2019 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Triple S Advantage Basic (HMO) | ||||
Location: | Toa Baja, Puerto Rico Click to see other locations | ||||
Plan ID: | H5774 - 003 - 0 Click to see other plans | ||||
Member Services: | |||||
— 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 Triple S Advantage Basic (HMO) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $0.00 | ||||
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 Toa Baja, Puerto Rico: | less than 10 members | ||||
Number of Members enrolled in this plan in (H5774 - 003): | 308 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: | 3 out of 5 Stars. |
— Plan Health Benefits — | |||||
** Benefit Highlights ** | |||||
Health plan deductible | |||||
• $0 | |||||
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | |||||
• $3,400 In-network | |||||
Optional supplemental benefits | |||||
• No | |||||
Inpatient hospital coverage | |||||
• Tier 1 $0 copay per stay Tier 2 $50 per stay | |||||
Outpatient hospital coverage | |||||
• $25 per visit | |||||
Preventive care | |||||
• $0 copay | |||||
Other health plan deductibles? | |||||
• In-Network: No | |||||
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? | |||||
• In-Network: No | |||||
Doctor visits | |||||
• Primary: $0 copay | |||||
• Specialist: $0-5 per visit | |||||
Emergency care/Urgent care | |||||
• Emergency: $50 per visit (always covered) | |||||
• Urgent care: $0 copay | |||||
Skilled Nursing Facility | |||||
• $0 copay | |||||
Ground ambulance | |||||
• $65 | |||||
Transportation | |||||
• $0 copay | |||||
Wellness programs (e.g., fitness, nursing hotline) | |||||
• Covered | |||||
Vision | |||||
• Routine eye exam: $0 copay | |||||
• Other: $0 copay | |||||
• Contact lenses: $0 copay | |||||
• Eyeglasses (frames and lenses): $0 copay | |||||
• Eyeglass frames: $0 copay | |||||
• Eyeglass lenses: $0 copay | |||||
• Upgrades: Not covered | |||||
Mental health services | |||||
• Inpatient hospital - psychiatric: $0 copay | |||||
• Outpatient group therapy visit with a psychiatrist: $5 | |||||
• Outpatient individual therapy visit with a psychiatrist: $5 | |||||
• Outpatient group therapy visit: $5 | |||||
• Outpatient individual therapy visit: $5 | |||||
Rehabilitation services | |||||
• Occupational therapy visit: $5 | |||||
• Physical therapy and speech and language therapy visit: $0 copay | |||||
Foot care (podiatry services) | |||||
• Foot exams and treatment: $0-5 | |||||
• Routine foot care: $0-5 | |||||
Medical equipment/supplies | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen): 0-20% per item | |||||
• Prosthetics (e.g., braces, artificial limbs): 0-20% per item | |||||
• Diabetes supplies: $0 copay | |||||
Medicare Part B drugs | |||||
• Chemotherapy: 20% | |||||
• Other Part B drugs: 20% | |||||
** Benefits Services ** | |||||
Diagnostic procedures/lab services/imaging | |||||
• Diagnostic tests and procedures: 0-10% | |||||
• Lab services: 0-10% | |||||
• Diagnostic radiology services (e.g., MRI): 0-10% | |||||
• Outpatient x-rays: $0 copay | |||||
Hearing | |||||
• Hearing exam: $10-20 | |||||
• Fitting/evaluation: $5-15 | |||||
• Hearing aids: $0 copay | |||||
Preventive dental | |||||
• Oral exam: $0 copay | |||||
• Cleaning: $0 copay | |||||
• Fluoride treatment: $0 copay | |||||
• Dental x-ray(s): $0 copay | |||||
Comprehensive dental | |||||
• Non-routine services: $0 copay | |||||
• Diagnostic services: $0 copay | |||||
• Restorative services: $0 copay | |||||
• Endodontics: $0 copay | |||||
• Periodontics: $0 copay | |||||
• Extractions: $0 copay | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services: $0 copay |