2016 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | MMM - Original (HMO) | ||||
Location: | Canovanas, Puerto Rico Click to see other locations | ||||
Plan ID: | H4003 - 018 - 0 Click to see other plans | ||||
Member Services: | 1-866-333-5470 TTY users 1-866-333-5469 | ||||
— 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 MMM - Original (HMO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $36.00 (see Plan Premium Details below) | ||||
Annual Deductible: | no drug coverage | ||||
Health Plan Type: | Local HMO * | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,250 | ||||
Number of Members enrolled in this plan in Canovanas, Puerto Rico: | less than 10 members | ||||
Number of Members enrolled in this plan in (H4003 - 018): | 294 members | ||||
Plan’s Summary Star Rating: | 4 out of 5 Stars. | ||||
• Customer Service Rating: | 4 out of 5 Stars. | ||||
• Member Experience Rating: | 5 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 3 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 | |||||
$36.00 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: | |||||
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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 | |||||
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 | |||||
$36.00 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: | |||||
| |||||
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 | |||||
Not covered | |||||
Ambulance | |||||
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 | |||||
Dental services | |||||
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): 50% of the cost | |||||
Dental services: $5 copay for a single office visit that includes: | |||||
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 (Costs for these services may be different if received in an outpatient surgery setting) | |||||
Diagnostic radiology services (such as MRIs CT scans): $0-30 copay depending on the service | |||||
Diagnostic tests and procedures: You pay nothing | |||||
Lab services: 0-10% of the cost depending on the service | |||||
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.) | |||||
0-20% of the cost depending on the equipment | |||||
Emergency care | |||||
$50 copay | |||||
If you are admitted to the hospital within 1 day 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 | |||||
Routine foot care (for up to 1 visit(s) every year): $5 copay | |||||
Hearing services | |||||
Exam to diagnose and treat hearing and balance issues: $10 copay | |||||
Routine hearing exam (for up to 1 every year): You pay nothing | |||||
Hearing aid fitting/evaluation (for up to 1 every year): $5 copay | |||||
Hearing aid: You pay nothing | |||||
Our plan pays up to $200 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. | |||||
Outpatient group therapy visit: You pay nothing | |||||
Outpatient individual therapy visit: You pay nothing | |||||
Outpatient rehabilitation | |||||
Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): $5 copay | |||||
Occupational therapy visit: $4 copay | |||||
Physical therapy and speech and language therapy visit: $4 copay | |||||
Outpatient substance abuse | |||||
Group therapy visit: You pay nothing | |||||
Individual therapy visit: You pay nothing | |||||
Outpatient surgery | |||||
Ambulatory surgical center: $25 copay | |||||
Outpatient hospital: $0-30 copay or 0-10% of the cost depending on the service | |||||
Over-the-counter items | |||||
Please visit our website to see our list of covered over-the-counter items. | |||||
Prosthetic devices (braces, artificial limbs, etc.) | |||||
Prosthetic devices: You pay nothing | |||||
Related medical supplies: You pay nothing | |||||
Renal dialysis | |||||
0-20% of the cost depending on the service | |||||
Transportation | |||||
Not covered | |||||
Urgently needed services | |||||
You pay nothing | |||||
Vision services | |||||
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $0-5 copay depending on the service | |||||
Routine eye exam (for up to 1 every year): $10 copay | |||||
Eyeglasses (frames and lenses) (for up to 1 every year): You pay nothing | |||||
Eyeglasses or contact lenses after cataract surgery: You pay nothing | |||||
Our plan pays up to $100 every year 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:
| |||||
** Inpatient Care ** | |||||
Inpatient hospital care | |||||
Our plan covers an unlimited number of days for an inpatient hospital stay. | |||||
Your costs may vary depending on your hospital's tier (or group). | |||||
Tier 1 | |||||
Tier 2 | |||||
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 ** | |||||
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: $15 copay | |||||
Routine foot care (for up to 1 visit(s) every year): $5 copay | |||||
Hearing services | |||||
Exam to diagnose and treat hearing and balance issues: $10 copay | |||||
Routine hearing exam (for up to 1 every year): You pay nothing | |||||
Hearing aid fitting/evaluation (for up to 1 every year): $5 copay | |||||
Hearing aid: You pay nothing | |||||
Our plan pays up to $200 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. |