2016 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | AHM Platino Plus (HMO SNP) | ||||
Location: | Culebra, Puerto Rico Click to see other locations | ||||
Plan ID: | H5774 - 024 - 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 AHM Platino Plus (HMO SNP) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 for people who qualify for both Medicare and Medicaid. (see Plan Premium Details below) | ||||
Annual Rx Deductible: | $0 for people who qualify for both Medicare and Medicaid. | ||||
Annual Rx Initial Coverage Limit (ICL): | $3,310 | ||||
Health Plan Type: | Local HMO | ||||
Special Needs Plan (SNP) Eligibility Requirement: | Dual-Eligible | ||||
Additional Rx Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||
Total Number of Formulary Drugs: | 3,036 drugs | Browse the AHM Platino Plus (HMO SNP) Formulary | |||
This plan has 5 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: | $4.00 | $13.00 | $35.00 | $50.00 | 25% |
• Number of Drugs per Tier: | 557 | 1324 | 195 | 452 | 508 |
Plan's Pharmacy Search: | http://www.sssadvantage.com | ||||
Plan Offers Mail Order? | Yes | ||||
Number of Members enrolled in this plan in Culebra, Puerto Rico: | less than 10 members | ||||
Number of Members enrolled in this plan in (H5774 - 024): | 44,210 members | ||||
Plan’s Summary Star Rating: | 3 out of 5 Stars. | ||||
• Customer Service Rating: | 5 out of 5 Stars. | ||||
• Member Experience Rating: | Insufficient data to rate this plan. | ||||
• Drug Cost Accuracy Rating: | 3 out of 5 Stars. | ||||
— Plan Premium Details — | |||||
The Monthly Premium is Split as Follows: ❔ | Total Premium | Part C Premium | Part D Basic Premium | Part D Supplemental Premium | |
$0.00 | $0.00 | $0.00 | $0.00 | ||
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 | |
Total Monthly Premium with LIS (Parts C & D): | $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 per month. | |||||
Triple S Advantage will reduce your Medicare Part B premium by up to $10. | |||||
This plan does not have a deductible. | |||||
This plan does not have a deductible for chemotherapy and other drugs administered in your doctor's office (Part B drugs). | |||||
This plan does not have a deductible for Part D prescription drugs. | |||||
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. | |||||
In this plan you may pay nothing for Medicare-covered services depending on your level of [insert State Medicaid plan name] eligibility. | |||||
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. Refer to the "Medicare & You" handbook for Medicare-covered services. For [insert State Medicaid plan name]-covered services refer to the Medicaid Coverage section in this document. Please note that you will still need to pay your monthly premiums and 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 | |||||
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 | |||||
In 2016 you will pay the following amounts for prescription drugs: Deductible Level 0 (Low Income Threshold 0 - 50%) and Level 1 (Low Income Threshold 51% - 100%) $1 for generic drugs$3 for brand drugs | |||||
You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy. | |||||
** Important Information ** | |||||
Monthly premium, deductible, and limits on how much you pay for covered services | |||||
$0 per month. | |||||
Triple S Advantage will reduce your Medicare Part B premium by up to $10. | |||||
This plan does not have a deductible. | |||||
This plan does not have a deductible for chemotherapy and other drugs administered in your doctor's office (Part B drugs). | |||||
This plan does not have a deductible for Part D prescription drugs. | |||||
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. | |||||
In this plan you may pay nothing for Medicare-covered services depending on your level of [insert State Medicaid plan name] eligibility. | |||||
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. Refer to the "Medicare & You" handbook for Medicare-covered services. For [insert State Medicaid plan name]-covered services refer to the Medicaid Coverage section in this document. Please note that you will still need to pay your monthly premiums and 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 | |||||
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): You pay nothing | |||||
Routine chiropractic visit (for up to 5 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 | |||||
Dental services: $1 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): 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 | |||||
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 | |||||
Routine foot care (for up to 4 visit(s) every year): You pay nothing | |||||
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: | |||||
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. | |||||
You pay nothing | |||||
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): 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 services | |||||
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 | |||||
Eyeglasses or contact lenses after cataract surgery: You pay nothing | |||||
** 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:
| |||||
Annual physical exam: You pay nothing | |||||
** 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. | |||||
You pay nothing | |||||
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 drugs1: You pay nothing | |||||
Other Part B drugs1: You pay nothing | |||||
In 2016 you will pay the following amounts for prescription drugs: Deductible Level 0 (Low Income Threshold 0 - 50%) and Level 1 (Low Income Threshold 51% - 100%) $1 for generic drugs$3 for brand drugs | |||||
You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy. | |||||
** 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 | |||||
Routine foot care (for up to 4 visit(s) every year): You pay nothing | |||||
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: 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. |