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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 Metro Chicago. 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 $4.50. 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 an enhanced alternative drug benefit. The plan has no deductible. During the initial coverage phase, you will pay different copays based on the drug tier and pharmacy type. For example, preferred generic drugs have no copay at a preferred pharmacy or through mail order, but a $19 copay at a standard pharmacy. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Clear Spring Health Essential (HMO) plan offers a variety of benefits with varying costs. For inpatient hospital stays, you'll pay a $225 copay for days 1-8, with no copay for days 9-90. Outpatient services have copays ranging from $30 to $200, and emergency services have a $90 copay. The plan covers primary care, hearing, vision, and dental services, with copays for exams and services. It also includes coverage for ambulance, transportation, and home health services with no copay, as well as home infusion and dialysis services with coinsurance. Additionally, the plan provides OTC items with a monthly allowance.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care, with a copay of $225 for days 1-8, and no copay for days 9-90. Additional days, non-Medicare-covered stays, and upgrades are not covered.
Outpatient Services See details
Outpatient Services are covered by the Clear Spring Health Essential (HMO) plan, including outpatient hospital services with a $30-$200 copay, observation services with a $200 copay, ambulatory surgical center services with a $30 copay, and outpatient substance abuse services with a $30-$40 copay. 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. You will pay a $55 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with no coinsurance. Ground and air ambulance services have a $225 copay, and transportation services to a plan-approved health-related location are covered for up to 12 one-way trips per year. 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 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. Worldwide Emergency Services are not covered.
Primary Care See details
The Clear Spring Health Essential (HMO) plan 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, and mental health specialty services with a $30 copay for individual and group sessions. It also covers physical therapy and speech-language pathology services with a $30 copay, additional telehealth benefits, and opioid treatment program services with a $30 copay. However, routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The Clear Spring Health Essential (HMO) plan covers preventive services, including Medicare-covered preventive services with no copay. Annual physical exams, health education, in-home safety assessments, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), 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 Benefit, 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 are not covered. Kidney Disease Education Services are covered with 20% coinsurance. Other preventive services, including Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit, are covered.
Hearing Services See details
Hearing Services include routine hearing exams with a $30 copay, and fitting/evaluation for hearing aids. Prescription hearing aids are covered up to $500 per year, and the plan covers 2 prescription hearing aids per year. OTC hearing aids, prescription hearing aids - inner ear, prescription hearing aids - outer ear, and prescription hearing aids - over the ear are not covered.
Vision Services See details
Vision services include eye exams with a $30 copay, routine eye exams once per year, and eyewear with a combined maximum benefit of $200 per year. Contact lenses, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Clear Spring Health Essential (HMO) plan covers dental services, 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, orthodontics services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, and oral and maxillofacial surgery. Orthodontic services have a maximum benefit of $1,500 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered. For Medicare Part B Insulin Drugs, there is a $35 copay, with coinsurance between 0% and 20%, while the other Part B drugs have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Clear Spring Health Essential (HMO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits are covered under the Clear Spring Health Essential (HMO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies - Non-Medicare benefit and Medical Supplies have a 20% coinsurance, while Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, but Diagnostic Procedures/Tests and Lab Services are not covered. Diagnostic Radiological Services have a copay of at most $175, and Outpatient X-Ray Services have a $4 copay. Therapeutic Radiological Services have a coinsurance of at most 20%.
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. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Clear Spring Health Essential (HMO) 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, but require prior authorization. For days 1-20, the copay is $20, and for days 21-100, the copay is $178; additional and non-Medicare-covered SNF days are not covered.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) Items, offering up to $60 per month for items such as nicotine replacement therapy and Naloxone, but acupuncture, meal benefits, and other services are not covered.
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