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2021 Medicare Advantage Plan Benefit Details for the Gateway Health Medicare Assured Ruby (HMO D-SNP) - H5932-009-0


2021 Medicare Advantage Plan Details
Medicare Plan Name:Gateway Health Medicare Assured Ruby (HMO D-SNP)
Location:Venango, Pennsylvania
Plan ID:H5932 - 009 - 0     Click to see other plans
Member Services:1-412-255-1323 TTY users 711
— Enrollment Options —
Medicare Contact Information:1-800-MEDICARE (1-800-633-4227)
TTY users 1-877-486-2048
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Call Medicare Solutions at 855-373-9484 / TTY 711

Monday ‐ Friday 8:30am — 10pm EST
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Email a copy of the Gateway Health Medicare Assured Ruby (HMO D-SNP) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 for people who qualify for both Medicare and Medicaid. (see Plan Premium Details below)
Annual Deductible:$0 for people who qualify for both Medicare and Medicaid.
Annual Initial Coverage Limit (ICL):$4,130
Health Plan Type:Local HMO
Special Needs Plan (SNP)
Eligibility Requirement:
Dual-Eligible
Additional Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:3,289 drugsBrowse the Gateway Health Medicare Assured Ruby (HMO D-SNP) Formulary
This plan has 5 drug tiers. 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:
$0.00$20.00$47.0050%25%
Number of Drugs per
  Tier:
579833641568668
Plan's Pharmacy Search:http://www.MedicareAssured.com
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in Venango, Pennsylvania:15 members
Number of Members enrolled in this plan in Pennsylvania:6,624 members
Number of Members enrolled in this plan in (H5932 - 009):6,676 members
Plan’s Summary Star Rating: 4 out of 5 Stars.
Customer Service Rating: 4 out of 5 Stars.
Member Experience Rating: 4 out of 5 Stars.
Drug Cost Accuracy Rating: 4 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
$37.50$0.00$37.50$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$9.40$18.80$28.10
Total Monthly Premium with LIS (Parts C & D):$0.00$9.40$18.80$28.10
— Plan Health Benefits —
** Base Plan **
Premium
• Health plan premium: $0
• Drug plan premium: $37.50
• 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
• Drug plan deductible: $445.00 annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $6,700 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: $0 or $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): $0 or $175 copay (authorization required)
• Outpatient x-rays: $0 or $35 copay (authorization required)
Emergency care/Urgent care
• Emergency: $0 or $90 copay per visit (always covered)
• Urgent care: $0 or $45 copay per visit (always covered)
Inpatient hospital coverage
• $0 or $275 per day for days 1 through 5
$0 per day for days 6 through 90 (authorization required)
Outpatient hospital coverage
• $0 or $200 copay per visit (authorization required)
Skilled Nursing Facility
• $0 per day for days 1 through 20
$0 or $184 per day for days 21 through 100 (authorization required)
Preventive care
• $0 copay
Ground ambulance
• $0 or $200 copay
Rehabilitation services
• Occupational therapy visit: $0 or $25 copay (authorization required)
• Physical therapy and speech and language therapy visit: $0 or $25 copay (authorization required)
Mental health services
• Inpatient hospital - psychiatric: $0 or $275 per day for days 1 through 5
$0 per day for days 6 through 90 (authorization required)
• Outpatient group therapy visit with a psychiatrist: $0 or $25 copay
• Outpatient individual therapy visit with a psychiatrist: $0 or $25 copay
• Outpatient group therapy visit: $0 or $25 copay
• Outpatient individual therapy visit: $0 or $25 copay
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): 0% or 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs): 0% or 20% coinsurance per item (authorization required)
• Diabetes supplies: $0 copay
Hearing
• Hearing exam: $0 or $25 copay
• Fitting/evaluation: $0 copay (limits apply)
• Hearing aids: $0 copay (limits apply)
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: $0 copay (limits apply, authorization required)
• Restorative services: $0 copay (limits apply, authorization required)
• Endodontics: $0 copay (limits apply, authorization required)
• Periodontics: $0 copay (limits apply, authorization required)
• Extractions: $0 copay (limits apply, authorization required)
• Prosthodontics, other oral/maxillofacial surgery, other services: $0 copay (limits apply, authorization 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: 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: $0 or $25 copay
• Routine foot care: $25 copay
Medicare Part B drugs
• Chemotherapy: 0% or 20% coinsurance (authorization required)
• Other Part B drugs: 0% or 20% coinsurance (authorization required)




Tips & Disclaimers
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  • 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.
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  • 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.
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  • 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.
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