A non-government entity
CalOptima Health OneCare Flex Plus (HMO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for CalOptima Health OneCare Flex Plus (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 Flex Plus (HMO D-SNP) in 2025, please refer to our full plan details page.
CalOptima Health OneCare Flex Plus (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 Flex Plus (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 Flex Plus (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 Flex Plus (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 Flex Plus (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:
Sign up for CalOptima Health OneCare Flex Plus (HMO D-SNP)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The CalOptima Health OneCare Flex Plus (HMO D-SNP) plan has an enhanced alternative drug benefit. The plan has a deductible of $590.00. Once you meet the deductible, you will pay 25% coinsurance for preferred generic drugs at a standard pharmacy. After your total drug costs reach $2000.00, you enter the catastrophic coverage phase where you pay nothing for Medicare Part D covered drugs.
Additional Benefits
The CalOptima Health OneCare Flex Plus (HMO D-SNP) plan offers a range of benefits with various cost-sharing structures. Many services, including primary care, outpatient services, and preventive services, have a 20% coinsurance. Emergency, ambulance, and transportation services are covered, and many have a $0 copay. The plan also covers hearing, vision, and dental services. Hearing exams have a coinsurance up to 20%, and prescription hearing aids are covered up to $1,000 per year. Vision services include eye exams with a 20% coinsurance, and eyewear with a 20% coinsurance, up to $300 per year. Dental services are covered with a 20% coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits for CalOptima Health OneCare Flex Plus (HMO D-SNP) include Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both of which require prior authorization and a doctor referral. Additional Days, Non-Medicare-covered Stays, 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, observation services, ambulatory surgical center services, and outpatient substance abuse services, are covered. Outpatient hospital services have a 20% coinsurance, while individual and group sessions for outpatient substance abuse have a 20% coinsurance. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the CalOptima Health OneCare Flex Plus (HMO D-SNP) plan. This benefit has a 20% coinsurance.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with no copay for any services. Ground and Air Ambulance Services have a 20% coinsurance, which is waived if you are admitted to the hospital. Transportation Services to a plan-approved health-related location are covered, but transportation to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the CalOptima Health OneCare Flex Plus (HMO D-SNP) plan. Emergency Services and Urgently Needed Services have a 20% coinsurance, with maximum per visit amounts of $110 and $45, respectively, and no copay. Worldwide Emergency Services are covered up to a maximum of $100,000.
Primary Care See details
The CalOptima Health OneCare Flex Plus (HMO D-SNP) plan covers primary care physician services, chiropractic services, occupational therapy, physician specialist services, mental health specialty services, other health care professional services, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Most services have a 20% coinsurance, while routine chiropractic care and podiatry services are not covered.
Preventive Services See details
Preventive services are covered, including no-cost Medicare-covered preventive services with a doctor referral, and annual physical exams. Additional preventive services are partially covered, with services such as health education, and in-home safety assessments not covered. Other preventive services include a 20% coinsurance for glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit.
Hearing Services See details
Hearing Services include coverage for hearing exams with a coinsurance of at most 20%, but routine hearing exams and fitting/evaluation for hearing aids are not covered. Prescription hearing aids are covered up to a maximum of $1,000 per year, but prescription hearing aids for inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams have a 20% coinsurance for routine eye exams. Eyewear, including contact lenses, is covered with a 20% coinsurance and a combined maximum of $300 per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services are covered, including Medicare Dental Services with 20% coinsurance. Other Dental Services include oral exams (1 visit every six months), dental x-rays (4 x-rays every year), and other diagnostic dental services (1 visit every six months), though prophylaxis (cleaning) and fluoride treatment are not covered. Orthodontic Services cover restorative services (1 visit every year), adjunctive general services, endodontics, periodontics, prosthodontics (removable), prosthodontics (fixed), and oral and maxillofacial surgery. Maxillofacial prosthetics, implant services, 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 and 0-20% coinsurance, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the CalOptima Health OneCare Flex Plus (HMO D-SNP) plan, with a doctor's referral required. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance and Prosthetics/Medical Supplies with a 20% coinsurance. Diabetic Equipment is covered, and includes a 20% coinsurance for Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with a doctor referral and prior authorization required. Diagnostic Procedures/Tests, Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services have a coinsurance of at most 20%, while Lab Services are not covered.
Home Health Services See details
Home Health Services are covered by the CalOptima Health OneCare Flex Plus (HMO D-SNP) 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 under the CalOptima Health OneCare Flex Plus (HMO D-SNP) plan, but no specific services are covered. Prior authorization and a doctor referral are required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the CalOptima Health OneCare Flex Plus (HMO D-SNP) plan, but require prior authorization and a doctor's referral. The plan does not cover additional days beyond Medicare-covered SNF stays, nor does it cover non-Medicare-covered SNF stays.
Other Services See details
Other Services include Over-the-Counter (OTC) Items, with a maximum plan benefit coverage amount of $245 every three months, and the plan offers Nicotine Replacement Therapy (NRT) as a Part C OTC benefit. 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 are not covered.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
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.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved