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2019 AARP MedicareComplete (HMO) in Falls, Texas

Medicare Advantage Plan Benefit Details in Plain Text
The following Medicare Advantage plan benefits apply to the AARP MedicareComplete (HMO) (H4527 - 038) in Falls, Texas .

This plan is administered by PHYSICIANS HEALTH CHOICE OF TEXAS, LLC.  To switch to a different Medicare Advantage plan or to change your location, click here.
Click here to see the AARP MedicareComplete (HMO) health and prescription benefit details in chart format or email and view benefits chart

Plan Premium
This plan has a $0.00 monthly premium. Although you pay no additional monthly premium, you must continue to pay your Medicare Part B premium. If you have a premium penalty, your premium will be higher. Or if you have a higher income you would be subject to the Income Related Adjustment Amount (IRMAA).

This Medicare Advantage Plan with Prescription Drug Coverage is a Local HMO plan.

Plan Membership and Plan Ratings
The AARP MedicareComplete (HMO) (H4527 - 038) currently has 2,256 members. There are 99 members enrolled in this plan in Falls, Texas.

The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 4.5 stars. The detail CMS plan carrier ratings are as follows:
  • Customer Service Rating of 5 out of 5 stars
  • Member Experience Rating of 4 out of 5 stars
  • Drug Cost Information Accuracy Rating of 5 out of 5 stars
Prescription Drug Coverage: Deductible, Cost-sharing, Formulary
This plan has a $255 deductible. However, formulary drugs on Tier 1, 2, and 3 are excluded from the $255 deductible and have first dollar coverage (or a $0 deductible). So, you are 100% responsible for the first $255 in medication costs for drugs not on the excluded tiers. After you have met the deductible, the AARP MedicareComplete (HMO) will share the costs of your medications with you (see cost-sharing below). The maximum deductible for 2019 is $415, but this plan (AARP MedicareComplete (HMO)) has a $255. There are other plans with a lower deductible or even a $0 deductible for all formulary drugs. Click here to review plans with a $0 deductible.

The following information is about the AARP MedicareComplete (HMO) formulary (or drug list). There are 3516 drugs on the AARP MedicareComplete (HMO) formulary. Click here to browse the AARP MedicareComplete (HMO) Formulary.
The Initial Coverage Phase (ICP) can be thought of as the cost-sharing phase of the plan. During this phase, you and the insurance company share your prescription costs. Once you have spent $255, your initial coverage phase will start. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The AARP MedicareComplete (HMO)’s formulary is divided into 5 tiers. Every plan can name their tiers differently, and can place medications on any tier. The cost-sharing for this plan is divided as follows:
  • Tier 1 (Preferred Generic) contains 300 drugs and has a co-payment of $3.00.
  • Tier 2 (Generic) contains 653 drugs and has a co-payment of $14.00.
  • Tier 3 (Preferred Brand) contains 869 drugs and has a co-payment of $47.00.
  • Tier 4 (Non-Preferred Drug) contains 1,072 drugs and has a co-payment of $100.00.
  • Tier 5 (Specialty Tier) contains 768 drugs and has a co-insurance of 28% of the drug cost.
Click here to browse the AARP MedicareComplete (HMO) Formulary.

The Coverage Gap, which is also known as the Donut (Doughnut) Hole is the phase of your Medicare Part D plan where you are responsible for 100% of your medication costs. Healthcare Reform mandates that the insurance carrier pay 63% of your generic drug prescription costs in the donut hole on your behalf.

The brand-name drug manufacturer will pay 70% and your plan will pay an additional 5% of the cost of your brand-name drugs purchased in the Donut Hole, for a total of 75% discount. The 70% paid by the brand-name drug manufacturer is paid on your behalf and therefore counts toward your TrOOP (or True Out-of-Pocket) costs. The portion paid by your plan, does not count toward TrOOP. Some Medicare Part D plans offer coverage during the Coverage Gap that is beyond the mandated discounts. Any drug not covered by the plan’s Gap Coverage will still receive the discounts noted above -- even if the plan has "No Gap Coverage". This plan (AARP MedicareComplete (HMO)) offers No Coverage during the Coverage Gap phase.

The AARP MedicareComplete (HMO) offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.

** Benefit Highlights **
Health plan deductible $0
Other health plan deductibles? In-Network:  No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) $4,900 In-network
Optional supplemental benefits Yes
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? In-Network:  No
Inpatient hospital coverage $295 per day for days 1 through 6
$0 per day for days 7 through 90
$0 per day for days 91 and beyond
Outpatient hospital coverage $260 per visit
Doctor visits Primary:  $0 copay
  Specialist:  $45 per visit
Preventive care $0 copay
Emergency care/Urgent care Emergency:  $90 per visit (always covered)
  Urgent care:  $30-40 per visit (always covered)
Vision Routine eye exam:  $0 copay
  Other:  Not covered
  Contact lenses:  Not covered
  Eyeglasses (frames and lenses):  Not covered
  Eyeglass frames:  Not covered
  Eyeglass lenses:  Not covered
  Upgrades:  Not covered
Mental health services Inpatient hospital - psychiatric:  $295 per day for days 1 through 5
$0 per day for days 6 through 90
  Outpatient group therapy visit with a psychiatrist:  $40
  Outpatient individual therapy visit with a psychiatrist:  $40
  Outpatient group therapy visit:  $40
  Outpatient individual therapy visit:  $40
Skilled Nursing Facility $0 per day for days 1 through 20
$160 per day for days 21 through 51
$0 per day for days 52 through 100
Rehabilitation services Occupational therapy visit:  $40
  Physical therapy and speech and language therapy visit:  $40
Ground ambulance $190
Transportation $0 copay
Foot care (podiatry services) Foot exams and treatment:  $45
  Routine foot care:  Not covered
Medical equipment/supplies Durable medical equipment (e.g., wheelchairs, oxygen):  20% per item
  Prosthetics (e.g., braces, artificial limbs):  20% per item
  Diabetes supplies:  $0 per item
Wellness programs (e.g., fitness, nursing hotline) Covered
Medicare Part B drugs Chemotherapy:  20%
  Other Part B drugs:  20%
** Benefits Services **
Diagnostic procedures/lab services/imaging Diagnostic tests and procedures:  $0 copay
  Lab services:  $0 copay
  Diagnostic radiology services (e.g., MRI):  20%
  Outpatient x-rays:  $0
Hearing Hearing exam:  $0 copay
  Fitting/evaluation:  Not covered
  Hearing aids:  $300-2,025
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
** Optional Supplemental Benefits **
Package #1 Comprehensive dental, Preventive dental
  Monthly Premium:  $39.00
  Deductible:  $100.00

Tips & Disclaimers
  • The Medicare Advantage and Medicare Part D prescription drug plan data on our site comes directly from Medicare and is subject to change.
  • Medicare has neither reviewed nor endorsed the information on our site.
  • We provide our Q1Medicare.com site for educational purposes and strive to present unbiased and accurate information. However, Q1Medicare is not intended as a substitute for your lawyer, doctor, healthcare provider, financial advisor, or pharmacist. For more information on your Medicare coverage, please be sure to seek legal, medical, pharmaceutical, or financial advice from a licensed professional or telephone Medicare at 1-800-633-4227.
  • We are an independent education, research, and technology company. We are not affiliated with any Medicare plan, plan carrier, healthcare provider, or insurance company. We are not compensated for Medicare plan enrollments. We do not sell leads or share your personal information.
  • Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. Our PDP-Compare.com and MA-Compare.com provide highlights of annual plan benefit changes.
  • The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan.
  • Limitations, copayments, and restrictions may apply.
  • We make every effort to show all available Medicare Part D or Medicare Advantage plans in your service area. However, since our data is provided by Medicare, it is possible that this may not be a complete listing of plans available in your service area. For a complete listing please contact 1-800-MEDICARE (TTY users should call 1-877-486-2048), 24 hours a day/7 days a week or consult www.medicare.gov.
  • When enrolling in a Medicare Advantage plan, you must continue to pay your Medicare Part B premium.
  • Medicare beneficiaries with higher incomes may be required to pay both a Medicare Part B and Medicare Part D Income Related Monthly Adjustment Amount (IRMAA). Read more on IRMAA.
  • Medicare Advantage plans that include prescription drug coverage (MAPDs) are considered Medicare Part D plans and members with higher incomes may be subject to the Medicare Part D Income Related Monthly Adjustment Amount (IRMAA), just as members in stand-alone Part D plans. In certain situations, you can appeal IRMAA.
  • You must be enrolled in both Medicare Part A and Part B to enroll in a Medicare Advantage plan. Members may enroll in a Medicare Advantage plan only during specific times of the year. Contact the Medicare plan for more information.
  • If you are enrolled in a Medicare plan with Part D prescription drug coverage, you may be eligible for financial Extra Help to assist with the payment of your prescription drug premiums and drug purchases. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/ 7 days a week or consult www.medicare.gov; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call, 1-800-325-0778; or your state Medicaid Office.
  • Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
  • A Medicare Advantage Private Fee-for-Service plan (PFFS) is not a Medicare supplement plan. Providers who do not contract with the plan are not required to see you except in an emergency.
  • Disclaimer for Institutional Special Needs Plan (SNP): This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.
  • Disclaimer for Dual Eligible (Medicare/Medicaid) Special Needs Plan (SNP): This plan is available to anyone who has both Medical Assistance from the State and Medicare. Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
  • Disclaimer for Chronic Condition Special Needs Plan (SNP): This plan is available to anyone with Medicare who has been diagnosed with the plan specific Chronic Condition.
  • Medicare MSA Plans combine a high deductible Medicare Advantage Plan and a trust or custodial savings account (as defined and/or approved by the IRS). The plan deposits money from Medicare into the account. You can use this money to pay for your health care costs, but only Medicare-covered expenses count toward your deductible. The amount deposited is usually less than your deductible amount, so you generally have to pay out-of-pocket before your coverage begins.
  • Medicare MSA Plans do not cover prescription drugs. If you join a Medicare MSA Plan, you can also join any separate (stand-alone) Medicare Part D prescription drug plan
  • There are additional restrictions to join an MSA plan, and enrollment is generally for a full calendar year unless you meet certain exceptions. Those who disenroll during the calendar year will owe a portion of the account deposit back to the plan. Contact the plan provider for additional information.
  • Medicare beneficiaries may enroll through the CMS Medicare Online Enrollment Center located at www.medicare.gov.
  • Medicare beneficiaries can file a complaint with the Centers for Medicare & Medicaid Services by calling 1-800-MEDICARE 24 hours a day/7 days or using the medicare.gov site. Beneficiaries can appoint a representative by submitting CMS Form-1696.