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2022 Medicare Advantage Plan Benefit Details for the PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan) - H9869-001-0
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2022 Medicare Advantage Plan Details
Medicare Plan Name:PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan)
Location:Queens, New York 11372     Click to see other locations
Plan ID:H9869 - 001 - 0     Click to see other plans
Member Services:1-855-747-5483 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 PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 (see Plan Premium Details below)
Annual Deductible:$0
Health Plan Type:MMP
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$0
Additional Gap Coverage?All Generics,
All Brands
Total Number of Formulary Drugs:3,554 drugsBrowse the PHP Care Complete FIDA-IDD Plan (Medicare-Medicaid Plan) Formulary
This plan has 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:		cost-sharing data not available.
• Number of Drugs per
  Tier:
Plan's Pharmacy Search:http://www.phpcares.org
Plan Offers Mail Order?Yes
Medicare Plan Pharmacy Numbers: BIN: 015574   PCN: ASPROD1   See BIN/PCNs for all plans
Number of Members enrolled in this plan in Queens, New York:130 members
Number of Members enrolled in this plan in (H9869 - 001):1,670 members
Plan’s Summary Star Rating: Insufficient data to rate this plan.
• Customer Service Rating: Insufficient data to rate this plan.
• Member Experience Rating: Insufficient data to rate this plan.
• Drug Cost Accuracy Rating: Insufficient data to rate this plan.
— Plan Premium Details —
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$0.00$0.00$0.00
— 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
• Drug plan deductible: No annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• Not Applicable
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 copay
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 copay (authorization required)
• Outpatient x-rays: $0 copay (authorization required)
Emergency care/Urgent care
• Emergency: $0 copay
• Urgent care: $0 copay
Inpatient hospital coverage
• $0 copay (authorization required)
Outpatient hospital coverage
• $0 copay
Skilled Nursing Facility
• $0 copay (authorization required)
Preventive care
• $0 copay
Ground ambulance
• $0 copay
Rehabilitation services
• Occupational therapy visit: $0 copay (authorization required)
• Physical therapy and speech and language therapy visit: $0 copay (authorization required)
Mental health services
• Inpatient hospital - psychiatric: $0 copay (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
• Outpatient individual therapy visit: $0 copay
Opioid treatment program services
• In-network: 0% coinsurance or $0 copay
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): $0 copay (authorization required)
• Prosthetics (e.g., braces, artificial limbs): $0 copay (authorization required)
• Diabetes supplies: $0 copay (authorization required)
Home health services - Medicare-Medicaid plans
• Additional Hours of Care: Covered
• Personal Care Services: Covered
Dialysis
• 0% coinsurance or $0 copay
Hearing
• Hearing exam: $0 copay
• Fitting/evaluation: $0 copay
• Hearing aids: $0 copay (authorization required)
Preventive dental
• Oral exam: $0 copay (limits apply, authorization required)
• Cleaning: $0 copay (limits apply, authorization required)
• Fluoride treatment: Not covered
• Dental x-ray(s): $0 copay (limits apply, authorization required)
Additional Benefits & Services - Medicare-Medicaid plans
• Non-Medicare covered Prosthetics/Medical Supplies: Covered
• Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services: Not covered
• Tobacco Cessation Counseling for Pregnant Women: Not covered
• Freestanding Birth Center Services: Not covered
• Respiratory Care Services: Not covered
• Family Planning Services: Not covered
• Nursing Home Services: Not covered
• Home and Community Based Services: Not covered
• Personal Care Services: Not covered
• Self-Directed Personal Assistance Services: Not covered
• Private Duty Nursing Services: Not covered
• Case Management (Long Term Care): Not covered
• Institution for Mental Disease Services for Individuals 65 or Older: Not covered
• Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities: Not covered
• Case Management: Not covered
Comprehensive dental
• Non-routine services: $0 copay (authorization required)
• Diagnostic services: $0 copay (authorization required)
• Restorative services: $0 copay (authorization required)
• Endodontics: $0 copay (authorization required)
• Periodontics: $0 copay (authorization required)
• Extractions: $0 copay (authorization required)
• Prosthodontics, other oral/maxillofacial surgery, other services: $0 copay (authorization required)
Vision
• Routine eye exam: $0 copay (limits apply)
• Other: Not covered
• Contact lenses: $0 copay (limits apply, authorization required)
• Eyeglasses (frames and lenses): $0 copay (limits apply, authorization required)
• Eyeglass frames: Not covered
• Eyeglass lenses: Not covered
• Upgrades: Not covered
Medically-approved non-opioid pain management services
• Chiropractic services: Routine care coverage
• Acupuncture: Not covered
• Therapeutic Massage: Not covered
• Alternative Therapies: Not covered
More benefits
• Transportation services: Not covered
• Transportation services for non-emergency care: Any health-related locations: Not covered
• Over-the-counter drug benefits: Not covered
• Meals for short duration: Not covered
• Annual physical exams: Not covered
• Telehealth: Some coverage
• WorldWide emergency: Not covered
• Fitness Benefit: Not covered
• In-Home Support Services: Not covered
• Bathroom Safety Devices: Not covered
• Health Education: Some coverage
• In-Home Safety Assessment: Not covered
• Personal Emergency Response System (PERS): Not covered
• Medical Nutrition Therapy (MNT): Not covered
• Post discharge In-Home Medication Reconciliation: Not covered
• Re-admission Prevention: Not covered
• Wigs for Hair Loss Related to Chemotherapy: Not covered
• Weight Management Programs: Not covered
• Adult Day Health Services: Some coverage
• 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: Not covered
• Enhanced Disease Management: Not covered
• Telemonitoring Services: Some coverage
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage
• Counseling Services: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• $0 copay (authorization required)
Foot care (podiatry services)
• Foot exams and treatment: $0 copay (authorization required)
• Routine foot care: $0 copay (limits apply, authorization required)
Medicare Part B drugs
• Chemotherapy: $0 copay (authorization required)
• Other Part B drugs: $0 copay (authorization required)




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