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Clear Spring Health Essential (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Clear Spring Health Essential (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Clear Spring Health Essential (HMO) in 2025, please refer to our full plan details page.
Clear Spring Health Essential (HMO) is a HMO plan offered by Group 1001 available for enrollment in 2025 to people living in Rockford, Metro St Louis. The overall rating for this plan is not yet available for 2025.
It's important to know that Clear Spring Health Essential (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 Clear Spring Health Essential (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 Clear Spring Health Essential (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $5.50. You must continue to pay paying your reduced 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 $2900.00 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 Clear Spring Health Essential (HMO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you'll pay varying copays or coinsurance depending on the drug tier and pharmacy you use. For example, preferred generic drugs have no copay at preferred pharmacies and preferred mail order, while standard generic drugs have a $42 or $47 copay. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for covered Part D drugs. If you qualify for the low-income subsidy, your Part D costs will be $0.
Additional Benefits
The Clear Spring Health Essential (HMO) plan covers a variety of services, including inpatient and outpatient hospital care, with varying copays. It also includes coverage for emergency services, primary care, preventive services, hearing, vision, and dental services. This plan offers additional benefits like transportation, home health services, and medical equipment, with some services requiring prior authorization. Additionally, there is a monthly allowance for over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital benefits, including both acute and psychiatric care, are covered, but require prior authorization. For days 1-8, the copay is $225, and for days 9-90, there is no copay.
Outpatient Services See details
Outpatient services, including all outpatient hospital services, are covered. Outpatient hospital services have a copay of $30-$200, observation services have a $200 copay per stay, and ambulatory surgical center services have a $30 copay. Outpatient substance abuse services, including individual sessions with a $30 copay and group sessions with a $40 copay, are also covered, but outpatient blood services are not covered.
Partial Hospitalization See details
Partial hospitalization is covered by the Clear Spring Health Essential (HMO) plan, but requires prior authorization. The copay for this benefit is $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with no coinsurance. Ground and air ambulance services have a copay of $225.00. Transportation services to a plan-approved health-related location are covered for 12 one-way trips per year, and transportation to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Clear Spring Health Essential (HMO) plan. Emergency Services have a $90 copay and no coinsurance, while Urgently Needed Services have a $35 copay and no coinsurance; however, Worldwide Emergency Services, Worldwide Urgent Coverage, and Worldwide Emergency Transportation are not covered.
Primary Care See details
Primary Care for Clear Spring Health Essential (HMO) covers Primary Care Physician Services, Chiropractic Services (with a $20 copay), Occupational Therapy Services (with a $30 copay), Physician Specialist Services (with a $0-$35 copay), Mental Health Specialty Services (with a $30 copay for individual and group sessions), Other Health Care Professional (with a $30 copay), Psychiatric Services (with a $30 copay for individual and group sessions), Physical Therapy and Speech-Language Pathology Services (with a $30 copay), Additional Telehealth Benefits, and Opioid Treatment Program Services (with a $30 copay). Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
Preventive Services are covered by the Clear Spring Health Essential (HMO) plan, including Medicare-covered zero-dollar preventive services, with the exception of annual physical exams, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, 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, home and bathroom safety devices and modifications, and counseling services. Kidney Disease Education Services are covered with 20% coinsurance, and other preventive services like glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit are covered.
Hearing Services See details
Hearing Services include routine hearing exams with a $30 copay, and fitting/evaluation for hearing aids, both covered once per year. Prescription hearing aids are covered up to $500 per year, and prescription hearing aids (all types) are covered twice per year, but prescription hearing aids for the inner, outer, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $30 copay, and routine eye exams once per year. Eyewear is covered with a combined maximum of $200 per year for all eyewear, but contact lenses, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are covered, including Medicare dental services with a $30 copay. Other dental services include oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, orthodontic services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics, with a maximum benefit of $1500 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, Medicare Part B Chemotherapy/Radiation Drugs with 0-20% coinsurance, and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for this benefit.
Dialysis Services See details
Dialysis Services are covered under the Clear Spring Health Essential (HMO) plan. You will pay a coinsurance of 20% for these services.
Medical Equipment See details
Medical Equipment is covered by the Clear Spring Health Essential (HMO) plan, including Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts with 20% coinsurance, but Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered, and include a copay for some services. Diagnostic Procedures/Tests and Lab Services are not covered. Diagnostic Radiological Services have a copay of at most $175, with a minimum copay of $20, and Therapeutic Radiological Services have a coinsurance of at most 20%, with a minimum coinsurance of 20. Outpatient X-Ray Services have a $4 copay.
Home Health Services See details
Home Health Services are covered by the Clear Spring Health Essential (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover the following sub-services: Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. For days 1-20, the copay is $20 per day, and for days 21-100, the copay is $178 per day.
Other Services See details
Other Services offered by the Clear Spring Health Essential (HMO) plan include a monthly allowance of $55 for Over-the-Counter (OTC) items, which may include nicotine replacement therapy and Naloxone, but acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, and several other services are not covered.
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