Clover Health Choice (PPO)

Inpatient Hospital See details

The Clover Health Choice (PPO) plan covers inpatient hospital stays, including services not usually covered by Medicare, but requires prior authorization. For Inpatient Hospital-Acute, you will pay a $375 copay for days 1-6, and no copay for days 7-90, and for Inpatient Hospital Psychiatric, you will pay a $320 copay for days 1-6, and no copay for days 7-90. Additional days and upgrades for Inpatient Hospital-Acute, as well as additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.

Outpatient Services See details

Outpatient Services, including Outpatient Hospital Services and Observation Services, have a copay of $390.00. Ambulatory Surgical Center (ASC) Services have a $250.00 copay, while Outpatient Substance Abuse services have a copay of $45.00 for individual sessions and $35.00 for group sessions. Outpatient Blood Services are also covered.

Partial Hospitalization See details

Partial Hospitalization is covered under the Clover Health Choice (PPO) plan, but requires prior authorization. The copay for this benefit is $70.

Ambulance and Transportation Services See details

Ambulance and Transportation Services are covered by the Clover Health Choice (PPO) plan. Ground and Air Ambulance Services have a $350 copay, with no coinsurance, while 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 under the Clover Health Choice (PPO) plan. Emergency Services have a $100 copay, and Urgently Needed Services have a $40 copay, and there is no coinsurance for either. Worldwide Emergency Coverage has a $100 copay, Worldwide Urgent Coverage has a $40 copay, and Worldwide Emergency Transportation has a $350 copay. There is a $50,000 maximum plan benefit coverage for Worldwide Emergency Services.

Primary Care See details

The Clover Health Choice (PPO) plan covers primary care physician services, chiropractic services with a $15 copay, occupational therapy services with a $25 copay, physician specialist services with a $10 copay, and mental health specialty services with a $45 copay for individual sessions and a $35 copay for group sessions. The plan also covers physical therapy and speech-language pathology services with a $25 copay, additional telehealth benefits with a $0-$10 copay, and opioid treatment program services with a $20 copay. Routine chiropractic care and podiatry services are not covered.

Preventive Services See details

The Clover Health Choice (PPO) plan covers preventive services, including annual physical exams, with no copay. Additional preventive services such as Health Education, In-Home Safety Assessment, and others are not covered, but the plan does cover fitness benefits and remote access technologies.

Hearing Services See details

Hearing Services include hearing exams with a $10 copay, and routine hearing exams and fitting/evaluation for hearing aids are covered. Prescription hearing aids are partially covered, with a copay between $699 and $999 for all types, but not for inner ear, outer ear, or over the ear hearing aids. OTC hearing aids are not covered.

Vision Services See details

Vision services include eye exams with a $10 copay, and eyewear, including contact lenses and eyeglasses (lenses and frames). The plan covers one pair of contact lenses and one pair of eyeglasses (lenses and frames) every year, and has a combined maximum benefit of $100 per year for all eyewear. Eyeglass lenses, eyeglass frames, and upgrades are not covered.

Dental Services See details

Dental Services are covered, including Medicare Dental Services with a $10 copay. Other dental services are covered, up to a maximum of $1250 per year.

Restorative, Adjunctive General, Endodontics, Periodontics, Maxillofacial Prosthetics, Implant Services, Prosthodontics, fixed, and Oral and Maxillofacial Surgery services have a $20 copay. Prosthodontics, removable services have a 50% coinsurance. Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Fluoride Treatment, and Other Preventive Dental Services are also covered. 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, while 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 Clover Health Choice (PPO) plan. You will pay 20% coinsurance for these services.

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 Prosthetics/Medical Supplies have a 20% coinsurance, and Diabetic Equipment limits supplies to specified manufacturers; however, Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.

Diagnostic and Radiological Services See details

Diagnostic and Radiological Services are covered, including all diagnostic services and lab services with no copay. Diagnostic Procedures/Tests have a copay between $0 and $200, while Diagnostic Radiological Services have a copay between $50 and $200. Therapeutic Radiological Services have 20% coinsurance. Outpatient X-Ray Services have a $40 copay.

Home Health Services See details

Home Health Services are covered by Clover Health Choice (PPO) 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 Clover Health Choice (PPO) plan. This includes 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.

Skilled Nursing Facility (SNF) See details

Skilled Nursing Facility (SNF) services are covered by the Clover Health Choice (PPO) plan, but require prior authorization. For days 1-20, there is no copay, while days 21-100 have a $203 copay; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.

Other Services See details

Other Services include coverage for over-the-counter (OTC) items, with a maximum benefit of $75 every three months, and the plan does not cover Acupuncture, Meal Benefit, 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.