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Clear Spring Health Community Advantage Plan (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Clear Spring Health Community Advantage Plan (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Clear Spring Health Community Advantage Plan (HMO) in 2025, please refer to our full plan details page.
Clear Spring Health Community Advantage Plan (HMO) is a HMO plan offered by Group 1001 available for enrollment in 2025 to people living in Rockford Area, Chicago Area. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that Clear Spring Health Community Advantage Plan (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 Clear Spring Health Community Advantage Plan (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 Clear Spring Health Community Advantage Plan (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 $2950.00 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 Clear Spring Health Community Advantage Plan (HMO) has no deductible for prescription drugs. In the initial coverage phase, you will pay a copay for your prescriptions, which varies depending on the drug tier and whether you use a preferred or standard pharmacy. For example, preferred generic drugs have no copay, while standard generic drugs have a $42 copay at a preferred pharmacy. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase and pay nothing for your Part D covered drugs. If you qualify for the low-income subsidy, the plan's premium may be reduced. Be sure to check the plan's formulary for a list of covered drugs.
Additional Benefits
The Clear Spring Health Community Advantage Plan (HMO) offers comprehensive coverage, including inpatient hospital stays with a $220 copay for the first seven days, and then no copay. The plan also covers outpatient services, emergency services, and primary care with varying copays. This plan includes additional benefits such as hearing, vision, and dental services, each with its own set of copays and coverage limits. You can also get home health services with no copay, and skilled nursing facility services with no copay for the first 20 days.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care, both of which require prior authorization. For days 1-7 of inpatient hospital acute or psychiatric care, the copay is $220, and for days 8-90, there is no copay.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services and Observation Services with a $225 copay, Ambulatory Surgical Center (ASC) Services with a $175 copay, and Outpatient Substance Abuse Services with a $40 copay for both individual and group sessions. Outpatient Blood Services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Clear Spring Health Community Advantage Plan (HMO) with a $25 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by the Clear Spring Health Community Advantage Plan (HMO). Ground ambulance services have a $200 copay, and air ambulance services have a 20% coinsurance. Transportation services to a plan-approved health-related location are covered for up to 12 one-way trips per year.
Emergency Services See details
Emergency Services, including Urgently Needed Services, are covered by the Clear Spring Health Community Advantage Plan (HMO), with a $90 copay for Emergency Services and a $35 copay for Urgently Needed Services, and no coinsurance. Worldwide Emergency Services are not covered.
Primary Care See details
The Clear Spring Health Community Advantage Plan (HMO) covers primary care physician services, occupational therapy, physician specialist services, mental health specialty services, other health care professional, psychiatric services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services are covered with a $20 copay, but routine care is not covered. Individual and group sessions for mental health and psychiatric services have a $20 and $30 copay, respectively.
Preventive Services See details
The Clear Spring Health Community Advantage Plan (HMO) covers a variety of preventive services, including annual physical exams, with no copay. Additional preventive services are partially covered, with Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services not covered.
Hearing Services See details
Hearing services include routine hearing exams with a $30 copay, and fitting/evaluation for hearing aids. Prescription hearing aids (all types) are covered, up to $500 per year, with coverage for 2 hearing aids per year. However, prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services with the Clear Spring Health Community Advantage Plan (HMO) include routine eye exams with a $30 copay, and eyewear benefits with a combined maximum of $300 every year. Contact lenses, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Clear Spring Health Community Advantage Plan (HMO) covers a range of dental services. Medicare Dental Services have a $30 copay. Other dental services include oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics, all with limited visits per year. Orthodontic Services have a maximum benefit of $3,000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Clear Spring Health Community Advantage Plan (HMO) and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay with 0-20% coinsurance, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Clear Spring Health Community Advantage Plan (HMO), with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment is covered by the Clear Spring Health Community Advantage Plan (HMO), with Durable Medical Equipment (DME) and Prosthetic Devices subject to a 20% coinsurance and no copay, while Durable Medical Equipment for use outside the home is not covered. Diabetic Therapeutic Shoes/Inserts also have a 20% coinsurance, while Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, but Diagnostic Procedures/Tests and Lab Services are not covered. Diagnostic Radiological Services have a copay of up to $100, and Therapeutic Radiological Services have a coinsurance of 20%. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Clear Spring Health Community Advantage Plan (HMO) with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Clear Spring Health Community Advantage Plan (HMO). This includes Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Clear Spring Health Community Advantage Plan (HMO), but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $178.
Other Services See details
The Clear Spring Health Community Advantage Plan (HMO) covers Over-the-Counter (OTC) items with a maximum plan benefit of $65.00 every month, including nicotine replacement therapy and Naloxone. Acupuncture, meal benefits, dual eligible SNPs, and many other services are not covered.
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