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2020 Medicare Advantage Plan Benefit Details for the Martin's Point Generations Advantage Value (HMO) - H5591-003-0
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2020 Medicare Advantage Plan Details
Medicare Plan Name:Martin's Point Generations Advantage Value (HMO)
Location:Sagadahoc, Maine     Click to see other locations
Plan ID:H5591 - 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
Email a copy of the Martin's Point Generations Advantage Value (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):$5,000
Number of Members enrolled in this plan in Sagadahoc, Maine:64 members
Number of Members enrolled in this plan in Maine:2,455 members
Number of Members enrolled in this plan in (H5591 - 003):2,855 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: 5 out of 5 Stars.
— Plan Health Benefits —
** Base Plan **
Premium
• Health plan premium: $0
• Drug plan premium: $0
• You must continue to pay your Part B premium.
• Part B premium reduction: $55
Deductible
• Health plan deductible: $0
• Other health plan deductibles: In-network: No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $5,000 In-network
Optional supplemental benefits
• No
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: Yes, contact plan for further details
Doctor visits
• Primary: $0 copay
• Specialist: $5 copay per visit (referral required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: 0-5% coinsurance (authorization and referral required)
• Lab services: $0-5 copay or 0-20% coinsurance (authorization and referral required)
• Diagnostic radiology services (e.g., MRI): 20% coinsurance (authorization and referral required)
• Outpatient x-rays: 5% coinsurance (authorization and referral required)
Emergency care/Urgent care
• Emergency: $90 copay per visit (always covered)
• Urgent care: $0 copay
Inpatient hospital coverage
• $300 per day for days 1 through 5
$0 per day for days 6 through 90 (authorization required)
Outpatient hospital coverage
• $0-350 copay per visit (authorization required)
Skilled Nursing Facility
• $0 per day for days 1 through 20
$178 per day for days 21 through 100 (authorization required)
Preventive care
• $0 copay
Ground ambulance
• $295 copay
Rehabilitation services
• Occupational therapy visit: $0 copay (authorization and referral required)
• Physical therapy and speech and language therapy visit: $0 copay (authorization and referral required)
Mental health services
• Inpatient hospital - psychiatric: $220 per day for days 1 through 7
$0 per day for days 8 through 90 (authorization required)
• Outpatient group therapy visit with a psychiatrist: $0 copay (authorization required)
• Outpatient individual therapy visit with a psychiatrist: $0 copay (authorization required)
• Outpatient group therapy visit: $0 copay (authorization required)
• Outpatient individual therapy visit: $0 copay (authorization required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): 10% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs): 10% coinsurance per item (authorization required)
• Diabetes supplies: $0 copay
Dialysis
• 20% coinsurance (authorization required)
Hearing
• Hearing exam: $5 copay (referral required)
• Fitting/evaluation: $0 copay (limits apply, referral required)
• Hearing aids: $0-295 copay (limits apply)
Preventive dental
• Office visit: $5.00
• Oral exam: Covered under office visit (limits apply)
• Cleaning: Covered under office visit (limits apply)
• Fluoride treatment: Not covered
• Dental x-ray(s): Covered under office visit (limits apply)
Comprehensive dental
• Non-routine services: $5 copay or 20% coinsurance (limits apply, authorization and referral required)
• Diagnostic services: $5 copay or 20% coinsurance (limits apply, authorization and referral required)
• Restorative services: $5 copay or 50% coinsurance (limits apply, authorization and referral required)
• Endodontics: $5 copay or 20% coinsurance (limits apply, authorization and referral required)
• Periodontics: $5 copay or 20% coinsurance (limits apply, authorization and referral required)
• Extractions: $5 copay or 20% coinsurance (limits apply, authorization and referral required)
• Prosthodontics, other oral/maxillofacial surgery, other services: $5 copay or 50% coinsurance (limits apply, authorization and referral required)
Vision
• Routine eye exam: $0 copay (limits apply)
• Other: Not covered
• Contact lenses: $0 copay (limits apply)
• Eyeglasses (frames and lenses): $0 copay (limits apply)
• Eyeglass frames: $0 copay (limits apply)
• Eyeglass lenses: $0 copay (limits apply)
• Upgrades: $0 copay (limits apply)
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• Not covered
Foot care (podiatry services)
• Foot exams and treatment: $5 copay (referral required)
• Routine foot care: Not covered
Medicare Part B drugs
• Chemotherapy: 20% coinsurance (authorization required)
• Other Part B drugs: 20% coinsurance (authorization required)
Medically-approved non-opioid pain management services
• Chiropractic services: Not covered
• Acupuncture: Some coverage
• Therapeutic Massage: Not covered
• Alternative Therapies: Some coverage
More benefits
• Over-the-counter drug benefits: Some coverage
• Meals for short duration: Some coverage
• Annual physical exams: Some coverage
• Telehealth: Some coverage
• WorldWide emergency transportation: Some coverage
• WorldWide emergency coverage: Some coverage
• WorldWide emergency urgent care: Some coverage
• Fitness Benefit: Some coverage
• In-Home Support Services: Not covered
• Bathroom Safety Devices: Some coverage
• Health Education: Some coverage
• In-Home Safety Assessment: Not covered
• Personal Emergency Response System (PERS): Some coverage
• Medical Nutrition Therapy (MNT): Some coverage
• Post discharge In-Home Medication Reconciliation: Not covered
• Re-admission Prevention: Not covered
• Wigs for Hair Loss Related to Chemotherapy: Some coverage
• Weight Management Programs: Some coverage
• Adult Day Health Services: Not covered
• Nutritional/Dietary Benefit: Some coverage
• Home-Based Palliative Care: Not covered
• Support for Caregivers of Enrollees: Not covered
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Some coverage
• Enhanced Disease Management: Not covered
• Telemonitoring Services: Not covered
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage
• Counseling Services: Some coverage




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