2015 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | IU Health Plans Medicare Select (HMO) | ||||
Location: | Bartholomew, Indiana Click to see other locations | ||||
Plan ID: | H7220 - 002 - 0 Click to see other plans | ||||
Member Services: | 1-800-455-9776 TTY users 1-800-743-3333 | ||||
— 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 IU Health Plans Medicare Select (HMO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | no drug coverage | ||||
Health Plan Type: | Local HMO * | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $4,750 | ||||
Number of Members enrolled in this plan in Bartholomew, Indiana: | less than 10 members | ||||
Number of Members enrolled in this plan in Indiana: | 769 members | ||||
Number of Members enrolled in this plan in (H7220 - 002): | 856 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 | |||||
Indiana University Health Plans - Medicare will reduce your Medicare Part B premium by up to $25. | |||||
This plan does not have a deductible. | |||||
** 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 drugs1: 20% of the cost | |||||
Other Part B drugs1: 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 | |||||
Indiana University Health Plans - Medicare will reduce your Medicare Part B premium by up to $25. | |||||
This plan does not have a deductible. | |||||
** Outpatient Care and Services ** | |||||
Acupuncture and Other Alternative Therapies | |||||
Not covered | |||||
Ambulance Services | |||||
$225 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): $20 copay | |||||
Dental Services | |||||
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): You pay nothing | |||||
Dental services: $10 copay for a single office visit that includes: | |||||
Diagnostic Tests, Lab and Radiology Services, and X-Rays | |||||
Diagnostic radiology services (such as MRIs CT scans): $125 copay | |||||
Diagnostic tests and procedures: $10 copay | |||||
Lab services: $10 copay | |||||
Outpatient x-rays: $25 copay | |||||
Therapeutic radiology services (such as radiation treatment for cancer): $25 copay | |||||
Doctor’s Office Visits | |||||
Primary care physician visit: You pay nothing | |||||
Specialist visit: $30 copay | |||||
Durable Medical Equipment (wheelchairs, oxygen, etc.) | |||||
20% of the cost | |||||
Emergency Care | |||||
$65 copay | |||||
Foot Care (podiatry services) | |||||
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $15 copay | |||||
Hearing Services | |||||
Routine hearing exam: You pay nothing | |||||
Home Health Care | |||||
You pay nothing | |||||
Mental Health Care | |||||
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. | |||||
Outpatient group therapy visit: $40 copay | |||||
Outpatient individual therapy visit: $40 copay | |||||
Outpatient Rehabilitation Services | |||||
Occupational therapy visit: $15 copay | |||||
Physical therapy and speech and language therapy visit: $15 copay | |||||
Outpatient Substance Abuse | |||||
Individual therapy visit: $25 copay | |||||
Outpatient Surgery | |||||
Ambulatory surgical center: $265 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 | |||||
You pay nothing | |||||
Transportation | |||||
Not covered | |||||
Urgently Needed Care | |||||
$50 copay | |||||
Vision Services | |||||
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing | |||||
Routine eye exam (for up to 1 every year): You pay nothing | |||||
Contact lenses (for up to 1 every two years): You pay nothing | |||||
Eyeglasses frames (for up to 1 every two years): $20 copay | |||||
Eyeglasses lenses (for up to 1 every two years): $20 copay | |||||
Eyeglasses or contact lenses after cataract surgery: You pay nothing | |||||
** 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. | |||||
** Inpatient Care ** | |||||
Inpatient Hospital Care | |||||
Our plan covers 90 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. | |||||
Outpatient Prescription Drugs | |||||
For Part B drugs such as chemotherapy drugs1: 20% of the cost | |||||
Other Part B drugs1: 20% of the cost | |||||
Our plan does not cover Part D prescription drug. | |||||
** Outpatient Care ** | |||||
Foot Care (podiatry services) | |||||
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $15 copay | |||||
Hearing Services | |||||
Routine hearing exam: You pay nothing | |||||
** Outpatient Medical Services and Supplies ** | |||||
Outpatient Substance Abuse | |||||
Individual therapy visit: $25 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. |