2021 Medicare Advantage Plan Details | ||||||||
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Medicare Plan Name: | Allwell Medicare Simple (HMO) | |||||||
Location: | Kent, Texas Click to see other locations | |||||||
Plan ID: | H5294 - 014 - 0 Click to see other plans | |||||||
Member Services: | 1-844-796-6811 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 |
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Email a copy of the Allwell Medicare Simple (HMO) benefit details | ||||||||
— Medicare Plan Features — | ||||||||
Monthly Premium: | $0.00 (see Plan Premium Details below) | |||||||
Annual Rx Deductible: | no drug coverage | |||||||
Health Plan Type: | Local HMO * | |||||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,450 | |||||||
Number of Members enrolled in this plan in Kent, Texas: | less than 10 members | |||||||
Number of Members enrolled in this plan in (H5294 - 014): | 266 members | |||||||
Plan’s Summary Star Rating: | 4 out of 5 Stars. | |||||||
• Customer Service Rating: | 4 out of 5 Stars. | |||||||
• Member Experience Rating: | 5 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): | data not available |
— 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: No | |||||
Deductible | |||||
• Health plan deductible: $0 | |||||
• Other health plan deductibles: In-network: No | |||||
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | |||||
• $3,450 In-network | |||||
Optional supplemental benefits | |||||
• No | |||||
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions? | |||||
• In-network: No | |||||
Doctor visits | |||||
• Primary: $0 copay | |||||
• Specialist: $25 copay per visit | |||||
Diagnostic procedures/lab services/imaging | |||||
• Diagnostic tests and procedures: $0 copay (authorization required) | |||||
• Lab services: $0 copay (authorization required) | |||||
• Diagnostic radiology services (e.g., MRI): 20% coinsurance (authorization required) | |||||
• Outpatient x-rays: $0 copay (authorization required) | |||||
Emergency care/Urgent care | |||||
• Emergency: $120 copay per visit (always covered) | |||||
• Urgent care: $40 copay per visit (always covered) | |||||
Inpatient hospital coverage | |||||
• $225 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) | |||||
Outpatient hospital coverage | |||||
• $225 copay per visit (authorization required) | |||||
Skilled Nursing Facility | |||||
• $0 per day for days 1 through 20 $184 per day for days 21 through 100 (authorization required) | |||||
Preventive care | |||||
• $0 copay | |||||
Ground ambulance | |||||
• $250 copay | |||||
Rehabilitation services | |||||
• Occupational therapy visit: $20 copay (authorization required) | |||||
• Physical therapy and speech and language therapy visit: $20 copay (authorization required) | |||||
Mental health services | |||||
• Inpatient hospital - psychiatric: $225 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) | |||||
• Outpatient group therapy visit with a psychiatrist: $25 copay | |||||
• Outpatient individual therapy visit with a psychiatrist: $25 copay | |||||
• Outpatient group therapy visit: $25 copay | |||||
• Outpatient individual therapy visit: $25 copay | |||||
Medical equipment/supplies | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen): 20% coinsurance per item (authorization required) | |||||
• Prosthetics (e.g., braces, artificial limbs): 20% coinsurance per item (authorization required) | |||||
• Diabetes supplies: $0 copay (authorization required) | |||||
Hearing | |||||
• Hearing exam: $25 copay | |||||
• Fitting/evaluation: $0 copay (limits apply) | |||||
• Hearing aids: $0-1,350 copay (limits apply) | |||||
Preventive dental | |||||
• Oral exam: $0 copay (limits apply) | |||||
• Cleaning: $0 copay (limits apply) | |||||
• Fluoride treatment: $0 copay (limits apply) | |||||
• Dental x-ray(s): $0 copay (limits apply) | |||||
Comprehensive dental | |||||
• Non-routine services: $0 copay (limits apply) | |||||
• Diagnostic services: $0 copay (limits apply) | |||||
• Restorative services: $0 copay (limits apply) | |||||
• Endodontics: $0 copay (limits apply) | |||||
• Periodontics: $0 copay (limits apply) | |||||
• Extractions: $0 copay (limits apply) | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services: $0 copay (limits apply) | |||||
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: Not covered | |||||
• Eyeglass lenses: Not covered | |||||
• Upgrades: Not covered | |||||
Wellness programs (e.g., fitness, nursing hotline) | |||||
• Covered | |||||
Transportation | |||||
• $0 copay (limits apply) | |||||
Foot care (podiatry services) | |||||
• Foot exams and treatment: $25 copay | |||||
• Routine foot care: Not covered | |||||
Medicare Part B drugs | |||||
• Chemotherapy: 20% coinsurance (authorization required) | |||||
• Other Part B drugs: 20% coinsurance (authorization required) |