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2016 Medicare Advantage Plan Benefit Details for the PrimeTime Health Plan Basic - MA Only (HMO-POS) - H3664-014-0
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2016 Medicare Advantage Plan Details
Medicare Plan Name:PrimeTime Health Plan Basic - MA Only (HMO-POS)
Location:Summit, Ohio     Click to see other locations
Plan ID:H3664 - 014 - 0     Click to see other plans
Member Services:1-800-577-5084 TTY users 1-800-617-7446
— 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 PrimeTime Health Plan Basic - MA Only (HMO-POS) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 (see Plan Premium Details below)
Annual Deductible:no drug coverage
Health Plan Type:Local HMO *
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$3,400
Number of Members enrolled in this plan in Summit, Ohio:less than 10 members
Number of Members enrolled in this plan in (H3664 - 014):697 members
Plan’s Summary Star Rating: 4.5 out of 5 Stars.
• Customer Service Rating: 5 out of 5 Stars.
• Member Experience Rating: 5 out of 5 Stars.
• Drug Cost Accuracy Rating: 4 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:
  • $3 400 for services you receive from in-network providers.
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 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:
  • In-network:  20% of the cost
Other Part B drugs1:
  • In-network:  20% of the cost
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:
  • $3 400 for services you receive from in-network providers.
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 in-network benefits. Contact us for the services that apply.
** Outpatient Care and Services **
Acupuncture
Not covered
Ambulance
  • In-network:  $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):
  • In-network:  $20 copay
Dental services
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):
  • In-network:  $50 copay
Preventive dental services:
  • Cleaning:
    • In-network:  You pay nothing. You are covered for up to 2 every year.
    • Out-of-network:  You pay nothing.  There may be a limit to how often these services are covered.
  • Dental x-ray(s):
    • In-network:  You pay nothing. You are covered for up to 1 every year.
    • Out-of-network:  You pay nothing.  There may be a limit to how often these services are covered.
  • Oral exam:
    • In-network:  You pay nothing. You are covered for up to 2 every year.
    • Out-of-network:  You pay nothing.  There may be a limit to how often these services are covered.
    Our plan pays up to $125 every year for preventive dental services from an in-network provider. There is a limit to how much our plan will pay from an out-of-network provider.
    Diabetes supplies and services
    Diabetes monitoring supplies:
    • In-network:  20% of the cost
    Diabetes self-management training:
    • In-network:  You pay nothing
    Therapeutic shoes or inserts:
    • In-network:  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):
    • In-network:  $185 copay
    Diagnostic tests and procedures:
    • In-network:  $45 copay
    Lab services:
    • In-network:  $45 copay
    Outpatient x-rays:
    • In-network:  $45 copay
    Therapeutic radiology services (such as radiation treatment for cancer):
    • In-network:  20% of the cost
    Doctor's office visits
    Primary care physician visit:
    • In-network:  $35 copay
    Specialist visit:
    • In-network:  $45 copay
    Durable medical equipment (wheelchairs, oxygen, etc.)
    • In-network:  20% of the cost
    Emergency care
    $65 copay
    If you are admitted to the hospital within 23 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:
    • In-network:  $45 copay
    Hearing services
    Exam to diagnose and treat hearing and balance issues:
    • In-network:  $30 copay
    Home health care
    • In-network:  $20 copay
    Mental health care
    Inpatient visit:
    Our plan covers an unlimited number of days for an inpatient hospital stay.
    • In-network:  
      • $175 copay per day for days 1 through 10
      • You pay nothing per day for days 11 through 90
      • You pay nothing per day for days 91 and beyond
        • Outpatient group therapy visit:
        • In-network:  $35 copay
        Outpatient individual therapy visit:
        • In-network:  $35 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):
        • In-network:  You pay nothing
        Occupational therapy visit:
        • In-network:  $15 copay
        Physical therapy and speech and language therapy visit:
        • In-network:  $15 copay
        Outpatient substance abuse
        Group therapy visit:
        • In-network:  $35 copay
        Individual therapy visit:
        • In-network:  $35 copay
        Outpatient surgery
        Ambulatory surgical center:
        • In-network:  20% of the cost
        Outpatient hospital:
        • In-network:  20% of the cost
        Over-the-counter items
        Not Covered
        Prosthetic devices (braces, artificial limbs, etc.)
        Prosthetic devices:
        • In-network:  20% of the cost
        Related medical supplies:
        • In-network:  20% of the cost
        Renal dialysis
        • In-network:  You pay nothing
        Transportation
        Not covered
        Urgently needed services
        $45 copay
        If you are admitted to the hospital within 23 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):
        • In-network:  $0-50 copay depending on the service
        Routine eye exam:
        • In-network:  $35 copay. You are covered for up to 1 every year.
        Contact lenses:
        • In-network:  You pay nothing. You are covered for up to 1 every year.
        • Out-of-network:  You pay nothing.  There may be a limit to how often these services are covered.
        Eyeglasses (frames and lenses):
        • In-network:  You pay nothing. You are covered for up to 1 every year.
        • Out-of-network:  You pay nothing.  There may be a limit to how often these services are covered.
        Eyeglasses or contact lenses after cataract surgery:
        • In-network:  20% of the cost
        Our plan pays up to $70 every year for contact lenses and eyeglasses (frames and lenses) from an in-network provider. There is a limit to how much our plan will pay from an out-of-network 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
        • In-network:  You pay nothing
        Our plan covers many preventive services including:
        • Abdominal aortic aneurysm screening
        • Alcohol misuse counseling
        • Bone mass measurement
        • Breast cancer screening (mammogram)
        • Cardiovascular disease (behavioral therapy)
        • Cardiovascular screenings
        • Cervical and vaginal cancer screening
        • Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
        • Depression screening
        • Diabetes screenings
        • HIV screening
        • Medical nutrition therapy services
        • Obesity screening and counseling
        • Prostate cancer screenings (PSA)
        • Sexually transmitted infections screening and counseling
        • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
        • Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
        • "Welcome to Medicare" preventive visit (one-time)
        • Yearly "Wellness" visit
        Any additional preventive services approved by Medicare during the contract year will be covered.
        ** Inpatient Care **
        Inpatient hospital care
        Our plan covers an unlimited number of days for an inpatient hospital stay.
        • In-network:  
          • $300 copay per day for days 1 through 6
          • You pay nothing per day for days 7 through 90
          • You pay nothing per day for days 91 and beyond
            • 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.
            • In-network:  
              • $40 copay per day for days 1 through 20
              • $150 copay per day for days 21 through 39
              • You pay nothing per day for days 40 through 100
                • Outpatient prescription drugs
                For Part B drugs such as chemotherapy drugs1:
                • In-network:  20% of the cost
                Other Part B drugs1:
                • In-network:  20% of the cost
                Our plan does not cover Part D prescription drug.
                ** Outpatient Care **
                Diabetes supplies and services
                Diabetes monitoring supplies:
                • In-network:  20% of the cost
                Diabetes self-management training:
                • In-network:  You pay nothing
                Therapeutic shoes or inserts:
                • In-network:  20% of the cost
                Foot care (podiatry services)
                Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
                • In-network:  $45 copay
                Hearing services
                Exam to diagnose and treat hearing and balance issues:
                • In-network:  $30 copay
                ** Outpatient Medical Services and Supplies **
                Outpatient substance abuse
                Group therapy visit:
                • In-network:  $35 copay
                Individual therapy visit:
                • In-network:  $35 copay
                Prosthetic devices (braces, artificial limbs, etc.)
                Prosthetic devices:
                • In-network:  20% of the cost
                Related medical supplies:
                • In-network:  20% of the cost
                ** Additional Benefits **
                Inpatient mental health care
                For inpatient mental health care see the "Mental Health Care" section.




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