2015 Medicare Advantage Plan Details | |||||||||||||||
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Medicare Plan Name: | L.A Care Cal MediConnect Plan (Medicare-Medicaid Plan) | ||||||||||||||
Location: | Los Angeles, California Click to see other locations | ||||||||||||||
Plan ID: | H8258 - 001 - 0 Click to see other plans | ||||||||||||||
Member Services: | 1-888-522-1298 TTY users 1-888-212-4460 | ||||||||||||||
— 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 L.A Care Cal MediConnect Plan (Medicare-Medicaid Plan) benefit details | |||||||||||||||
— Medicare Plan Features — | |||||||||||||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||||||||||||
Annual Deductible: | $0 | ||||||||||||||
Health Plan Type: | Medicare-Medicaid Plan | ||||||||||||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $0 | ||||||||||||||
Additional Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||||||||||||
Total Number of Formulary Drugs: | 3,783 drugs | Browse the L.A Care Cal MediConnect Plan (Medicare-Medicaid Plan) Formulary | |||||||||||||
This plan has 4 drug tiers. See cost-sharing for all pharmacies and tiers. | |||||||||||||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 | ||||||||||
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $0.00 | $0.00 | $0.00 | $0.00 | |||||||||||
• Number of Drugs per Tier: | 2375 | 1408 | |||||||||||||
Plan's Pharmacy Search: | http://www.lacare.org | ||||||||||||||
Plan Offers Mail Order? | Yes | ||||||||||||||
Number of Members enrolled in this plan in Los Angeles, California: | 14,578 members | ||||||||||||||
Number of Members enrolled in this plan in (H8258 - 001): | 14,838 members | ||||||||||||||
Plan’s Summary Star Rating: | New plan - No summary rating as of yet. | ||||||||||||||
• Customer Service Rating: | New plan - not yet rated. | ||||||||||||||
• Member Experience Rating: | New plan - not yet rated. | ||||||||||||||
• Drug Cost Accuracy Rating: | New plan - not yet rated. | ||||||||||||||
— 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 | |||||||||||||||
You pay nothing | |||||||||||||||
You pay nothing | |||||||||||||||
No. This plan does not have any limits. | |||||||||||||||
In this plan you will pay nothing for services from any provider. | |||||||||||||||
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 cost-sharing for your Part D prescription drugs. | |||||||||||||||
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 drugs1: You pay nothing | |||||||||||||||
Other Part B drugs1: You pay nothing | |||||||||||||||
You may get your drugs at network retail pharmacies and mail order pharmacies. | |||||||||||||||
You pay the following: | |||||||||||||||
Standard Retail Cost-Sharing
| |||||||||||||||
Standard Mail Order Cost-Sharing
| |||||||||||||||
If you reside in a long-term care facility you pay the same as at a retail pharmacy. | |||||||||||||||
You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. | |||||||||||||||
You pay nothing | |||||||||||||||
Institutional Care | |||||||||||||||
Institution for mental disease services for individuals 65 or older: You pay nothing | |||||||||||||||
Nursing home services: You pay nothing | |||||||||||||||
** Important Information ** | |||||||||||||||
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services | |||||||||||||||
You pay nothing | |||||||||||||||
You pay nothing | |||||||||||||||
No. This plan does not have any limits. | |||||||||||||||
In this plan you will pay nothing for services from any provider. | |||||||||||||||
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 cost-sharing for your Part D prescription drugs. | |||||||||||||||
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 | |||||||||||||||
Additional Services | |||||||||||||||
Case management: You pay nothing | |||||||||||||||
Nursing Facility Resident Chiropractic Care & Foot Care: You pay nothing | |||||||||||||||
Nursing Facility Resident Vision & Dental: You pay nothing | |||||||||||||||
Nursing Facility Resident Acupuncture: You pay nothing | |||||||||||||||
Nursing Facility Resident Hearing Exams & Hearing Aids: You pay nothing | |||||||||||||||
Multi-Senior Services Program (MSSP): You pay nothing (there is a limit to how much our plan will pay) | |||||||||||||||
Non-Emergency Medical Transportation: You pay nothing | |||||||||||||||
In-Home Supportive Services (IHSS) (for up to 283 hours every month): You pay nothing | |||||||||||||||
Acupuncture (Pregnant Women): You pay nothing | |||||||||||||||
Transgender Services: You pay nothing | |||||||||||||||
Incontinence Cream and Diapers: You pay nothing | |||||||||||||||
Ambulance Services | |||||||||||||||
You pay nothing | |||||||||||||||
Chiropractic Care | |||||||||||||||
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): You pay nothing | |||||||||||||||
Routine chiropractic visit (for up to 12 every year): You pay nothing | |||||||||||||||
Dental Services | |||||||||||||||
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): You pay nothing | |||||||||||||||
Preventive dental services: | |||||||||||||||
Diabetes Supplies and Services | |||||||||||||||
Diabetes monitoring supplies: You pay nothing | |||||||||||||||
Diabetes self-management training: You pay nothing | |||||||||||||||
Therapeutic shoes or inserts: You pay nothing | |||||||||||||||
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: You pay nothing | |||||||||||||||
Specialist visit: You pay nothing | |||||||||||||||
Durable Medical Equipment (wheelchairs, oxygen, etc.) | |||||||||||||||
You pay nothing | |||||||||||||||
Durable medical equipment for use outside the home: You pay nothing | |||||||||||||||
Emergency Care | |||||||||||||||
You pay nothing | |||||||||||||||
Foot Care (podiatry services) | |||||||||||||||
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing | |||||||||||||||
Hearing Services | |||||||||||||||
Exam to diagnose and treat hearing and balance issues: You pay nothing | |||||||||||||||
Hearing aid: You pay nothing | |||||||||||||||
Our plan pays up to $1510 for hearing aids. | |||||||||||||||
Home Health Care | |||||||||||||||
You pay nothing | |||||||||||||||
Additional hours of care: You pay nothing | |||||||||||||||
Personal Care Services: You pay nothing | |||||||||||||||
Home Health (Community Based Adult Services enrollees): 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. | |||||||||||||||
You pay nothing | |||||||||||||||
Outpatient group therapy visit: You pay nothing | |||||||||||||||
Outpatient individual therapy visit: You pay nothing | |||||||||||||||
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): You pay nothing | |||||||||||||||
Occupational therapy visit: You pay nothing | |||||||||||||||
Non-Medicare Occupational Therapy Service: You pay nothing | |||||||||||||||
Physical therapy and speech and language therapy visit: You pay nothing | |||||||||||||||
Speech & Physical Therapy Services for CBAS enrollees: You pay nothing | |||||||||||||||
Outpatient Substance Abuse | |||||||||||||||
Group therapy visit: You pay nothing | |||||||||||||||
Individual therapy visit: You pay nothing | |||||||||||||||
Outpatient Surgery | |||||||||||||||
Ambulatory surgical center: You pay nothing | |||||||||||||||
Outpatient hospital: You pay nothing | |||||||||||||||
Over-the-Counter Items | |||||||||||||||
Not Covered | |||||||||||||||
Prosthetic Devices (braces, artificial limbs, etc.) | |||||||||||||||
Prosthetic devices: You pay nothing | |||||||||||||||
Related medical supplies: You pay nothing | |||||||||||||||
Renal Dialysis | |||||||||||||||
You pay nothing | |||||||||||||||
Transportation | |||||||||||||||
You pay nothing | |||||||||||||||
Urgently Needed Care | |||||||||||||||
You pay nothing | |||||||||||||||
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: You pay nothing | |||||||||||||||
Eyeglasses (frames and lenses): You pay nothing | |||||||||||||||
Eyeglasses or contact lenses after cataract surgery: You pay nothing | |||||||||||||||
Our plan pays up to $175 every two years 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:
| |||||||||||||||
Family planning services: You pay nothing | |||||||||||||||
Tobacco cessation counseling for pregnant women: You pay nothing | |||||||||||||||
** Inpatient Care ** | |||||||||||||||
Inpatient Hospital Care | |||||||||||||||
Our plan covers an unlimited number of days for an inpatient hospital stay. | |||||||||||||||
You pay nothing | |||||||||||||||
Inpatient Mental Health Care | |||||||||||||||
For inpatient mental health care see the "Mental Health Care" section. | |||||||||||||||
Institutional Care | |||||||||||||||
Institution for mental disease services for individuals 65 or older: You pay nothing | |||||||||||||||
Nursing home services: You pay nothing | |||||||||||||||
Skilled Nursing Facility (SNF) | |||||||||||||||
Our plan covers an unlimited number of days in a SNF. | |||||||||||||||
You pay nothing | |||||||||||||||
Outpatient Prescription Drugs | |||||||||||||||
For Part B drugs such as chemotherapy drugs1: You pay nothing | |||||||||||||||
Other Part B drugs1: You pay nothing | |||||||||||||||
You may get your drugs at network retail pharmacies and mail order pharmacies. | |||||||||||||||
You pay the following: | |||||||||||||||
Standard Retail Cost-Sharing
| |||||||||||||||
Standard Mail Order Cost-Sharing
| |||||||||||||||
If you reside in a long-term care facility you pay the same as at a retail pharmacy. | |||||||||||||||
You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. | |||||||||||||||
You pay nothing | |||||||||||||||
** Outpatient Care ** | |||||||||||||||
Diabetes Supplies and Services | |||||||||||||||
Diabetes monitoring supplies: You pay nothing | |||||||||||||||
Diabetes self-management training: You pay nothing | |||||||||||||||
Therapeutic shoes or inserts: You pay nothing | |||||||||||||||
Foot Care (podiatry services) | |||||||||||||||
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing | |||||||||||||||
Hearing Services | |||||||||||||||
Exam to diagnose and treat hearing and balance issues: You pay nothing | |||||||||||||||
Hearing aid: You pay nothing | |||||||||||||||
Our plan pays up to $1510 for hearing aids. | |||||||||||||||
** Outpatient Medical Services and Supplies ** | |||||||||||||||
Outpatient Substance Abuse | |||||||||||||||
Group therapy visit: You pay nothing | |||||||||||||||
Individual therapy visit: You pay nothing | |||||||||||||||
Prosthetic Devices (braces, artificial limbs, etc.) | |||||||||||||||
Prosthetic devices: You pay nothing | |||||||||||||||
Related medical supplies: You pay nothing | |||||||||||||||
** Additional Benefits ** | |||||||||||||||
Inpatient Mental Health Care | |||||||||||||||
For inpatient mental health care see the "Mental Health Care" section. | |||||||||||||||
Institutional Care | |||||||||||||||
Institution for mental disease services for individuals 65 or older: You pay nothing | |||||||||||||||
Nursing home services: You pay nothing |