2016 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Optimo (PPO) | ||||
Location: | Las Piedras, Puerto Rico Click to see other locations | ||||
Plan ID: | H4005 - 001 - 0 Click to see other plans | ||||
Member Services: | 1-888-620-1919 TTY users 1-866-620-2520 | ||||
— 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 Optimo (PPO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||
Annual Rx Deductible: | no drug coverage | ||||
Health Plan Type: | Local PPO * | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $6,700 | ||||
Number of Members enrolled in this plan in Las Piedras, Puerto Rico: | less than 10 members | ||||
Number of Members enrolled in this plan in (H4005 - 001): | 874 members | ||||
Plan’s Summary Star Rating: | 3.5 out of 5 Stars. | ||||
• Customer Service Rating: | 5 out of 5 Stars. | ||||
• Member Experience Rating: | 4 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 | |||||
$0.00 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 benefits from any provider. Contact us for 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:
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Other Part B drugs1:
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Our plan does not cover Part D prescription drug. | |||||
** Important Information ** | |||||
Monthly premium, deductible, and limits on how much you pay for covered services | |||||
$0.00 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 benefits from any provider. Contact us for services that apply. | |||||
** Outpatient Care and Services ** | |||||
Acupuncture | |||||
Not covered | |||||
Ambulance | |||||
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Chiropractic care | |||||
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):
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Routine chiropractic visit (for up to 6 every year):
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Dental services | |||||
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):
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A single office visit that includes: | |||||
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Diabetes supplies and services | |||||
Diabetes monitoring supplies:
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Diabetes self-management training:
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Therapeutic shoes or inserts:
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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):
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Diagnostic tests and procedures:
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Lab services:
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Outpatient x-rays:
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Therapeutic radiology services (such as radiation treatment for cancer):
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Doctor's office visits | |||||
Primary care physician visit:
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Specialist visit:
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Durable medical equipment (wheelchairs, oxygen, etc.) | |||||
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Emergency care | |||||
$35 copay | |||||
If you are admitted to the hospital within 24 hours 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:
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Routine foot care (for up to 6 visit(s) every year):
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Hearing services | |||||
Exam to diagnose and treat hearing and balance issues:
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Routine hearing exam (for up to 1 every year):
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Hearing aid fitting/evaluation (for up to 1 every year):
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Hearing aid:
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Our plan pays up to $500 every two years for hearing aids from any provider. | |||||
Home health care | |||||
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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. | |||||
The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. | |||||
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:
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Outpatient individual therapy visit:
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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):
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Occupational therapy visit:
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Physical therapy and speech and language therapy visit:
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Outpatient substance abuse | |||||
Group therapy visit:
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Individual therapy visit:
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Outpatient surgery | |||||
Ambulatory surgical center:
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Outpatient hospital:
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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:
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Related medical supplies:
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Renal dialysis | |||||
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Transportation | |||||
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Urgently needed services | |||||
$10 copay | |||||
If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for urgently needed services. 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):
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Routine eye exam (for up to 1 every year):
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Contact lenses (for up to 1 every two years):
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Eyeglasses (frames and lenses) (for up to 1 every two years):
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Eyeglass frames (for up to 1 every two years):
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Eyeglass lenses (for up to 1 every two years):
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Eyeglasses or contact lenses after cataract surgery:
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Our plan pays up to $100 every two years for eyewear from any provider. | |||||
** 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 | |||||
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Our plan covers many preventive services including:
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** Inpatient Care ** | |||||
Inpatient hospital care | |||||
The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods. | |||||
Our plan covers an unlimited number of 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. | |||||
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Outpatient prescription drugs | |||||
For Part B drugs such as chemotherapy drugs1:
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Other Part B drugs1:
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Our plan does not cover Part D prescription drug. | |||||
** Outpatient Care ** | |||||
Diabetes supplies and services | |||||
Diabetes monitoring supplies:
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Diabetes self-management training:
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Therapeutic shoes or inserts:
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Foot care (podiatry services) | |||||
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
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Routine foot care (for up to 6 visit(s) every year):
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Hearing services | |||||
Exam to diagnose and treat hearing and balance issues:
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Routine hearing exam (for up to 1 every year):
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Hearing aid fitting/evaluation (for up to 1 every year):
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Hearing aid:
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Our plan pays up to $500 every two years for hearing aids from any provider. | |||||
** Outpatient Medical Services and Supplies ** | |||||
Outpatient substance abuse | |||||
Group therapy visit:
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Individual therapy visit:
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Prosthetic devices (braces, artificial limbs, etc.) | |||||
Prosthetic devices:
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Related medical supplies:
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** Additional Benefits ** | |||||
Inpatient mental health care | |||||
For inpatient mental health care see the "Mental Health Care" section. |