Sentara Medicare Value (HMO)

Inpatient Hospital See details

Inpatient Hospital services, including acute and psychiatric care, are covered, with a $285 copay for days 1-7 and no copay for days 8-90. Additional days for inpatient hospital acute and psychiatric care are covered with no copay, but non-Medicare covered stays and upgrades for inpatient hospital acute and psychiatric care are not covered.

Outpatient Services See details

Outpatient Services include coverage for Outpatient Hospital Services and Observation Services with a $325 copay, Ambulatory Surgical Center (ASC) Services with a $200 copay, and Outpatient Blood Services. Outpatient Substance Abuse Services are not covered.

Partial Hospitalization See details

Partial Hospitalization is covered by the Sentara Medicare Value (HMO) plan with a $35 copay, and requires prior authorization.

Ambulance and Transportation Services See details

Ambulance and Transportation Services are covered by the Sentara Medicare Value (HMO) plan. Ground and air ambulance services have a copay of $290.00, with no coinsurance. Transportation services to a plan-approved health-related location are covered for up to 36 one-way trips per year. 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 Sentara Medicare Value (HMO) plan. Emergency Services have a $140 copay, and Urgently Needed Services have a $15 copay, with no coinsurance for either. Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $50 copay.

Primary Care See details

The Sentara Medicare Value (HMO) plan covers primary care physician services, chiropractic services with a $10 copay (excluding routine care), occupational therapy services with a $20 copay, and specialist services with a $15 copay. Mental health services, including individual and group sessions, have a $25 copay, while physical therapy and speech-language pathology services have a $20 copay. Other health care professional services have a copay from $0 to $25. Psychiatric services are covered with a $25 copay for individual and group sessions. Podiatry services are not covered. Additional telehealth benefits and opioid treatment program services are covered.

Preventive Services See details

The Sentara Medicare Value (HMO) plan covers preventive services, including Medicare-covered services with prior authorization, annual physical exams, and additional preventive services like health education, personal emergency response systems, re-admission prevention, nutritional/dietary benefits, in-home support services, additional smoking cessation sessions, fitness benefits, enhanced disease management, remote access technologies, home and bathroom safety devices and modifications, kidney disease education services, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs after the welcome visit. However, in-home safety assessments, medical nutrition therapy, post-discharge in-home medication reconciliation, wigs for chemotherapy-related hair loss, weight management programs, alternative therapies, therapeutic massage, adult day health services, home-based palliative care, support for caregivers, telemonitoring services, and counseling services are not covered.

Hearing Services See details

Hearing Services include coverage for hearing exams with a $15 copay, along with routine hearing exams and fitting/evaluation for hearing aids. Prescription hearing aids (all types) are covered up to a maximum of $2,000 per year, but prescription hearing aids - inner ear, prescription hearing aids - outer ear, and prescription hearing aids - over the ear are not covered, nor are OTC hearing aids.

Vision Services See details

The Sentara Medicare Value (HMO) plan covers vision services, including routine eye exams with no copay, and eyewear. Eyewear has a combined maximum plan benefit coverage of $200 every year and includes contact lenses and eyeglasses (lenses and frames). However, eyeglass lenses, eyeglass frames, and upgrades are not covered.

Dental Services See details

The Sentara Medicare Value (HMO) plan covers other dental services with no copay, and also covers oral exams, dental x-rays, prophylaxis (cleaning), fluoride treatment, and orthodontic services. Restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable), and oral and maxillofacial surgery have a $35 copay. Maxillofacial prosthetics, implant services, prosthodontics (fixed), and orthodontics are not covered.

Home Infusion bundled Services See details

Home Infusion bundled Services are covered by the Sentara Medicare Value (HMO) plan, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.

Dialysis Services See details

Dialysis Services are covered under the Sentara Medicare Value (HMO) plan. You will pay 20% coinsurance for these services.

Medical Equipment See details

Medical Equipment benefits are covered under the Sentara Medicare Value (HMO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered.

Prosthetics/Medical Supplies - Non-Medicare benefit has a coinsurance for Medicare-covered Prosthetic Devices and Medical Supplies, and Diabetic Equipment has a coinsurance for Medicare-covered Diabetic Supplies and Therapeutic Shoes/Inserts.

Diagnostic and Radiological Services See details

Diagnostic and Radiological Services include coverage for diagnostic procedures/tests with a maximum copay of $85, and diagnostic radiological services with a maximum copay of $285. Therapeutic radiological services have a 20% coinsurance and a maximum copay of $15, and outpatient X-ray services have no copay.

Home Health Services See details

Home Health Services are covered by the Sentara Medicare Value (HMO) plan with no copay and no coinsurance, but prior authorization is required. Additional hours of care and personal care services are not covered.

Cardiac Rehabilitation Services See details

Cardiac Rehabilitation Services are covered, but Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. Prior authorization is required for the covered services; however, the copay for these services is not specified.

Skilled Nursing Facility (SNF) See details

Skilled Nursing Facility (SNF) services are covered under the Sentara Medicare Value (HMO) plan, but require prior authorization. There is no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.

Other Services See details

Other Services includes coverage for Over-the-Counter (OTC) items, with a maximum benefit coverage amount of $130 every three months, including Nicotine Replacement Therapy (NRT). Acupuncture, Meal Benefit, 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.