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CommuniCare Advantage Emerald (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for CommuniCare Advantage Emerald (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on CommuniCare Advantage Emerald (HMO) in 2025, please refer to our full plan details page.
CommuniCare Advantage Emerald (HMO) is a HMO plan offered by SNP Holdings, LLC available for enrollment in 2025 to people living in Indiana, Maryland, Ohio. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that CommuniCare Advantage Emerald (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 CommuniCare Advantage Emerald (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 CommuniCare Advantage Emerald (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $38.00. 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 $6750.00 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 CommuniCare Advantage Emerald (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 the pharmacy you use. For example, you can expect to pay a $10 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 Part D covered drugs. This plan's premium may be reduced if you qualify for the low-income subsidy, and the monthly premium is $38.00.
Additional Benefits
The CommuniCare Advantage Emerald (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while outpatient services have copays ranging from $0 to $295. The plan covers ambulance services with a $220 copay and emergency services with a $90 copay. Primary care services have copays between $15 and $50, and preventive services are covered with a 10% coinsurance for some services. The plan also provides coverage for hearing, vision, and dental services, with specific copays and an annual maximum for dental benefits. Other covered services include home health, home infusion, and medical equipment with coinsurance or copay requirements.
Inpatient Hospital See details
Inpatient Hospital coverage includes a copay of $295 for days 1-5 and $0 for days 6-90, and a copay of $788 for days 1-60. Additional days, non-Medicare-covered stays, and upgrades for Inpatient Hospital-Acute are not covered, and additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, with a copay between $0 and $295, and observation services with a $295 copay. Ambulatory Surgical Center (ASC) Services have no copay, and outpatient substance abuse services have a $25 copay for both individual and group sessions. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the CommuniCare Advantage Emerald (HMO) plan, with a $55 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered. Ground and Air Ambulance Services have a $220 copay, and no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered by the CommuniCare Advantage Emerald (HMO) plan. Emergency Services have a $90 copay, and Urgently Needed Services have a $40 copay; both have no coinsurance. Worldwide Emergency Coverage has a $95 copay, while Worldwide Urgent Coverage and Worldwide Emergency Transportation are not covered.
Primary Care See details
The CommuniCare Advantage Emerald (HMO) plan covers primary care services, including a $15 copay for chiropractic services, a $20 copay for occupational therapy services, and a $25 copay for physician specialist services. Mental health specialty services have a $25 copay for individual sessions and a $15 copay for group sessions, while podiatry services and other healthcare professionals have a $25 and $50 copay, respectively. It also covers psychiatric services with a $25 copay for individual sessions and a $25 copay for group sessions, physical therapy, and speech-language pathology services with a $20 copay, additional telehealth benefits, and opioid treatment program services.
Preventive Services See details
The CommuniCare Advantage Emerald (HMO) plan covers preventive services, but does not cover annual physical exams, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, 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 benefits, 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, remote access technologies, home and bathroom safety devices and modifications, and counseling services. Kidney disease education services have a $10 copay, while glaucoma screening and diabetes self-management training have a 10% coinsurance.
Hearing Services See details
Hearing Services include routine hearing exams and fitting/evaluation for hearing aids with no copay or coinsurance. Prescription hearing aids are covered with a copay between $100 and $350, depending on the type of hearing aid. Some services are covered, but prescription hearing aids - inner ear, outer ear, and over the ear, as well as OTC hearing aids, are not covered.
Vision Services See details
Vision services are covered, including routine eye exams and eyewear. Routine eye exams are covered with no copay, and contact lenses and eyeglasses (lenses and frames) are covered. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services are covered, with a maximum plan benefit of $2,000 per year. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), restorative services, endodontics, periodontics, prosthodontics (removable), maxillofacial prosthetics, implant services, prosthodontics (fixed), and oral and maxillofacial surgery are covered, while fluoride treatment, adjunctive general services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay. 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 CommuniCare Advantage Emerald (HMO) plan. You will pay 20% coinsurance for this benefit.
Medical Equipment See details
Medical equipment, including durable medical equipment (DME), prosthetics, medical supplies, and diabetic equipment, is covered. DME has a 20% coinsurance and requires authorization, while medical supplies have a 20% coinsurance. Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the CommuniCare Advantage Emerald (HMO) plan. Diagnostic Procedures/Tests have a $30 copay, while Lab Services are not covered. Diagnostic Radiological Services have a maximum copay of $110, Therapeutic Radiological Services have a minimum copay of $60, and Outpatient X-Ray Services have a $15 copay.
Home Health Services See details
Home Health Services are covered by the CommuniCare Advantage Emerald (HMO) plan with no copay and no coinsurance, but authorization is required. Additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the CommuniCare Advantage Emerald (HMO) plan. The plan does not cover any of the sub-services, including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by the CommuniCare Advantage Emerald (HMO) plan, but require prior authorization. For days 1-20, there is no copay, days 21-40 have a $196 copay, and days 41-100 have no copay. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The CommuniCare Advantage Emerald (HMO) plan offers Over-the-Counter (OTC) Items with a maximum benefit of $50.00 every three months. The plan also covers a Meal Benefit for chronic illness with a doctor referral. 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.
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