** Cost ** |
Monthly Premium, Deductible, and Limits on How Much You Pay for Covered Services |
$120.00 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: |
- $3 400 for services you receive from in-network providers.
|
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: 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 |
$120.00 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: |
- $3 400 for services you receive from in-network providers.
|
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 |
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): $15 copay |
Routine chiropractic visit: $15 copay |
Dental Services |
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): $20 copay |
Diabetes Supplies and Services |
Diabetes monitoring supplies: 5-25% of the cost depending on the supply |
Diabetes self-management training: You pay nothing |
Therapeutic shoes or inserts: 10% 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: $20 copay |
Specialist visit: $20 copay |
Durable Medical Equipment (wheelchairs, oxygen, etc.) |
10% of the cost |
Emergency Care |
$0-50 copay depending on the service |
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: $20 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 |
Home Health Care |
You pay nothing |
Mental Health Care |
Inpatient visit: |
Our plan covers an unlimited number of days for an inpatient hospital stay. |
|
$500 copay per stay |
You pay nothing per day for days 91 and beyond |
|
Outpatient group therapy visit: $20 copay |
Outpatient individual therapy visit: $20 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): $10 copay. Additional visits are covered but your cost may be more. |
Occupational therapy visit: $20 copay |
Physical therapy and speech and language therapy visit: $20 copay |
Outpatient Substance Abuse |
Group therapy visit: $20 copay |
Individual therapy visit: $20 copay |
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: 10% of the cost |
Related medical supplies: 10% of the cost |
Renal Dialysis |
20% of the cost |
Transportation |
Not covered |
Urgently Needed Care |
$20 copay |
Vision Services |
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-20 copay depending on the service |
Routine eye exam: $0-20 copay depending on the service |
Eyeglasses (frames and lenses): You pay nothing |
Eyeglass frames: You pay nothing |
Eyeglass lenses: You pay nothing |
Eyeglasses or contact lenses after cataract surgery: You pay nothing |
Our plan pays up to $300 every year for eyeglasses (frames and lenses) eyeglass lenses and eyeglass frames. |
** 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. |
|
$500 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 per day for days 1 through 20 |
$125 copay per day for days 21 through 100 |
|
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: 5-25% of the cost depending on the supply |
Diabetes self-management training: You pay nothing |
Therapeutic shoes or inserts: 10% of the cost |
Foot Care (podiatry services) |
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $20 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 |
** Outpatient Medical Services and Supplies ** |
Outpatient Substance Abuse |
Group therapy visit: $20 copay |
Individual therapy visit: $20 copay |
Prosthetic Devices (braces, artificial limbs, etc.) |
Prosthetic devices: 10% of the cost |
Related medical supplies: 10% of the cost |
** Additional Benefits ** |
Inpatient Mental Health Care |
For inpatient mental health care see the "Mental Health Care" section. |