | |||||
Specialist visit: $15 copay | |||||
Durable Medical Equipment (wheelchairs, oxygen, etc.) | |||||
20% of the cost | |||||
Emergency Care | |||||
$50 copay | |||||
If you are admitted to the hospital within 24 hours 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: $15 copay | |||||
Hearing Services | |||||
Exam to diagnose and treat hearing and balance issues: $15 copay | |||||
Routine hearing exam (for up to 1 every year): $15 copay | |||||
Hearing aid fitting/evaluation (for up to 1 every year): $15 copay | |||||
Hearing aid: You pay nothing | |||||
Our plan pays up to $450 every year for hearing aids. | |||||
Home Health Care | |||||
You pay nothing | |||||
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: $15 copay | |||||
Outpatient individual therapy visit: $15 copay | |||||
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): $15 copay | |||||
Occupational therapy visit: $15 copay | |||||
Physical therapy and speech and language therapy visit: $15 copay | |||||
Outpatient Substance Abuse | |||||
Group therapy visit: $15 copay | |||||
Individual therapy visit: $15 copay | |||||
Outpatient Surgery | |||||
Ambulatory surgical center: $50 copay | |||||
Outpatient hospital: $50 copay | |||||
Over-the-Counter Items | |||||
Not Covered | |||||
Prosthetic Devices (braces, artificial limbs, etc.) | |||||
Prosthetic devices: 20% of the cost | |||||
Related medical supplies: 20% of the cost | |||||
Renal Dialysis | |||||
$15 copay | |||||
Transportation | |||||
Not covered | |||||
Urgently Needed Care | |||||
$25 copay | |||||
Vision Services | |||||
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-15 copay depending on the service | |||||
Routine eye exam (for up to 1 every year): You pay nothing | |||||
Contact lenses: You pay nothing | |||||
Eyeglasses (frames and lenses): You pay nothing | |||||
Eyeglasses or contact lenses after cataract surgery: 20% of the cost | |||||
Our plan pays up to $125 every year for contact lenses and eyeglasses (frames and lenses). | |||||
** 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 | |||||
You pay nothing | |||||
Our plan covers many preventive services including:
| |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
Our plan covers an unlimited number of days for an inpatient hospital stay. | |||||
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. | |||||
You pay nothing | |||||
Outpatient Prescription Drugs | |||||
For Part B drugs such as chemotherapy drugs: 20% of the cost | |||||
Other Part B drugs: 20% of the cost | |||||
Our plan does not cover Part D prescription drug. | |||||
** Outpatient Care ** | |||||
Diabetes Supplies and Services | |||||
Diabetes monitoring supplies: 20% of the cost | |||||
Diabetes self-management training: You pay nothing | |||||
Therapeutic shoes or inserts: 20% of the cost | |||||
Foot Care (podiatry services) | |||||
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $15 copay | |||||
Hearing Services | |||||
Exam to diagnose and treat hearing and balance issues: $15 copay | |||||
Routine hearing exam (for up to 1 every year): $15 copay | |||||
Hearing aid fitting/evaluation (for up to 1 every year): $15 copay | |||||
Hearing aid: You pay nothing | |||||
Our plan pays up to $450 every year for hearing aids. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Outpatient Substance Abuse | |||||
Group therapy visit: $15 copay | |||||
Individual therapy visit: $15 copay | |||||
Prosthetic Devices (braces, artificial limbs, etc.) | |||||
Prosthetic devices: 20% of the cost | |||||
Related medical supplies: 20% of the cost | |||||
** Additional Benefits ** | |||||
Inpatient Mental Health Care | |||||
For inpatient mental health care see the "Mental Health Care" section. |