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2021 Medicare Advantage Plan Benefit Details for the NHC Advantage (HMO I-SNP) - H4172-001-0
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2021 Medicare Advantage Plan Details
Medicare Plan Name:NHC Advantage (HMO I-SNP)
Location:St. Charles, Missouri     Click to see other locations
Plan ID:H4172 - 001 - 0     Click to see other plans
Member Services:1-844-854-6886 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
Email a copy of the NHC Advantage (HMO I-SNP) benefit details
— Medicare Plan Features —
Monthly Premium:$30.20 (see Plan Premium Details below)
Annual Deductible:$445
Annual Initial Coverage Limit (ICL):$4,130
Health Plan Type:Local HMO
Special Needs Plan (SNP)
Eligibility Requirement:		Institutional
Additional Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:3,811 drugsBrowse the NHC Advantage (HMO I-SNP) Formulary
This plan has 1 drug tier. See cost-sharing for all pharmacies and tiers. 
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		25%    
• Number of Drugs per
  Tier:		3811
Plan's Pharmacy Search:http://www.nhcadvantageplan.com
Plan Offers Mail Order?No
Number of Members enrolled in this plan in St. Charles, Missouri:18 members
Number of Members enrolled in this plan in Missouri:35 members
Number of Members enrolled in this plan in (H4172 - 001):919 members
Plan’s Summary Star Rating: Insufficient data to rate this plan.
• Customer Service Rating: 4 out of 5 Stars.
• Member Experience Rating: Insufficient data to rate this plan.
• Drug Cost Accuracy Rating: 5 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
$30.20$0.00$30.20$0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$0.00$7.50$15.10$22.60
Total Monthly Premium with LIS (Parts C & D):$0.00$7.50$15.10$22.60
— Plan Health Benefits —
** Base Plan **
Premium
• Health plan premium: $0
• Drug plan premium: $30.20
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: Coming soon
• Other health plan deductibles: In-network: No
• Drug plan deductible: $445.00 annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $5,900 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: 20% coinsurance per visit (authorization required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: 20% coinsurance (authorization required)
• Lab services: $0 copay (authorization required)
• Diagnostic radiology services (e.g., MRI): 20% coinsurance (authorization required)
• Outpatient x-rays: 20% coinsurance (authorization required)
Emergency care/Urgent care
• Emergency: $90 copay per visit (always covered)
• Urgent care: 20% coinsurance per visit (always covered)
Inpatient hospital coverage
• Coming soon (authorization required)
Outpatient hospital coverage
• 20% coinsurance per visit (authorization required)
Skilled Nursing Facility
• $0 copay (authorization required)
Preventive care
• $0 copay
Ground ambulance
• 20% coinsurance
Rehabilitation services
• Occupational therapy visit: 20% coinsurance (authorization required)
• Physical therapy and speech and language therapy visit: 20% coinsurance (authorization required)
Mental health services
• Inpatient hospital - psychiatric: Coming soon (authorization required)
• Outpatient group therapy visit with a psychiatrist: 20% coinsurance
• Outpatient individual therapy visit with a psychiatrist: 20% coinsurance
• Outpatient group therapy visit: 20% coinsurance (authorization required)
• Outpatient individual therapy visit: 20% coinsurance (authorization required)
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: 20% coinsurance per item
Hearing
• Hearing exam: 20% coinsurance
• 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: $0 copay (limits apply)
• Cleaning: $0 copay (limits apply)
• Fluoride treatment: Not covered
• Dental x-ray(s): $0 copay (limits apply)
Comprehensive dental
• Non-routine services: Not covered
• Diagnostic services: Not covered
• Restorative services: $0 copay (limits apply, authorization required)
• Endodontics: $0 copay (limits apply, authorization required)
• Periodontics: Not covered
• Extractions: Not covered
• Prosthodontics, other oral/maxillofacial surgery, other services: $0 copay (limits apply, authorization required)
Vision
• Routine eye exam: $0 copay (limits apply)
• Other: $0 copay (limits apply)
• 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)
• Not covered
Transportation
• $0 copay (limits apply)
Foot care (podiatry services)
• Foot exams and treatment: 20% coinsurance
• Routine foot care: $0 copay (limits apply)
Medicare Part B drugs
• Chemotherapy: 20% coinsurance (authorization required)
• Other Part B drugs: 20% coinsurance (authorization required)




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