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Experience Health Medicare Advantage (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Experience Health Medicare Advantage (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Experience Health Medicare Advantage (HMO) in 2025, please refer to our full plan details page.
Experience Health Medicare Advantage (HMO) is a HMO plan offered by Blue Cross and Blue Shield of North Carolina available for enrollment in 2025 to people living in Triangle and surrounding area. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Experience Health Medicare Advantage (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 Experience Health Medicare Advantage (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 Experience Health Medicare Advantage (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $25.00. 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 $3900.00 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 Experience Health Medicare Advantage (HMO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you'll pay a copay for your prescriptions depending on the drug tier and pharmacy type, with costs ranging from $5 to $99. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for Part D-covered drugs. If you qualify for the low-income subsidy, your monthly premium will be $9.30.
Additional Benefits
The Experience Health Medicare Advantage (HMO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay, but many other services have no copay, including primary care visits, preventive services, and home health services. The plan also covers hearing and vision services, dental services, and offers additional benefits like transportation and over-the-counter items. This plan includes copays for outpatient services, emergency services, and specialist visits. Additionally, this plan includes coverage for services such as ambulance, and covers some prescription hearing aids. The plan also provides coverage for services such as ambulance, and covers some prescription hearing aids.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care, with a copay of $295 for days 1-6 and no copay for days 7-90 for acute care, and a copay of $275 for days 1-6 and no copay for days 7-90 for psychiatric care. Additional days for acute psychiatric are covered with no copay, while non-Medicare-covered stays and upgrades for acute and psychiatric care are not covered.
Outpatient Services See details
Outpatient Services include all outpatient hospital services, with a $200 copay, and observation services with no copay. Ambulatory Surgical Center (ASC) Services have a $200 copay, while Outpatient Substance Abuse Services have no copay for both individual and group sessions. Outpatient blood services have a 20% coinsurance.
Partial Hospitalization See details
Partial Hospitalization is covered by the plan with no copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Experience Health Medicare Advantage (HMO) plan. Ground and air ambulance services have a $295 copay, and transportation services to a plan-approved health-related location have no copay for up to 12 one-way trips per year.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $120 copay, Urgently Needed Services have a $60 copay, Worldwide Emergency Coverage has a $120 copay, Worldwide Urgent Coverage has a $60 copay, and Worldwide Emergency Transportation has a $295 copay.
Primary Care See details
Primary Care benefits include coverage for Primary Care Physician Services with no copay, Chiropractic Services with a $20 copay, Occupational Therapy Services with a $20 copay, Physician Specialist Services with a $20 copay, and Physical Therapy and Speech-Language Pathology Services with a $20 copay. Mental Health Specialty Services, Psychiatric Services, and Opioid Treatment Program Services are covered with no copay for individual and group sessions, while Other Health Care Professional services are covered with a copay between $0 and $20. Additional Telehealth Benefits are covered with a copay between $0 and $20. Podiatry Services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered zero dollar preventive services, annual physical exams with no copay, additional preventive services, kidney disease education services, and other preventive services. The plan does not cover health education, in-home safety assessments, 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, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, and counseling services. The plan covers Personal Emergency Response System (PERS) with no copay, In-Home Support Services with no copay, Fitness Benefit with no copay, Home and Bathroom Safety Devices and Modifications with no copay, Glaucoma Screening with no copay, Diabetes Self-Management Training with no copay, Barium Enemas with no copay, Digital Rectal Exams with no copay, and EKG following Welcome Visit with no copay.
Hearing Services See details
The Experience Health Medicare Advantage (HMO) plan covers hearing exams with no copay, and routine hearing exams once per year with no copay. Fitting/evaluation for hearing aids is covered with no copay, while prescription hearing aids (all types) are covered with a copay between $599 and $899, but prescription hearing aids for the inner, outer, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services are covered, including eye exams and eyewear. Eye exams and eyewear have no copay.
Dental Services See details
Dental Services are covered, with a $20 copay for Medicare Dental Services, and no copay for Other Dental Services. This plan also covers Orthodontic Services with a $1,500 maximum benefit per year, as well as 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 with no copay.
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 by the Experience Health Medicare Advantage (HMO) plan, 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 coinsurance and copay information available. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
The Experience Health Medicare Advantage (HMO) plan covers diagnostic and radiological services, including diagnostic procedures and tests with a copay between $0 and $20, and lab services with no copay. Diagnostic radiological services have a copay up to $150, and therapeutic radiological services have no copay and a coinsurance up to 20%. Outpatient X-ray services have no copay.
Home Health Services See details
Home Health Services are covered by the Experience Health Medicare Advantage (HMO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Experience Health Medicare Advantage (HMO) plan, but the plan does not cover any of the sub-services in practice. The plan has a copay for services, but the specific amount is not listed.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Experience Health Medicare Advantage (HMO) plan. For days 1-20, there is no copay, for days 21-60 the copay is $214, and for days 61-100, there is no copay.
Other Services See details
The Experience Health Medicare Advantage (HMO) plan covers acupuncture with a $50 copay per visit, up to 20 treatments per year. This plan also covers over-the-counter (OTC) items, including nicotine replacement therapy and Naloxone, with a maximum benefit of $116 every three months. The plan provides a meal benefit with no copay, and requires a doctor referral. However, the plan does not cover Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, or other specific services such as Private Duty Nursing Services.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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