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2015 Medicare Advantage Plan Benefit Details for the DeanCare Gold Shared Value (Cost) - H5264-005-0
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2015 Medicare Advantage Plan Details
Medicare Plan Name:DeanCare Gold Shared Value (Cost)
Location:Grant, Wisconsin     Click to see other locations
Plan ID:H5264 - 005 - 0     Click to see other plans
Member Services:1-888-422-3326 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
Email a copy of the DeanCare Gold Shared Value (Cost) benefit details
— Medicare Plan Features —
Monthly Premium:$68.00 (see Plan Premium Details below)
Annual Deductible:no drug coverage
Health Plan Type:Cost *
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$0
Number of Members enrolled in this plan in Grant, Wisconsin:179 members
Number of Members enrolled in this plan in Wisconsin:4,254 members
Number of Members enrolled in this plan in (H5264 - 005):4,288 members
Plan’s Summary Star Rating: Not Applicable.
• Customer Service Rating: Plan not required to report measure.
• Member Experience Rating: Plan not required to report measure.
• Drug Cost Accuracy Rating: Plan not required to report measure.
— 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
$68.00 per month. In addition you must keep paying your Medicare Part B premium.
This plan has deductibles for some hospital and medical services.
No. There are no limits on how much our plan will pay.
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
There is a limit to how much our plan will pay:  You pay nothing
** 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:  You pay nothing
Other Part B drugs:  You pay nothing
Our plan does not cover Part D prescription drug.
** Important Information **
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services
$68.00 per month. In addition you must keep paying your Medicare Part B premium.
This plan has deductibles for some hospital and medical services.
No. There are no limits on how much our plan will pay.
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
There is a limit to how much our plan will pay:  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):  $10 copay
Routine chiropractic visit:  $10 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
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:  $10 copay
Specialist visit:  $10 copay
Durable Medical Equipment (wheelchairs, oxygen, etc.)
You pay nothing
Emergency Care
$50 copay
If you are admitted to the hospital within 3 days 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:  $10 copay
Hearing Services
Exam to diagnose and treat hearing and balance issues:  You pay nothing
Routine hearing exam (for up to 1 every year):  You pay nothing
Hearing aid fitting/evaluation (for up to 1 every three years):  You pay nothing
Hearing aid:  You pay nothing
Our plan pays up to $500 every three years 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.
  • $200 copay per stay
    • 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
    Physical therapy and speech and language therapy visit:  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
    Not covered
    Urgently Needed Care
    $10 copay
    If you are admitted to the hospital within 3 days you do not have to pay your share of the cost for urgent care. See the "Inpatient Hospital Care" section for other costs.
    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
    Eyeglasses (frames and lenses) (for up to 1 every two years):  You pay nothing
    Eyeglasses or contact lenses after cataract surgery:  You pay nothing
    Our plan pays up to $250 every two years for 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:
    • Abdominal aortic aneurysm screening
    • Alcohol misuse counseling
    • Bone mass measurement
    • Breast cancer screening (mammogram)
    • Cardiovascular disease (behavioral therapy)
    • Cardiovascular screenings
    • Cervical and vaginal cancer screening
    • Colonoscopy
    • Colorectal cancer screenings
    • Depression screening
    • Diabetes screenings
    • Fecal occult blood test
    • Flexible sigmoidoscopy
    • HIV screening
    • Medical nutrition therapy services
    • Obesity screening and counseling
    • Prostate cancer screenings (PSA)
    • Sexually transmitted infections screening and counseling
    • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
    • Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
    • "Welcome to Medicare" preventive visit (one-time)
    • Yearly "Wellness" visit
    Any additional preventive services approved by Medicare during the contract year will be covered.
    ** Inpatient Care **
    Inpatient Hospital Care
    Our plan covers an unlimited number of days for an inpatient hospital stay.
      • $200 copay per stay
    • You pay nothing per day for days 91 and beyond
      • 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:  You pay nothing
      Other Part B drugs:  You pay nothing
      Our plan does not cover Part D prescription drug.
      ** 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:  $10 copay
      Hearing Services
      Exam to diagnose and treat hearing and balance issues:  You pay nothing
      Routine hearing exam (for up to 1 every year):  You pay nothing
      Hearing aid fitting/evaluation (for up to 1 every three years):  You pay nothing
      Hearing aid:  You pay nothing
      Our plan pays up to $500 every three years 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.




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