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MercyOne Health Plan Cash Back (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for MercyOne Health Plan Cash Back (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on MercyOne Health Plan Cash Back (HMO) in 2025, please refer to our full plan details page.
MercyOne Health Plan Cash Back (HMO) is a HMO plan offered by Trinity Health Corporation available for enrollment in 2025 to people living in Select Counties in Iowa. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that MercyOne Health Plan Cash Back (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 MercyOne Health Plan Cash Back (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 MercyOne Health Plan Cash Back (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. Additionally, this plan comes with a Part B Premium reduction of $111.90. You must continue to pay paying your reduced 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 $275.00 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 $6900.00 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:
Sign up for MercyOne Health Plan Cash Back (HMO)
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Drug Coverage
The MercyOne Health Plan Cash Back (HMO) plan has a $275 deductible for prescription drugs. In the initial coverage phase, you will pay varying costs depending on the drug tier and pharmacy type. For example, you will pay a $10 copay for preferred generic drugs at a standard pharmacy, but no copay for the same drugs through mail order. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for Part D covered drugs. However, there may be some cost-sharing for drugs covered under any enhanced benefit.
Additional Benefits
The MercyOne Health Plan Cash Back (HMO) offers comprehensive coverage, including inpatient hospital stays with a copay, outpatient services, and partial hospitalization. It also covers ambulance services, emergency services, primary care, and preventive services, often with no copay. The plan provides additional benefits like hearing, vision, and dental services, with copays or coinsurance depending on the service. It also covers home infusion, dialysis, medical equipment, and diagnostic services, with a mix of copays and coinsurance. Other covered services include home health, skilled nursing, and additional services like acupuncture and over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric services with a $395 copay for days 1-5, and no copay for days 6-90, and additional days for Inpatient Hospital-Acute. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, and additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered. Outpatient hospital services have a copay of $10-$400, ambulatory surgical center services have a $400 copay, individual and group sessions for outpatient substance abuse have a $40 copay, and outpatient blood services and observation services have no copay.
Partial Hospitalization See details
Partial Hospitalization is covered with a $60 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the MercyOne Health Plan Cash Back (HMO). Ground ambulance services have a $275 copay, and air ambulance services have a $325 copay, but there is no coinsurance for either. 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 MercyOne Health Plan Cash Back (HMO). Emergency Services and Worldwide Emergency Coverage have a $110 copay, Urgently Needed Services has a $45 copay, and Worldwide Emergency Transportation has a copay between $275 and $325.
Primary Care See details
The MercyOne Health Plan Cash Back (HMO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, and occupational therapy with a $35 copay. Specialist visits have a $40 copay, while mental health and psychiatric individual and group sessions have a $40 copay. Physical therapy and speech-language pathology services have a $35 copay, and additional telehealth benefits range from no copay to a $40 copay. Opioid treatment program services have a $40 copay.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services, annual physical exams with no copay, and additional preventive services. The plan does not cover Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, 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. The Fitness Benefit, Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit have no copay.
Hearing Services See details
The MercyOne Health Plan Cash Back (HMO) plan covers hearing exams with a $40 copay, routine hearing exams with no copay for one visit per year, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $599 and $899 for two visits per year, but prescription hearing aids - inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
The MercyOne Health Plan Cash Back (HMO) plan covers vision services including eye exams and eyewear. Eye exams have a copay of $0 to $40, and routine eye exams have no copay. Eyewear has no copay, with a combined maximum benefit of $150 per year.
Dental Services See details
Dental Services are covered, including oral exams with no copay, dental x-rays with no copay, and prophylaxis (cleaning) with no copay. Restorative Services and Oral and Maxillofacial Surgery are covered with a 50% coinsurance, but other dental services like endodontics, periodontics, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the MercyOne Health Plan Cash Back (HMO) with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment, with details on the cost sharing to be provided. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services, with a copay for all outpatient diagnostic procedures, tests, and lab services, and a copay for all radiological services. Diagnostic Procedures/Tests have a $50 copay, Lab Services have a $10 copay, Diagnostic Radiological Services have a copay of at least $295, and Outpatient X-Ray Services have a $20 copay, and Therapeutic Radiological Services have at least 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the MercyOne Health Plan Cash Back (HMO) 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 not covered by the MercyOne Health Plan Cash Back (HMO), including Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services. There is no copay or coinsurance for the services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the MercyOne Health Plan Cash Back (HMO). There is no copay for days 1-20 and days 56-100, but there is a $214 copay for days 21-55.
Other Services See details
The MercyOne Health Plan Cash Back (HMO) plan covers acupuncture with a $20 copay, up to 6 treatments per year with prior authorization required, and also covers over-the-counter items with no copay, a maximum benefit of $50 every three months, and provides nicotine replacement therapy and naloxone. The plan also provides a meal benefit for a chronic illness with no copay. Several services, including Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, are not covered.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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