2018 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Presbyterian MediCare PPO Plan 1 (PPO) | ||||
Location: | DeBaca, New Mexico Click to see other locations | ||||
Plan ID: | H3206 - 003 - 0 Click to see other plans | ||||
Member Services: | 1-800-797-5343 TTY users 1-800-659-8331 | ||||
— 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 Presbyterian MediCare PPO Plan 1 (PPO) benefit details
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— Medicare Plan Features — | |||||
Monthly Premium: | $95.00 (see Plan Premium Details below) | ||||
Annual Deductible: | no drug coverage (Tier old excluded from the Deductible.) | ||||
Health Plan Type: | Local PPO * | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $6,700 | ||||
Number of Members enrolled in this plan in DeBaca, New Mexico: | less than 10 members | ||||
Number of Members enrolled in this plan in New Mexico: | 62 members | ||||
Number of Members enrolled in this plan in (H3206 - 003): | 200 members | ||||
Plan’s Summary Star Rating: | 3 out of 5 Stars. | ||||
• Customer Service Rating: | 5 out of 5 Stars. | ||||
• Member Experience Rating: | 1 out of 5 Stars. | ||||
• Drug Cost Accuracy Rating: | 4 out of 5 Stars. | ||||
— Plan Premium Details — | |||||
The Monthly Premium is Split as Follows: ❔ | Total Premium | Part C Premium | Part D Base Premium | Part D Supplemental Premium | |
$95.00 | $-99.00 | $-99.00 | $-99.00 | ||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $-99.00 | $-99.00 | $-99.00 | $-99.00 | |
Total Monthly Premium with LIS (Parts C & D): | $-198.00 | $-198.00 | $-198.00 | $-198.00 |
— Plan Health Benefits — | |||||
** Benefit Highlights ** | |||||
Health plan deductible | |||||
• $0 | |||||
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | |||||
• $10,000 In and Out-of-network $6,700 In-network | |||||
Optional supplemental benefits | |||||
• No | |||||
Other health plan deductibles? | |||||
• In-Network: No | |||||
Inpatient hospital coverage | |||||
• In-Network: $320 for days 1 through 5 $0 for days 6 through 90 | |||||
Outpatient hospital coverage | |||||
• In-Network: $80-320 per visit | |||||
Preventive care | |||||
• In-Network: $0 copay | |||||
Inpatient hospital coverage | |||||
• Out-of-Network: $500 for days 1 through 5 $0 for days 6 through 90 | |||||
Outpatient hospital coverage | |||||
• Out-of-Network: 20% per visit | |||||
Preventive care | |||||
• Out-of-Network: $35 | |||||
Doctor visits | |||||
• Primary: In-Network: $15 per visit | |||||
• Primary: Out-of-Network: $35 per visit | |||||
• Specialist: In-Network: $50 per visit | |||||
• Specialist: Out-of-Network: $60 per visit | |||||
Emergency care/Urgent care | |||||
• Emergency: $80 per visit (always covered) | |||||
• Urgent care: $15-65 per visit (always covered) | |||||
Diagnostic procedures/lab services/imaging | |||||
• Diagnostic tests and procedures: In-Network: $0 copay | |||||
• Diagnostic tests and procedures: Out-of-Network: 20% | |||||
• Lab services: In-Network: $0 copay | |||||
• Lab services: Out-of-Network: 20% | |||||
• Diagnostic radiology services (e.g., MRI): In-Network: $300 | |||||
• Diagnostic radiology services (e.g., MRI): Out-of-Network: 20% | |||||
• Outpatient x-rays: In-Network: $0 copay | |||||
• Outpatient x-rays: Out-of-Network: 20% | |||||
Transportation | |||||
• Not covered | |||||
Wellness programs (e.g., fitness, nursing hotline) | |||||
• Covered | |||||
Mental health services | |||||
• In-Network: $320 for days 1 through 5 $0 for days 6 through 90 | |||||
Skilled Nursing Facility | |||||
• In-Network: $0 for days 1 through 20 $95 for days 21 through 100 | |||||
Ambulance | |||||
• In-Network: $200 | |||||
Mental health services | |||||
• Out-of-Network: $500 for days 1 through 5 $0 for days 6 through 90 | |||||
Skilled Nursing Facility | |||||
• Out-of-Network: $0 for days 1 through 20 $150 for days 21 through 100 | |||||
Ambulance | |||||
• Out-of-Network: $200 | |||||
Mental health services | |||||
• Outpatient group therapy visit with a psychiatrist: In-Network: $40 | |||||
• Outpatient group therapy visit with a psychiatrist: Out-of-Network: 50% | |||||
• Outpatient individual therapy visit with a psychiatrist: In-Network: $40 | |||||
• Outpatient individual therapy visit with a psychiatrist: Out-of-Network: 50% | |||||
• Outpatient group therapy visit: In-Network: $40 | |||||
• Outpatient group therapy visit: Out-of-Network: 50% | |||||
• Outpatient individual therapy visit: In-Network: $40 | |||||
• Outpatient individual therapy visit: Out-of-Network: 50% | |||||
Rehabilitation services | |||||
• Occupational therapy visit: In-Network: $25 | |||||
• Occupational therapy visit: Out-of-Network: $35 | |||||
• Physical therapy and speech and language therapy visit: In-Network: $25 | |||||
• Physical therapy and speech and language therapy visit: Out-of-Network: $35 | |||||
Foot care (podiatry services) | |||||
• Foot exams and treatment: In-Network: $0 copay | |||||
• Foot exams and treatment: Out-of-Network: $60 | |||||
• Routine foot care: Not covered | |||||
Medical equipment/supplies | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen): In-Network: 20% per item | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen): Out-of-Network: 25% per item | |||||
• Prosthetics (e.g., braces, artificial limbs): In-Network: 20% per item | |||||
• Prosthetics (e.g., braces, artificial limbs): Out-of-Network: 25% per item | |||||
• Diabetes supplies: In-Network: $0-10 per item | |||||
• Diabetes supplies: Out-of-Network: 25% per item | |||||
Medicare Part B drugs | |||||
• Chemotherapy: In-Network: 0-15% | |||||
• Chemotherapy: Out-of-Network: 20% | |||||
• Other Part B drugs: In-Network: $10 or 0-15% | |||||
• Other Part B drugs: Out-of-Network: 20% | |||||
** Benefits Services ** | |||||
Hearing | |||||
• Hearing exam: In-Network: $50 | |||||
• Hearing exam: Out-of-Network: $60 | |||||
• Fitting/evaluation: Not covered | |||||
• Hearing aids - inner ear: Not covered | |||||
• Hearing aids - outer ear: Not covered | |||||
• Hearing aids - over the ear: Not covered | |||||
Preventive dental | |||||
• Oral exam: Not covered | |||||
• Cleaning: Not covered | |||||
• Fluoride treatment: Not covered | |||||
• Dental x-ray(s): Not covered | |||||
Comprehensive dental | |||||
• Non-routine services: Not covered | |||||
• Diagnostic services: Not covered | |||||
• Restorative services: Not covered | |||||
• Endodontics: Not covered | |||||
• Periodontics: Not covered | |||||
• Extractions: Not covered | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered | |||||
Vision | |||||
• Routine eye exam: In-Network: $0-50 | |||||
• Routine eye exam: Out-of-Network: $60 | |||||
• Other: Not covered | |||||
• Contact lenses: Not covered | |||||
• Eyeglasses (frames and lenses): Not covered | |||||
• Eyeglass frames: Not covered | |||||
• Eyeglass lenses: Not covered | |||||
• Upgrades: Not covered |