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2016 Medicare Advantage Plan Benefit Details for the Advocare Essence (HMO-POS) - H5211-003-0
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:Advocare Essence (HMO-POS)
Location:Ashland, Wisconsin     Click to see other locations
Plan ID:H5211 - 003 - 0     Click to see other plans
Member Services:1-877-998-0998 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
Email a copy of the Advocare Essence (HMO-POS) benefit details
— Medicare Plan Features —
Monthly Premium:$15.00 (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 Ashland, Wisconsin:203 members
Number of Members enrolled in this plan in Wisconsin:11,065 members
Number of Members enrolled in this plan in (H5211 - 003):11,092 members
Plan’s Summary Star Rating: 4.5 out of 5 Stars.
• Customer Service Rating: 5 out of 5 Stars.
• Member Experience Rating: 4 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
$15.00 per month. In addition you must keep paying your Medicare Part B premium.
This plan has deductibles for some hospital and medical services.
$1 500 per year for out-of-network services.
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.
  • $3 500 for services you receive from out-of-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.
No. There are no limits on how much our plan will pay.
** 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 drugs:
  • In-network:  20% of the cost
  • Out-of-network:  20% of the cost after you pay your deductible
Other Part B drugs:
  • In-network:  20% of the cost
  • Out-of-network:  20% of the cost after you pay your deductible
Our plan does not cover Part D prescription drug.
** Important Information **
Monthly premium, deductible, and limits on how much you pay for covered services
$15.00 per month. In addition you must keep paying your Medicare Part B premium.
This plan has deductibles for some hospital and medical services.
$1 500 per year for out-of-network services.
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.
  • $3 500 for services you receive from out-of-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.
No. There are no limits on how much our plan will pay.
** 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
  • Out-of-network:  20% of the cost after you pay your deductible
Routine chiropractic visit:
  • In-network:  $20 copay
  • Out-of-network:  20% of the cost after you pay your deductible
Dental services
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):
  • In-network:  You pay nothing
  • Out-of-network:  20% of the cost after you pay your deductible
Diabetes supplies and services
Diabetes monitoring supplies:
  • In-network:  You pay nothing
Diabetes self-management training:
  • In-network:  $0-50 copay depending on the service
  • Out-of-network:  20% of the cost after you pay your deductible
Therapeutic shoes or inserts:
  • In-network:  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):
  • In-network:  $200 copay
  • Out-of-network:  20% of the cost after you pay your deductible
Diagnostic tests and procedures:
  • In-network:  You pay nothing
  • Out-of-network:  20% of the cost after you pay your deductible
Lab services:
  • In-network:  You pay nothing
  • Out-of-network:  20% of the cost after you pay your deductible
Outpatient x-rays:
  • In-network:  You pay nothing
  • Out-of-network:  20% of the cost after you pay your deductible
Therapeutic radiology services (such as radiation treatment for cancer):
  • In-network:  You pay nothing
  • Out-of-network:  20% of the cost after you pay your deductible
Doctor's office visits
Primary care physician visit:
  • In-network:  $20 copay
  • Out-of-network:  20% of the cost after you pay your deductible
Specialist visit:
  • In-network:  $50 copay
  • Out-of-network:  20% of the cost after you pay your deductible
Durable medical equipment (wheelchairs, oxygen, etc.)
  • In-network:  20% of the cost
  • Out-of-network:  20% of the cost after you pay your deductible
If you go to a preferred vendor your cost may be less. Contact us for a list of preferred vendors.
Emergency care
$75 copay
If you are admitted to the hospital within 24 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:  $50 copay
  • Out-of-network:  20% of the cost after you pay your deductible
Hearing services
Exam to diagnose and treat hearing and balance issues:
  • In-network:  $50 copay
  • Out-of-network:  20% of the cost after you pay your deductible
Routine hearing exam:
  • In-network:  $50 copay. You are covered for up to 1 every year.
  • Out-of-network:  20% of the cost after you pay your deductible.  There may be a limit to how often these services are covered.
Home health care
  • In-network:  You pay nothing
  • Out-of-network:  20% of the cost after you pay your deductible
Mental health care
Inpatient visit:
Our plan covers an unlimited number of days for an inpatient hospital stay.
  • In-network:  
    • $300 copay per day for days 1 through 5
    • You pay nothing per day for days 6 through 90
    • You pay nothing per day for days 91 and beyond
      • Out-of-network:  
        • $1 500 deductible for inpatient hospital and mental health care
        • 20% of the cost per stay
          • Outpatient group therapy visit:
          • In-network:  $40 copay
          • Out-of-network:  20% of the cost after you pay your deductible
          Outpatient individual therapy visit:
          • In-network:  $40 copay
          • Out-of-network:  20% of the cost after you pay your deductible
          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
          • Out-of-network:  20% of the cost after you pay your deductible
          Occupational therapy visit:
          • In-network:  $20 copay
          • Out-of-network:  20% of the cost after you pay your deductible
          Physical therapy and speech and language therapy visit:
          • In-network:  $20 copay
          • Out-of-network:  20% of the cost after you pay your deductible
          Outpatient substance abuse
          Group therapy visit:
          • In-network:  $0-50 copay depending on the service
          • Out-of-network:  20% of the cost after you pay your deductible
          Individual therapy visit:
          • In-network:  $0-50 copay depending on the service
          • Out-of-network:  20% of the cost after you pay your deductible
          Outpatient surgery
          Ambulatory surgical center:
          • In-network:  $0-150 copay depending on the service
          • Out-of-network:  20% of the cost after you pay your deductible
          Outpatient hospital:
          • In-network:  $0-400 copay depending on the service
          • Out-of-network:  20% of the cost after you pay your deductible
          Over-the-counter items
          Not Covered
          Prosthetic devices (braces, artificial limbs, etc.)
          Prosthetic devices:
          • In-network:  20% of the cost
          • Out-of-network:  20% of the cost after you pay your deductible
          Related medical supplies:
          • In-network:  0-20% of the cost depending on the supply
          • Out-of-network:  20% of the cost after you pay your deductible
          Renal dialysis
          • In-network:  You pay nothing
          • Out-of-network:  You pay nothing
          Transportation
          Not covered
          Urgently needed services
          $20-50 copay depending on the service
          Vision services
          Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):
          • In-network:  $50 copay
          • Out-of-network:  20% of the cost after you pay your deductible
          Routine eye exam:
          • In-network:  $0-50 copay depending on the service
          • Out-of-network:  0-20% of the cost depending on the service after you pay your deductible
          Eyeglasses or contact lenses after cataract surgery:
          • In-network:  You pay nothing
          • Out-of-network:  20% of the cost after you pay your deductible
          ** 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
          • Out-of-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 5
            • You pay nothing per day for days 6 through 90
            • You pay nothing per day for days 91 and beyond
              • Out-of-network:  
                • $1 500 deductible for inpatient hospital and mental health care
                • 20% of the cost per stay
                  • 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:  
                    • You pay nothing per day for days 1 through 6
                    • $40 copay per day for days 7 through 45
                    • You pay nothing per day for days 46 through 100
                      • Out-of-network:  
                        • $1 500 deductible
                        • 20% of the cost per stay
                          • Outpatient prescription drugs
                          For Part B drugs such as chemotherapy drugs:
                          • In-network:  20% of the cost
                          • Out-of-network:  20% of the cost after you pay your deductible
                          Other Part B drugs:
                          • In-network:  20% of the cost
                          • Out-of-network:  20% of the cost after you pay your deductible
                          Our plan does not cover Part D prescription drug.
                          ** Outpatient Care **
                          Diabetes supplies and services
                          Diabetes monitoring supplies:
                          • In-network:  You pay nothing
                          Diabetes self-management training:
                          • In-network:  $0-50 copay depending on the service
                          • Out-of-network:  20% of the cost after you pay your deductible
                          Therapeutic shoes or inserts:
                          • In-network:  You pay nothing
                          Foot care (podiatry services)
                          Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
                          • In-network:  $50 copay
                          • Out-of-network:  20% of the cost after you pay your deductible
                          Hearing services
                          Exam to diagnose and treat hearing and balance issues:
                          • In-network:  $50 copay
                          • Out-of-network:  20% of the cost after you pay your deductible
                          Routine hearing exam:
                          • In-network:  $50 copay. You are covered for up to 1 every year.
                          • Out-of-network:  20% of the cost after you pay your deductible.  There may be a limit to how often these services are covered.
                          ** Outpatient Medical Services and Supplies **
                          Outpatient substance abuse
                          Group therapy visit:
                          • In-network:  $0-50 copay depending on the service
                          • Out-of-network:  20% of the cost after you pay your deductible
                          Individual therapy visit:
                          • In-network:  $0-50 copay depending on the service
                          • Out-of-network:  20% of the cost after you pay your deductible
                          Prosthetic devices (braces, artificial limbs, etc.)
                          Prosthetic devices:
                          • In-network:  20% of the cost
                          • Out-of-network:  20% of the cost after you pay your deductible
                          Related medical supplies:
                          • In-network:  0-20% of the cost depending on the supply
                          • Out-of-network:  20% of the cost after you pay your deductible
                          ** Additional Benefits **
                          Inpatient mental health care
                          For inpatient mental health care see the "Mental Health Care" section.




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                          .