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Health Alliance Medicare Guide HMO Rx (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Health Alliance Medicare Guide HMO Rx (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Health Alliance Medicare Guide HMO Rx (HMO) in 2025, please refer to our full plan details page.
Health Alliance Medicare Guide HMO Rx (HMO) is a HMO plan offered by The Carle Foundation available for enrollment in 2025 to people living in Scott County. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Health Alliance Medicare Guide HMO Rx (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Health Alliance Medicare Guide HMO Rx (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Health Alliance Medicare Guide HMO Rx (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4300.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Health Alliance Medicare Guide HMO Rx (HMO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, you will pay a $15 copay for preferred generic drugs at a standard pharmacy. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for covered drugs. If you qualify for the low-income subsidy, your Part D costs will be $0.
Additional Benefits
The Health Alliance Medicare Guide HMO Rx (HMO) plan offers a variety of healthcare benefits. You'll have a $275 copay for inpatient hospital stays for days 1-10, and then no copay for days 11-90, with different copays for psychiatric stays. Outpatient services have copays ranging from $0 to $350, and emergency services have a $125 copay. The plan includes coverage for primary care, preventive services with no copay, and vision and dental services. Hearing exams have a $45 copay, and hearing aids have copays between $699 and $999. The plan also covers home health services with no copay, and skilled nursing facility stays with a copay that varies from $10 to $214 depending on the length of stay.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, with a $275 copay for days 1-10 and no copay for days 11-90 for Inpatient Hospital-Acute, and a $395 copay for days 1-4 and no copay for days 5-90 for Inpatient Hospital Psychiatric. Additional Days for Inpatient Hospital-Acute are covered, and Upgrades, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a copay ranging from $0 to $350, and observation services with a $55 copay. Ambulatory Surgical Center (ASC) services have no copay, and outpatient substance abuse services have a 20% coinsurance for both individual and group sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Health Alliance Medicare Guide HMO Rx (HMO) plan with a $55 copay, and requires prior authorization.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Health Alliance Medicare Guide HMO Rx (HMO) plan. Ground ambulance services have a $265 copay, while air ambulance services have a $375 copay, and both have no coinsurance; however, transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Health Alliance Medicare Guide HMO Rx (HMO) plan. Emergency Services have a $125 copay, and Urgently Needed Services have a $55 copay, while Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $55 copay, and Worldwide Emergency Transportation has a copay between $265 and $375. There is no coinsurance for any of these services.
Primary Care See details
The Health Alliance Medicare Guide HMO Rx (HMO) plan covers primary care physician services, chiropractic services with a $15 copay, occupational therapy services with a $45 copay, physician specialist services with a $40 copay, and mental health specialty services with a $40 copay for individual and group sessions. The plan also covers physical therapy and speech-language pathology services with a $20 copay, additional telehealth benefits with a copay between $0 and $40, and opioid treatment program services with a $50 copay. Podiatry services are not covered, and routine chiropractic care is not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services with no copay, annual physical exams, additional preventive services, kidney disease education services, and other preventive services. Additional services such as health education, in-home safety assessments, personal emergency response systems (PERS), medical nutrition therapy (MNT), and others are not covered.
Hearing Services See details
Hearing Services include routine hearing exams with a $45 copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $699 and $999, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision services include coverage for routine eye exams once per year, and eyewear with a combined maximum benefit of $200 every year. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $35 copay, and other dental services with a $2,000 maximum benefit per year. Restorative, Endodontics, Periodontics, and Oral and Maxillofacial Surgery services have a 20% coinsurance, while Adjunctive General Services, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, and Implant Services have a 40% coinsurance. Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and a coinsurance between 0% and 20%, as well as Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with a coinsurance between 0% and 20%. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered by the Health Alliance Medicare Guide HMO Rx (HMO) plan with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment benefits are covered, including Durable Medical Equipment (DME) with 0-20% coinsurance and Prosthetic Devices/Medical Supplies, with a 20% coinsurance. Diabetic equipment is covered, including Diabetic Supplies with 0-20% coinsurance and Diabetic Therapeutic Shoes/Inserts with a 20% coinsurance; however, Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. Diagnostic Procedures/Tests and Lab Services have a coinsurance of at most 20%, while all other diagnostic services have no copay and a coinsurance that is described in more detail below. The plan also covers Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services, each with a coinsurance of at most 20%, and all radiological services have no copay.
Home Health Services See details
Home Health Services are covered by the Health Alliance Medicare Guide HMO Rx (HMO) plan with no copay and no coinsurance. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but not in practice. None of the sub-services, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services, are covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization and a doctor's referral. For days 1-20, the copay is $10, and for days 21-100, the copay is $214.
Other Services See details
Other Services include acupuncture with a $10 copay, and OTC items with a maximum benefit of $35 every three months, and meal benefits for chronic illnesses or medical conditions. Dual eligible SNPs with highly integrated services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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