HAP CareSource MI Coordinated Health (HMO D-SNP)
Available to residents of Wayne County, MI for 2027. Contract H4193, plan 001, segment 0.
- ✉ Email a copy of the plan benefit details
- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Wayne County
- Plan website
- Browse the HAP CareSource MI Coordinated Health (HMO D-SNP) formulary
2027 drug-by-drug coverage is not published by CMS yet. The drug lookup covers 2026, whose formulary is live.
Renewed for 2027. CMS carries this plan forward from 2026. Every MI plan’s 2026–2027 changes →
Plan details
| Monthly premium (Part C + D) | $6.30 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $6.30? |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | None |
| In-network out-of-pocket maximum | $9,850.00? |
| Drug deductible | $700.00 |
| Drug out-of-pocket threshold | $2,400.00 |
| Plan type | HMO D-SNP? |
| Special needs plan | Dual-eligible SNP |
| D-SNP integration status | Highly Integrated (HIDE) |
| Zero-dollar cost sharing D-SNP | Yes |
| Contract / plan | H4193-001-0 |
| Offered by | HAP CareSource MI Coordinated Health |
| Parent organization | Henry Ford Health System |
| Formulary tiers | 5 |
| Formulary exception tier | 4? |
| Pharmacy search | www.hap.org/medicare |
| Member services | (833)923-1713TTY (833)711-4711 |
CMS star ratings
- Overall
- —
- Health plan (Part C)
- —
- Drug plan (Part D)
- —
Published per contract — every plan under contract H4193 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | 20% coinsurance |
| Specialist | 20% coinsurance |
| Other health care professional | 20% coinsurance |
| Additional telehealth services | 20% coinsurance |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | Not covered |
| Kidney disease education | 20% coinsurance |
| Glaucoma screening | 20% coinsurance |
| Diabetes self-management training | 20% coinsurance |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | 20% coinsurance(authorization required) |
| Lab services | $0 copay(authorization required) |
| Diagnostic radiology (e.g. MRI, CT) | 20% coinsurance(authorization required) |
| Therapeutic radiology | 20% coinsurance(authorization required) |
| Outpatient x-rays | 20% coinsurance(authorization required) |
| Emergency and urgent care | |
| Emergency room | 20% coinsurance |
| Urgent care | 20% coinsurance |
| Worldwide emergency coverage | $0 copay · $10,000 plan limit |
| Worldwide urgent care | $0 copay · $10,000 plan limit |
| Worldwide emergency transportation | $0 copay |
| Hospital care | |
| Inpatient hospital stay | Original Medicare cost-sharing(authorization required) |
| Outpatient hospital services | 20% coinsurance(authorization required) |
| Outpatient observation | 20% coinsurance |
| Ambulatory surgical center | 20% coinsurance(authorization required) |
| Outpatient blood services | 20% coinsurance |
| Skilled nursing and home health | |
| Skilled nursing facility | Original Medicare cost-sharing(authorization required) |
| Home health care | $0 copay(authorization required) |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | 20% coinsurance(authorization required) |
| Physical therapy and speech-language therapy | 20% coinsurance(authorization required) |
| Cardiac rehabilitation | 20% coinsurance |
| Pulmonary rehabilitation | 20% coinsurance |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | Original Medicare cost-sharing(authorization required) |
| Outpatient mental health, individual session | 20% coinsurance(authorization required) |
| Outpatient mental health, group session | 20% coinsurance(authorization required) |
| Psychiatrist, individual session | 20% coinsurance(authorization required) |
| Psychiatrist, group session | 20% coinsurance(authorization required) |
| Partial hospitalization | 20% coinsurance(authorization required) |
| Intensive outpatient program | 20% coinsurance(authorization required) |
| Outpatient substance use, individual session | 20% coinsurance(authorization required) |
| Outpatient substance use, group session | 20% coinsurance(authorization required) |
| Opioid treatment program | 20% coinsurance(authorization required) |
| Ambulance and transportation | |
| Ground ambulance | 20% coinsurance(authorization required) |
| Air ambulance | 20% coinsurance(authorization required) |
| Transportation to plan-approved locations | Not covered |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | 20% coinsurance(authorization required) |
| Diabetic therapeutic shoes or inserts | 20% coinsurance(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | 20% coinsurance |
| Routine chiropractic care | Not covered |
| Acupuncture | Not covered |
| Foot exams and treatment (Medicare-covered) | 20% coinsurance |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | 20% coinsurance(authorization required) |
| Preventive dental plan limit | $3,000 plan limit every year |
| Oral exams | $0 copay |
| Cleanings | $0 copay |
| Fluoride treatment | $0 copay(limits apply) |
| Dental x-rays | $0 copay |
| Other diagnostic dental services | $0 copay |
| Other preventive dental services | $0 copay |
| Restorative services (fillings, crowns) | $0 copay |
| Endodontics (root canals) | $0 copay |
| Periodontics (gum disease) | $0 copay |
| Dentures and other removable prosthodontics | $0 copay |
| Maxillofacial prosthetics | Not covered |
| Implants | $0 copay(authorization required) |
| Bridges and other fixed prosthodontics | $0 copay |
| Oral and maxillofacial surgery | $0 copay |
| Orthodontics | Not covered |
| Adjunctive general services | $0 copay |
| Vision? | |
| Eye exam (Medicare-covered) | 20% coinsurance |
| Routine eye exam | $0 copay |
| Eyewear after cataract surgery (Medicare-covered) | 20% coinsurance(authorization required, limits apply) |
| Eyewear plan limit | $250 plan limit every year |
| Contact lenses | $0 copay(authorization required, limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(authorization required, limits apply) |
| Eyeglass lenses | $0 copay(authorization required, limits apply) |
| Eyeglass frames | $0 copay(authorization required, limits apply) |
| Eyewear upgrades | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | 20% coinsurance(authorization required) |
| Routine hearing exam | $0 copay(authorization required, limits apply) |
| Hearing aid fitting and evaluation | $0 copay(authorization required, limits apply) |
| Hearing aids (all types) | $0 copay(authorization required, limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | Covered (allowance not stated) |
| Meals after a hospital stay or for a chronic condition | Not covered |
| Fitness benefit | $0 copay |
| Health education | Not covered |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | Not covered |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | Not covered |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2027). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 · Preferred Generic | 25% |
| Tier 2 · Generic | 25% |
| Tier 3 · Preferred Brand | 25% |
| Tier 4 · Non-Preferred Drug | 25% |
| Tier 5 · Specialty Tier | 25% |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 2: Generic | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 3: Preferred Brand | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 4: Non-Preferred Drug | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 5: Specialty Tier | 25% | 25% | 25% | n/a | n/a | n/a |
These are the initial coverage phase amounts, as the plan filed them in its benefit package. The deductible and post-threshold phases are not stated per tier in that filing, so they are not shown here rather than being inferred; the plan's annual out-of-pocket threshold is $2,400.00.
Star rating measures
| Measure | 2027 | 2026 |
|---|---|---|
| Health Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · C32 | 4 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | too new |
| DD1: Drug Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · D01 | 5 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | too new |
Measures are paired between the two years by name, not by the C/D number: CMS reuses those numbers, and in 2027 nineteen of them refer to a different measure than they did in 2026. A measure introduced for 2027 has no 2026 score to show. Published per contract — every plan under H4193 shares it.
Also available in 1 other MI county
Benefits in plain text
HAP CareSource MI Coordinated Health (HMO D-SNP) (H4193-001-0) is a 2027 HMO D-SNP Medicare Advantage plan offered by HAP CareSource MI Coordinated Health, available to residents of Wayne County, MI.
The monthly premium is $6.30.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
Its in-network out-of-pocket maximum is $9,850.00.
The drug deductible is $700.00.
It is a special needs plan (Dual-eligible SNP).
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1 (Preferred Generic): 25%; tier 2 (Generic): 25%; tier 3 (Preferred Brand): 25%; tier 4 (Non-Preferred Drug): 25%; tier 5 (Specialty Tier): 25%.
Email a copy of the plan benefit details
Plan facts come from the CMS plan Landscape file and the CMS plan benefit package (PBP) files.