2016 Medicare Advantage Plan Details | |||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Medicare Plan Name: | GuildNet Gold Plus FIDA Plan (Medicare-Medicaid Plan) | ||||||||||||||
Location: | Nassau, New York Click to see other locations | ||||||||||||||
Plan ID: | H0811 - 001 - 0 Click to see other plans | ||||||||||||||
Member Services: | 1-800-815-0000 TTY users 1-800-662-1220 | ||||||||||||||
— 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 |
||||||||||||||
Email a copy of the GuildNet Gold Plus FIDA 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: | 3,554 drugs | Browse the GuildNet Gold Plus FIDA Plan (Medicare-Medicaid Plan) Formulary | |||||||||||||
This plan has 4 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 | $0.00 | |||||||||||
• Number of Drugs per Tier: | 2321 | 1233 | |||||||||||||
Plan's Pharmacy Search: | http://www.LighthouseGuild.org | ||||||||||||||
Plan Offers Mail Order? | Yes | ||||||||||||||
Number of Members enrolled in this plan in Nassau, New York: | 216 members | ||||||||||||||
Number of Members enrolled in this plan in (H0811 - 001): | 808 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:
| |||||||||||||||
Other Part B drugs1:
| |||||||||||||||
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 | |||||||||||||||
Case management (long term care):
| |||||||||||||||
Nursing home services:
| |||||||||||||||
** 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 home care services | |||||||||||||||
Home and community based services:
| |||||||||||||||
Personal care services:
| |||||||||||||||
Private duty nursing services:
| |||||||||||||||
Self-directed personal assistance services:
| |||||||||||||||
Additional services | |||||||||||||||
Case management:
| |||||||||||||||
Adult Day Health Care AIDS Adult Day Health Care:
| |||||||||||||||
Nutrition Wellness Counseling:
| |||||||||||||||
Assertive Community Treatment Assisted Living Program:
| |||||||||||||||
Outpatient Hospitalization Outpatient Surgery:
| |||||||||||||||
Community Integration Counseling Community Transition Services:
| |||||||||||||||
Day Treatment Continuing Day Treatment OMH Licensed CRs:
| |||||||||||||||
Substance Abuse Prog. Opioid Treatment Svcs - Substance Abuse:
| |||||||||||||||
Medication Therapy Managment:
| |||||||||||||||
Medicare Pt A and B Services as Covered by Medicaid:
| |||||||||||||||
Intensive Psychiatric Rehab. Svcs. Partial Hosp. (Medicaid):
| |||||||||||||||
Home Maintenance Services Moving Assistance:
| |||||||||||||||
Home Visits by Medical Personnel Respite Personal Emerg. Response Svcs:
| |||||||||||||||
Independent Living Skills Training and Development:
| |||||||||||||||
Peer-Delivered Services Peer Mentoring Mobile Mental Health:
| |||||||||||||||
Home and Comm. Support Services Medical Social Services:
| |||||||||||||||
Social Day Care Structured Day Program Soc. and Environmental Svcs.:
| |||||||||||||||
Outpat. MH Outpat. SA Outpat. Med. Supervised Subst. Withdrawal - SA:
| |||||||||||||||
Personalized Recovery Oriented Svcs. Pos. Behav. Interventions and Svcs:
| |||||||||||||||
Comprehensive Psychiatric Emergency Program (CPEP):
| |||||||||||||||
Crisis Intervention:
| |||||||||||||||
Residential Addiction Services:
| |||||||||||||||
Ambulance | |||||||||||||||
| |||||||||||||||
| |||||||||||||||
Chiropractic care | |||||||||||||||
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):
| |||||||||||||||
| |||||||||||||||
Dental services | |||||||||||||||
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):
| |||||||||||||||
Preventive dental services: | |||||||||||||||
| |||||||||||||||
| |||||||||||||||
| |||||||||||||||
Diabetes supplies and services | |||||||||||||||
Diabetes monitoring supplies:
| |||||||||||||||
| |||||||||||||||
Diabetes self-management training:
| |||||||||||||||
| |||||||||||||||
Therapeutic shoes or inserts:
| |||||||||||||||
| |||||||||||||||
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):
| |||||||||||||||
| |||||||||||||||
Diagnostic tests and procedures:
| |||||||||||||||
| |||||||||||||||
Lab services:
| |||||||||||||||
| |||||||||||||||
Outpatient x-rays:
| |||||||||||||||
| |||||||||||||||
Therapeutic radiology services (such as radiation treatment for cancer):
| |||||||||||||||
| |||||||||||||||
Doctor's office visits | |||||||||||||||
Primary care physician visit:
| |||||||||||||||
| |||||||||||||||
Specialist visit:
| |||||||||||||||
| |||||||||||||||
Durable medical equipment (wheelchairs, oxygen, etc.) | |||||||||||||||
| |||||||||||||||
| |||||||||||||||
Durable medical equipment for use outside the home:
| |||||||||||||||
Environmental Modifications Adaptive Devices:
| |||||||||||||||
Assistive Technology:
| |||||||||||||||
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:
| |||||||||||||||
| |||||||||||||||
Routine foot care:
| |||||||||||||||
Hearing services | |||||||||||||||
Exam to diagnose and treat hearing and balance issues:
| |||||||||||||||
Routine hearing exam:
| |||||||||||||||
Hearing aid fitting/evaluation:
| |||||||||||||||
Hearing aid:
| |||||||||||||||
Home health care | |||||||||||||||
| |||||||||||||||
| |||||||||||||||
Additional hours of care:
| |||||||||||||||
Personal Care Services:
| |||||||||||||||
Mental health care | |||||||||||||||
Inpatient visit: | |||||||||||||||
Our plan covers an unlimited number of days for an inpatient hospital stay. | |||||||||||||||
| |||||||||||||||
| |||||||||||||||
Outpatient group therapy visit:
| |||||||||||||||
| |||||||||||||||
Outpatient individual therapy visit:
| |||||||||||||||
| |||||||||||||||
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):
| |||||||||||||||
| |||||||||||||||
Respiratory care services:
| |||||||||||||||
Occupational therapy visit:
| |||||||||||||||
| |||||||||||||||
Medicaid Outpatient Rehabilitation:
| |||||||||||||||
Physical therapy and speech and language therapy visit:
| |||||||||||||||
| |||||||||||||||
Medicaid PT and SLPS:
| |||||||||||||||
Outpatient substance abuse | |||||||||||||||
Group therapy visit:
| |||||||||||||||
| |||||||||||||||
Individual therapy visit:
| |||||||||||||||
| |||||||||||||||
Outpatient surgery | |||||||||||||||
Ambulatory surgical center:
| |||||||||||||||
| |||||||||||||||
Outpatient hospital:
| |||||||||||||||
| |||||||||||||||
Freestanding birth center services:
| |||||||||||||||
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:
| |||||||||||||||
| |||||||||||||||
Related medical supplies:
| |||||||||||||||
| |||||||||||||||
Medicaid Prosthetics/Medical Supplies:
| |||||||||||||||
Renal dialysis | |||||||||||||||
| |||||||||||||||
Transportation | |||||||||||||||
| |||||||||||||||
Urgently needed services | |||||||||||||||
You pay nothing | |||||||||||||||
Vision services | |||||||||||||||
Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):
| |||||||||||||||
Routine eye exam:
| |||||||||||||||
Contact lenses:
| |||||||||||||||
Eyeglasses (frames and lenses):
| |||||||||||||||
Eyeglasses or contact lenses after cataract surgery:
| |||||||||||||||
** 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 | |||||||||||||||
| |||||||||||||||
| |||||||||||||||
Our plan covers many preventive services including:
| |||||||||||||||
Family planning services:
| |||||||||||||||
Tobacco cessation counseling for pregnant women:
| |||||||||||||||
** Inpatient Care ** | |||||||||||||||
Inpatient hospital care | |||||||||||||||
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. | |||||||||||||||
Institutional care | |||||||||||||||
Case management (long term care):
| |||||||||||||||
Nursing home services:
| |||||||||||||||
Skilled Nursing Facility (SNF) | |||||||||||||||
Our plan covers an unlimited number of days in a SNF. | |||||||||||||||
| |||||||||||||||
Outpatient prescription drugs | |||||||||||||||
For Part B drugs such as chemotherapy drugs1:
| |||||||||||||||
Other Part B drugs1:
| |||||||||||||||
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: | |||||||||||||||
| |||||||||||||||
Additional home care services | |||||||||||||||
Home and community based services:
| |||||||||||||||
Personal care services:
| |||||||||||||||
Private duty nursing services:
| |||||||||||||||
Self-directed personal assistance services:
| |||||||||||||||
** Outpatient Care ** | |||||||||||||||
Diabetes supplies and services | |||||||||||||||
Diabetes monitoring supplies:
| |||||||||||||||
| |||||||||||||||
Diabetes self-management training:
| |||||||||||||||
| |||||||||||||||
Therapeutic shoes or inserts:
| |||||||||||||||
| |||||||||||||||
Foot care (podiatry services) | |||||||||||||||
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
| |||||||||||||||
| |||||||||||||||
Routine foot care:
| |||||||||||||||
Hearing services | |||||||||||||||
Exam to diagnose and treat hearing and balance issues:
| |||||||||||||||
Routine hearing exam:
| |||||||||||||||
Hearing aid fitting/evaluation:
| |||||||||||||||
Hearing aid:
| |||||||||||||||
** Outpatient Medical Services and Supplies ** | |||||||||||||||
Outpatient substance abuse | |||||||||||||||
Group therapy visit:
| |||||||||||||||
| |||||||||||||||
Individual therapy visit:
| |||||||||||||||
| |||||||||||||||
Prosthetic devices (braces, artificial limbs, etc.) | |||||||||||||||
Prosthetic devices:
| |||||||||||||||
| |||||||||||||||
Related medical supplies:
| |||||||||||||||
| |||||||||||||||
Medicaid Prosthetics/Medical Supplies:
| |||||||||||||||
** Additional Benefits ** | |||||||||||||||
Inpatient mental health care | |||||||||||||||
For inpatient mental health care see the "Mental Health Care" section. | |||||||||||||||
Institutional care | |||||||||||||||
Case management (long term care):
| |||||||||||||||
Nursing home services:
|