2016 Medicare Advantage Plan Details | |||||||||||||
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Medicare Plan Name: | Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) | ||||||||||||
Location: | Los Angeles, California Click to see other locations | ||||||||||||
Plan ID: | H3237 - 001 - 0 Click to see other plans | ||||||||||||
Member Services: | 1-855-464-3571 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 Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) benefit details | |||||||||||||
— Medicare Plan Features — | |||||||||||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | ||||||||||||
Annual Deductible: | $0 | ||||||||||||
Health Plan Type: | MMP | ||||||||||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $0 | ||||||||||||
Additional Gap Coverage? | Yes, some additional gap coverage. | ||||||||||||
Total Number of Formulary Drugs: | 3,578 drugs | Browse the Health Net Cal MediConnect Plan (Medicare-Medicaid Plan) Formulary | |||||||||||
This plan has 3 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: | $0.00 | $0.00 | $0.00 | ||||||||||
• Number of Drugs per Tier: | 2288 | 1290 | |||||||||||
Plan's Pharmacy Search: | https://www.healthnet.com/medicare/pharmacy | ||||||||||||
Plan Offers Mail Order? | Yes | ||||||||||||
Number of Members enrolled in this plan in Los Angeles, California: | 14,474 members | ||||||||||||
Number of Members enrolled in this plan in (H3237 - 001): | 14,783 members | ||||||||||||
Plan’s Summary Star Rating: | New plan - No summary rating as of yet. | ||||||||||||
• Customer Service Rating: | New plan - not yet rated. | ||||||||||||
• Member Experience Rating: | New plan - not yet rated. | ||||||||||||
• Drug Cost Accuracy Rating: | New plan - not yet rated. | ||||||||||||
— 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 | |||||||||||||
You pay nothing | |||||||||||||
You pay nothing | |||||||||||||
In this plan you will pay nothing for services from any provider. | |||||||||||||
Please note that you will still need to pay your 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 | |||||||||||||
You may get your drugs at network retail pharmacies and mail order pharmacies. | |||||||||||||
You pay the following: | |||||||||||||
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. | |||||||||||||
You pay the following: | |||||||||||||
| |||||||||||||
Institutional care | |||||||||||||
Institution for mental disease services for individuals 65 or older: You pay nothing | |||||||||||||
Nursing home services: You pay nothing | |||||||||||||
** Important Information ** | |||||||||||||
Monthly premium, deductible, and limits on how much you pay for covered services | |||||||||||||
You pay nothing | |||||||||||||
You pay nothing | |||||||||||||
In this plan you will pay nothing for services from any provider. | |||||||||||||
Please note that you will still need to pay your 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 | |||||||||||||
Additional services | |||||||||||||
Case management: You pay nothing | |||||||||||||
Nursing Facility Resident Chiropractic Care & Foot Care: You pay nothing | |||||||||||||
Nursing Facility Resident Vision & Dental: You pay nothing | |||||||||||||
Nursing Facility Resident Acupuncture: You pay nothing | |||||||||||||
Nursing Facility Resident Hearing Exams & Hearing Aids: You pay nothing | |||||||||||||
Multipurpose Senior Services Program (MSSP): You pay nothing (there is a limit to how much our plan will pay) | |||||||||||||
Non-Emergency Medical Transportation: You pay nothing | |||||||||||||
In-Home Supportive Services (IHSS) (for up to 283 hours every month): You pay nothing | |||||||||||||
Acupuncture (Pregnant Women): You pay nothing | |||||||||||||
Transgender Services: You pay nothing | |||||||||||||
Incontinence Cream and Diapers: You pay nothing | |||||||||||||
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 | |||||||||||||
Dental services | |||||||||||||
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): You pay nothing | |||||||||||||
Preventive dental services: | |||||||||||||
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 | |||||||||||||
Durable medical equipment for use outside the home: 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 12 visit(s) every year): You pay nothing | |||||||||||||
Hearing services | |||||||||||||
Exam to diagnose and treat hearing and balance issues: You pay nothing | |||||||||||||
Hearing aid: You pay nothing | |||||||||||||
Our plan pays up to $1 510 every year for hearing aids. | |||||||||||||
Home health care | |||||||||||||
You pay nothing | |||||||||||||
Additional hours of care: You pay nothing | |||||||||||||
Personal Care Services: You pay nothing | |||||||||||||
Home Health (Community Based Adult Services enrollees): 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. | |||||||||||||
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 | |||||||||||||
Non-Medicare Occupational Therapy Service: You pay nothing | |||||||||||||
Physical therapy and speech and language therapy visit: You pay nothing | |||||||||||||
Speech & Physical Therapy Services for CBAS enrollees: 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 | |||||||||||||
You pay nothing | |||||||||||||
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 | |||||||||||||
Contact lenses: You pay nothing | |||||||||||||
Eyeglasses (frames and lenses): You pay nothing | |||||||||||||
Eyeglasses or contact lenses after cataract surgery: You pay nothing | |||||||||||||
Our plan pays up to $250 every two years 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:
| |||||||||||||
Family planning services: You pay nothing | |||||||||||||
Tobacco cessation counseling for pregnant women: You pay nothing | |||||||||||||
** Inpatient Care ** | |||||||||||||
Inpatient hospital care | |||||||||||||
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. | |||||||||||||
Institutional care | |||||||||||||
Institution for mental disease services for individuals 65 or older: You pay nothing | |||||||||||||
Nursing home services: You pay nothing | |||||||||||||
Skilled Nursing Facility (SNF) | |||||||||||||
Our plan covers an unlimited number of 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 | |||||||||||||
You may get your drugs at network retail pharmacies and mail order pharmacies. | |||||||||||||
You pay the following: | |||||||||||||
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. | |||||||||||||
You pay the following: | |||||||||||||
| |||||||||||||
** 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 12 visit(s) every year): You pay nothing | |||||||||||||
Hearing services | |||||||||||||
Exam to diagnose and treat hearing and balance issues: You pay nothing | |||||||||||||
Hearing aid: You pay nothing | |||||||||||||
Our plan pays up to $1 510 every year 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. | |||||||||||||
Institutional care | |||||||||||||
Institution for mental disease services for individuals 65 or older: You pay nothing | |||||||||||||
Nursing home services: You pay nothing |