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Blue Shield Inspire (HMO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Blue Shield Inspire (HMO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Blue Shield Inspire (HMO D-SNP) in 2025, please refer to our full plan details page.
Blue Shield Inspire (HMO D-SNP) is a HMO D-SNP plan offered by California Physicians' Service available for enrollment in 2025 to people living in Merced/San Joaquin/Stanislaus Counties. The overall rating for this plan is not yet available for 2025.
It's important to know that Blue Shield Inspire (HMO D-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Blue Shield Inspire (HMO D-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Blue Shield Inspire (HMO D-SNP).
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 Blue Shield Inspire (HMO D-SNP), 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 a $590.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $9350.00 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 Blue Shield Inspire (HMO D-SNP) plan has a $590 deductible for prescription drugs. After the deductible is met, you pay 25% coinsurance for many drugs at standard pharmacies. If you qualify for the low-income subsidy (LIS), your costs for Part D drugs may be reduced. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Blue Shield Inspire (HMO D-SNP) plan offers a wide range of benefits with varying cost-sharing. You will pay a 20% coinsurance for many outpatient services, including outpatient hospital services, ambulatory surgical center services, and substance abuse services. Many primary care services, such as primary care physician visits and chiropractic services, also have a 20% coinsurance, while preventive services such as annual physical exams are covered with no copay. This plan also covers hearing, vision, and dental services. Hearing exams have a coinsurance of at most 20%, and prescription hearing aids are covered up to $2000 per year. Eye exams have a 20% coinsurance, and eyeglasses and contact lenses are covered with an annual allowance. Finally, this plan covers Medicare Dental Services with a 20% coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered under the Blue Shield Inspire (HMO D-SNP) plan, but additional days and non-Medicare-covered stays are not covered. The plan requires prior authorization and a doctor referral, and the coinsurance details are available in the plan documents.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services and Observation Services, both with a 20% coinsurance, as well as Ambulatory Surgical Center (ASC) Services and Outpatient Substance Abuse Services, both with a coinsurance of 20%. Outpatient Blood Services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Blue Shield Inspire (HMO D-SNP) plan, but requires prior authorization and a doctor's referral. You will pay 20% coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Blue Shield Inspire (HMO D-SNP) plan. Ground and air ambulance services have a 20% coinsurance, and there is no copay. Transportation to a plan-approved health-related location is covered for up to 48 one-way trips per year, while transportation to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered under the Blue Shield Inspire (HMO D-SNP) plan, with a 20% coinsurance and no copay. Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Podiatry Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered by the Blue Shield Inspire (HMO D-SNP) plan. Primary Care Physician Services and Chiropractic Services have a 20% coinsurance. Occupational Therapy Services, Individual and Group Sessions for Mental Health, Routine Foot Care, Other Health Care Professional, Individual and Group Sessions for Psychiatric Services, and Opioid Treatment Program Services have a minimum and maximum coinsurance of 20%. Physical Therapy and Speech-Language Pathology Services have a 20% coinsurance. Physician Specialist Services have a coinsurance between 0% and 20%.
Preventive Services See details
The Blue Shield Inspire (HMO D-SNP) plan covers preventive services, including annual physical exams, with no copay. It also covers health education, Personal Emergency Response Systems, Remote Access Technologies, and Fitness Benefits with no copay. Kidney Disease Education Services are covered with 20% coinsurance, and other preventive services like Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit are covered. However, In-Home Safety Assessments, Medical Nutrition Therapy, Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefits, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing Services for the Blue Shield Inspire (HMO D-SNP) plan include routine hearing exams with a coinsurance of at most 20%, and fitting/evaluation for hearing aids with 2 visits per year. Prescription hearing aids (all types) are covered up to a maximum of $2000 per year, but prescription hearing aids for the inner, outer, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services are covered, including eye exams, eyewear, and contact lenses. Eye exams have a 20% coinsurance, and routine eye exams are covered once per year. Eyewear has a 20% coinsurance, and contact lenses are covered with a maximum plan benefit coverage amount of $275 every year. Eyeglass lenses are covered once per year, and eyeglass frames are covered with a maximum plan benefit coverage amount of $275 every two years. Eyeglasses (lenses and frames) and upgrades are not covered.
Dental Services See details
Dental services with the Blue Shield Inspire (HMO D-SNP) plan include coverage for Medicare Dental Services with 20% coinsurance. Orthodontic Services, Restorative Services, Prosthodontics (removable and fixed) are covered, but Adjunctive General Services, Endodontics, Periodontics, Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and 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 0-20% coinsurance, and other Medicare Part B drugs which have 0-20% coinsurance. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered with prior authorization and a doctor referral. You will pay 20% coinsurance.
Medical Equipment See details
Medical Equipment benefits are covered by the Blue Shield Inspire (HMO D-SNP) plan, with no copay. Durable Medical Equipment (DME) has a coinsurance between 0% and 20%, while Medical Supplies, Prosthetic Devices, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts all have a 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Blue Shield Inspire (HMO D-SNP) plan, with no copay for diagnostic and radiological services, but a coinsurance of at most 20% for diagnostic procedures/tests, lab services, diagnostic radiological services, therapeutic radiological services, and outpatient X-ray services. A doctor referral is required for all diagnostic and radiological services.
Home Health Services See details
Home Health Services are covered by the Blue Shield Inspire (HMO D-SNP) plan with no copay and no coinsurance, but require authorization and a referral. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover any of the specific services. Prior authorization and a doctor referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by the Blue Shield Inspire (HMO D-SNP) plan, but require prior authorization and a doctor's referral. The plan does not cover additional days beyond Medicare-covered for SNF, or non-Medicare-covered stays for SNF.
Other Services See details
Other Services include Over-the-Counter (OTC) Items, Meal Benefit, and Other Services. Acupuncture, 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. Over-the-Counter (OTC) Items has a maximum plan benefit coverage amount of $190 every three months.
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