2016 Medicare Advantage Plan Details | |||||||||||||||||||||||||||||
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Medicare Plan Name: | Gateway Health Medicare Assured Select (HMO) | ||||||||||||||||||||||||||||
Location: | Madison, Kentucky Click to see other locations | ||||||||||||||||||||||||||||
Plan ID: | H9190 - 021 - 0 Click to see other plans | ||||||||||||||||||||||||||||
Member Services: | 1-855-847-6380 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 |
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Email a copy of the Gateway Health Medicare Assured Select (HMO) benefit details | |||||||||||||||||||||||||||||
— Medicare Plan Features — | |||||||||||||||||||||||||||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||||||||||||||||||||||||||
Annual Rx Deductible: | $360 | ||||||||||||||||||||||||||||
Annual Rx Initial Coverage Limit (ICL): | $3,310 | ||||||||||||||||||||||||||||
Health Plan Type: | Local HMO | ||||||||||||||||||||||||||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $6,700 | ||||||||||||||||||||||||||||
Additional Rx Gap Coverage? | No additional gap coverage, only the Donut Hole Discount | ||||||||||||||||||||||||||||
Total Number of Formulary Drugs: | 3,078 drugs | Browse the Gateway Health Medicare Assured Select (HMO) 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: | $3.00 | $16.00 | $45.00 | $95.00 | 25% | ||||||||||||||||||||||||
• Number of Drugs per Tier: | 535 | 1511 | 440 | 213 | 379 | ||||||||||||||||||||||||
Plan's Pharmacy Search: | http://www.MedicareAssured.com | ||||||||||||||||||||||||||||
Plan Offers Mail Order? | Yes | ||||||||||||||||||||||||||||
Number of Members enrolled in this plan in Madison, Kentucky: | 15 members | ||||||||||||||||||||||||||||
Number of Members enrolled in this plan in Kentucky: | 672 members | ||||||||||||||||||||||||||||
Number of Members enrolled in this plan in (H9190 - 021): | 929 members | ||||||||||||||||||||||||||||
Plan’s Summary Star Rating: | Insufficient data to rate this plan. | ||||||||||||||||||||||||||||
• Customer Service Rating: | Insufficient data to rate this plan. | ||||||||||||||||||||||||||||
• 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. In addition you must keep paying your Medicare Part B premium. | |||||||||||||||||||||||||||||
This plan has deductibles for some hospital and medical services and Part D prescription drugs. | |||||||||||||||||||||||||||||
$225 per year for in-network services. | |||||||||||||||||||||||||||||
$360 per year for Part D prescription drugs except for drugs listed on Tier 1 which are excluded from the 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 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: 20% of the cost | |||||||||||||||||||||||||||||
Other Part B drugs1: 20% of the cost | |||||||||||||||||||||||||||||
After you pay your yearly deductible you pay the following until your total yearly drug costs reach $3 310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. | |||||||||||||||||||||||||||||
You may get your drugs at network retail pharmacies and mail order pharmacies. | |||||||||||||||||||||||||||||
Standard Retail Cost-Sharing
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Standard Mail Order Cost-Sharing
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If you reside in a long-term care facility you pay the same as at a retail pharmacy. | |||||||||||||||||||||||||||||
You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. | |||||||||||||||||||||||||||||
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3 310. After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 which is the end of the coverage gap. Not everyone will enter the coverage gap. | |||||||||||||||||||||||||||||
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay the greater of:
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** Important Information ** | |||||||||||||||||||||||||||||
Monthly premium, deductible, and limits on how much you pay for covered services | |||||||||||||||||||||||||||||
$0 per month. In addition you must keep paying your Medicare Part B premium. | |||||||||||||||||||||||||||||
This plan has deductibles for some hospital and medical services and Part D prescription drugs. | |||||||||||||||||||||||||||||
$225 per year for in-network services. | |||||||||||||||||||||||||||||
$360 per year for Part D prescription drugs except for drugs listed on Tier 1 which are excluded from the 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 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 | |||||||||||||||||||||||||||||
$200 copay | |||||||||||||||||||||||||||||
Chiropractic care | |||||||||||||||||||||||||||||
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): $20 copay | |||||||||||||||||||||||||||||
Dental services | |||||||||||||||||||||||||||||
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): $50 copay | |||||||||||||||||||||||||||||
Preventive dental services: | |||||||||||||||||||||||||||||
Diabetes supplies and services | |||||||||||||||||||||||||||||
Diabetes monitoring supplies: 20% of the cost | |||||||||||||||||||||||||||||
Diabetes self-management training: You pay nothing | |||||||||||||||||||||||||||||
Therapeutic shoes or inserts: 20% of the cost | |||||||||||||||||||||||||||||
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): $0-75 copay or 0-20% of the cost depending on the service | |||||||||||||||||||||||||||||
Diagnostic tests and procedures: You pay nothing | |||||||||||||||||||||||||||||
Lab services: You pay nothing | |||||||||||||||||||||||||||||
Outpatient x-rays: $75 copay | |||||||||||||||||||||||||||||
Therapeutic radiology services (such as radiation treatment for cancer): 20% of the cost | |||||||||||||||||||||||||||||
Doctor's office visits | |||||||||||||||||||||||||||||
Primary care physician visit: $10 copay | |||||||||||||||||||||||||||||
Specialist visit: $50 copay | |||||||||||||||||||||||||||||
Durable medical equipment (wheelchairs, oxygen, etc.) | |||||||||||||||||||||||||||||
15% of the cost | |||||||||||||||||||||||||||||
Emergency care | |||||||||||||||||||||||||||||
$75 copay | |||||||||||||||||||||||||||||
Foot care (podiatry services) | |||||||||||||||||||||||||||||
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $50 copay | |||||||||||||||||||||||||||||
Routine foot care: $50 copay | |||||||||||||||||||||||||||||
Hearing services | |||||||||||||||||||||||||||||
Exam to diagnose and treat hearing and balance issues: $50 copay | |||||||||||||||||||||||||||||
Routine hearing exam (for up to 1 every year): $50 copay | |||||||||||||||||||||||||||||
Hearing aid fitting/evaluation (for up to 1 every year): You pay nothing | |||||||||||||||||||||||||||||
Hearing aid: You pay nothing | |||||||||||||||||||||||||||||
Our plan pays up to $1 000 every two 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. | |||||||||||||||||||||||||||||
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: $40 copay | |||||||||||||||||||||||||||||
Outpatient individual therapy visit: $40 copay | |||||||||||||||||||||||||||||
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): 20% of the cost | |||||||||||||||||||||||||||||
Occupational therapy visit: $40 copay | |||||||||||||||||||||||||||||
Physical therapy and speech and language therapy visit: $40 copay | |||||||||||||||||||||||||||||
Outpatient substance abuse | |||||||||||||||||||||||||||||
Group therapy visit: $40 copay | |||||||||||||||||||||||||||||
Individual therapy visit: $40 copay | |||||||||||||||||||||||||||||
Outpatient surgery | |||||||||||||||||||||||||||||
Ambulatory surgical center: $200 copay | |||||||||||||||||||||||||||||
Outpatient hospital: $200-350 copay 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: 15% of the cost | |||||||||||||||||||||||||||||
Related medical supplies: 15% of the cost | |||||||||||||||||||||||||||||
Renal dialysis | |||||||||||||||||||||||||||||
20% of the cost | |||||||||||||||||||||||||||||
Transportation | |||||||||||||||||||||||||||||
Not covered | |||||||||||||||||||||||||||||
Urgently needed services | |||||||||||||||||||||||||||||
$45 copay | |||||||||||||||||||||||||||||
Vision services | |||||||||||||||||||||||||||||
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): $50 copay | |||||||||||||||||||||||||||||
Routine eye exam (for up to 1 every year): You pay nothing | |||||||||||||||||||||||||||||
Contact lenses (for up to 1 every year): You pay nothing | |||||||||||||||||||||||||||||
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 $225 every year for contact lenses and 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:
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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 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. | |||||||||||||||||||||||||||||
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 | |||||||||||||||||||||||||||||
After you pay your yearly deductible you pay the following until your total yearly drug costs reach $3 310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan. | |||||||||||||||||||||||||||||
You may get your drugs at network retail pharmacies and mail order pharmacies. | |||||||||||||||||||||||||||||
Standard Retail Cost-Sharing
| |||||||||||||||||||||||||||||
Standard Mail Order Cost-Sharing
| |||||||||||||||||||||||||||||
If you reside in a long-term care facility you pay the same as at a retail pharmacy. | |||||||||||||||||||||||||||||
You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy. | |||||||||||||||||||||||||||||
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3 310. After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 which is the end of the coverage gap. Not everyone will enter the coverage gap. | |||||||||||||||||||||||||||||
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay the greater of:
| |||||||||||||||||||||||||||||
** Outpatient Care ** | |||||||||||||||||||||||||||||
Diabetes supplies and services | |||||||||||||||||||||||||||||
Diabetes monitoring supplies: 20% of the cost | |||||||||||||||||||||||||||||
Diabetes self-management training: You pay nothing | |||||||||||||||||||||||||||||
Therapeutic shoes or inserts: 20% of the cost | |||||||||||||||||||||||||||||
Foot care (podiatry services) | |||||||||||||||||||||||||||||
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: $50 copay | |||||||||||||||||||||||||||||
Routine foot care: $50 copay | |||||||||||||||||||||||||||||
Hearing services | |||||||||||||||||||||||||||||
Exam to diagnose and treat hearing and balance issues: $50 copay | |||||||||||||||||||||||||||||
Routine hearing exam (for up to 1 every year): $50 copay | |||||||||||||||||||||||||||||
Hearing aid fitting/evaluation (for up to 1 every year): You pay nothing | |||||||||||||||||||||||||||||
Hearing aid: You pay nothing | |||||||||||||||||||||||||||||
Our plan pays up to $1 000 every two years for hearing aids. | |||||||||||||||||||||||||||||
** Outpatient Medical Services and Supplies ** | |||||||||||||||||||||||||||||
Outpatient substance abuse | |||||||||||||||||||||||||||||
Group therapy visit: $40 copay | |||||||||||||||||||||||||||||
Individual therapy visit: $40 copay | |||||||||||||||||||||||||||||
Prosthetic devices (braces, artificial limbs, etc.) | |||||||||||||||||||||||||||||
Prosthetic devices: 15% of the cost | |||||||||||||||||||||||||||||
Related medical supplies: 15% of the cost | |||||||||||||||||||||||||||||
** Additional Benefits ** | |||||||||||||||||||||||||||||
Inpatient mental health care | |||||||||||||||||||||||||||||
For inpatient mental health care see the "Mental Health Care" section. |