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CalOptima Health OneCare Complete (HMO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for CalOptima Health OneCare Complete (HMO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on CalOptima Health OneCare Complete (HMO D-SNP) in 2025, please refer to our full plan details page.
CalOptima Health OneCare Complete (HMO D-SNP) is a HMO D-SNP plan offered by Orange County Health Authority available for enrollment in 2025 to people living in Orange County, California. This plan received an overall rating of 2.5 out of 5 stars in 2025.
It's important to know that CalOptima Health OneCare Complete (HMO D-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
CalOptima Health OneCare Complete (HMO D-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about CalOptima Health OneCare Complete (HMO D-SNP).
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 CalOptima Health OneCare Complete (HMO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $29.70. 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 a $590.00 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 $9350.00 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 CalOptima Health OneCare Complete (HMO D-SNP) plan has a $590 deductible for prescription drugs. After the deductible is met, you will pay the costs for drugs in each tier until your total drug costs reach $2000. If you qualify for the low-income subsidy, the plan's premium is $29.70. Once your yearly out-of-pocket drug costs reach $2000, you will enter the catastrophic coverage phase where you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. The plan's formulary should be checked for specific drug coverage information.
Additional Benefits
The CalOptima Health OneCare Complete (HMO D-SNP) plan offers a wide range of benefits with varying cost-sharing. Many services, including outpatient, partial hospitalization, ambulance, emergency, primary care, vision, dental, dialysis, and medical equipment, typically involve a 20% coinsurance. The plan also provides coverage for hearing exams and prescription hearing aids up to $1,000 per year, and home health services are available with no copay or coinsurance. Additional benefits include coverage for home infusion services, diagnostic and radiological services, skilled nursing facilities, and over-the-counter items with a quarterly allowance. However, it's important to note that certain services like cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered. Additionally, many preventive services, like annual physical exams, have a 20% coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, which require prior authorization. The cost sharing for these services is the Medicare-defined cost share for tier 1, and additional days and non-medicare covered stays are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a 20% coinsurance, observation services, ambulatory surgical center services with a 20% coinsurance, and outpatient substance abuse services. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered with prior authorization, and requires a 20% coinsurance.
Ambulance and Transportation Services See details
Ambulance and Transportation Services includes coverage for ground and air ambulance services with a 20% coinsurance, and transportation services to plan-approved health-related locations. Transportation services to any health-related location are not covered. There is no copay for any of these services.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by CalOptima Health OneCare Complete (HMO D-SNP). Emergency Services and Urgently Needed Services have a 20% coinsurance, and Worldwide Emergency Services has a maximum plan benefit coverage of $100,000.
Primary Care See details
The CalOptima Health OneCare Complete (HMO D-SNP) plan covers primary care physician services, chiropractic services, occupational therapy, physician specialist services, mental health specialty services, other health care professionals, psychiatric services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Most services have a 20% coinsurance, but routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The CalOptima Health OneCare Complete (HMO D-SNP) plan covers preventive services, including annual physical exams and kidney disease education services. Some additional preventive services are covered, but 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, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered. Other preventive services like Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit have a 20% coinsurance.
Hearing Services See details
Hearing Services includes hearing exams with a coinsurance of at most 20% and prescription hearing aids up to a maximum of $1,000 every year, but does not cover routine hearing exams, fitting/evaluation for hearing aids, inner ear hearing aids, outer ear hearing aids, over the ear hearing aids, or OTC hearing aids. Prior authorization and a doctor referral are required for hearing exams and prescription hearing aids.
Vision Services See details
Vision services include coverage for eye exams and eyewear. Eye exams have a 20% coinsurance, and routine eye exams are limited to one per year. Eyewear, including contact lenses, is covered with a 20% coinsurance and a combined maximum of $300 per year, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services include coverage for Medicare Dental Services with 20% coinsurance. Other dental services include oral exams, dental x-rays, and other diagnostic dental services, but prophylaxis (cleaning) and fluoride treatment are not covered. Orthodontic services cover restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery, but maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Insulin and other Medicare Part B Drugs, are covered, but require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay with coinsurance between 0% and 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the CalOptima Health OneCare Complete (HMO D-SNP) plan, requiring a doctor's referral. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME and Diabetic Supplies have a 20% coinsurance, while Prosthetic Devices and Medical Supplies have a 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the CalOptima Health OneCare Complete (HMO D-SNP) plan. Diagnostic Procedures/Tests and Diagnostic Radiological Services have a coinsurance of at most 20%, while Therapeutic Radiological Services and Outpatient X-Ray Services also have a coinsurance of at most 20%. Lab Services are not covered.
Home Health Services See details
Home Health Services are covered by the CalOptima Health OneCare Complete (HMO D-SNP) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. A referral and authorization are required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the CalOptima Health OneCare Complete (HMO D-SNP) plan. The plan also does not cover Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the CalOptima Health OneCare Complete (HMO D-SNP) plan, but prior authorization and a doctor referral are required. The plan does not cover additional days beyond Medicare-covered for SNF, and does not cover non-Medicare-covered stays for SNF.
Other Services See details
Other Services includes coverage for over-the-counter (OTC) items, with a maximum benefit of $135 every three months, and nicotine replacement therapy is offered as a Part C OTC benefit. Acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, private duty nursing services, and other services are not covered.
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