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Clear Spring Health Essential (HMO C-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Clear Spring Health Essential (HMO C-SNP). 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 C-SNP) in 2025, please refer to our full plan details page.
Clear Spring Health Essential (HMO C-SNP) is a HMO C-SNP 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 C-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Clear Spring Health Essential (HMO C-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 Clear Spring Health Essential (HMO C-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 Clear Spring Health Essential (HMO C-SNP), 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 $5.00. 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 a $250.00 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 $6751.00 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 C-SNP) plan has a $250 deductible for prescription drugs. After the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, you'll have no copay at preferred pharmacies and mail order, and a $20 copay at standard pharmacies. The copays increase for higher tiers and non-preferred drugs have a 29% coinsurance. 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 C-SNP) plan offers a range of benefits. Inpatient hospital stays have a copay, with different amounts depending on the type of service and length of stay. Outpatient services, including substance abuse treatment, have copays. The plan also covers ambulance and transportation, emergency services, and primary care with varying copays. Preventive services are covered with no copay, while hearing, vision, and dental services have copays or coinsurance. Other covered services include home infusion, dialysis, medical equipment, and diagnostic services, each with its own cost structure. The plan also offers Skilled Nursing Facility (SNF) services, and covers home health services with no copay, and over-the-counter items with a monthly benefit.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, both of which require prior authorization. For Inpatient Hospital-Acute, you pay a $290 copay for days 1-5, and no copay for days 6-90, and a $800 copay for days 1-60. For Inpatient Hospital Psychiatric, you pay a $290 copay for days 1-5, and no copay for days 6-90, and a $800 copay for days 1-60. Additional days, non-Medicare-covered stays, and upgrades are not covered for either service.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center services, and outpatient substance abuse services. Outpatient hospital and observation services have a $225 copay, ambulatory surgical center services have a $175 copay, and outpatient substance abuse individual and group sessions have a $45 copay; outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Clear Spring Health Essential (HMO C-SNP) plan. The copay for this benefit is $50.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground and air ambulance services have a $225 copay, with no coinsurance. Transportation Services to a plan-approved health-related location are covered for 12 one-way trips per year.
Emergency Services See details
Emergency Services, including Urgently Needed Services, are covered by Clear Spring Health Essential (HMO C-SNP). Emergency Services have an $80 copay with no coinsurance, and Urgently Needed Services have a $45 copay with no coinsurance. Worldwide Emergency Services, including Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation, are not covered.
Primary Care See details
The Clear Spring Health Essential (HMO C-SNP) plan covers Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services. Chiropractic services have a $15 copay, while occupational therapy has a $35 copay. Physician Specialist Services have a copay between $0 and $25. Mental Health Specialty Services, Psychiatric Services, and Other Health Care Professional services have a $30 copay. Physical Therapy and Speech-Language Pathology Services have a $40 copay, and additional telehealth benefits have a $10 copay. This plan does not cover podiatry services.
Preventive Services See details
The Clear Spring Health Essential (HMO C-SNP) plan covers preventive services, including Medicare-covered services, with no copay. Additional preventive services are partially covered, with the following services not covered: annual physical exams, health education, in-home safety assessment, personal emergency response system, 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 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.
Hearing Services See details
Hearing Services include hearing exams with a $30 copay, as well as coverage for fitting/evaluation for hearing aids and prescription hearing aids (all types) with a maximum benefit of $500 per ear every year. Prescription hearing aids for the inner ear, outer ear, and over the ear, as well as OTC hearing aids, are not covered.
Vision Services See details
Vision Services include routine eye exams with a $30 copay, and the plan covers one routine eye exam every year. Eyewear is covered, with a combined maximum plan benefit coverage of $250 every year; however, contact lenses, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Clear Spring Health Essential (HMO C-SNP) plan covers dental services, including oral exams with a $30 copay, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, and other preventive dental services. The plan also covers orthodontic services, with a maximum benefit of $2000 per year. The plan also covers restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics.
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, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for these services.
Dialysis Services See details
Dialysis Services are covered under the Clear Spring Health Essential (HMO C-SNP) plan. You will pay 20% coinsurance for this benefit.
Medical Equipment See details
Medical Equipment is covered by the Clear Spring Health Essential (HMO C-SNP) plan, with Durable Medical Equipment (DME) requiring 20% coinsurance, and Prosthetics/Medical Supplies requiring 20% coinsurance; 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 include coverage for Diagnostic Procedures/Tests with a coinsurance of at most 20%, Lab Services with a $5 copay, Diagnostic Radiological Services with a coinsurance of at most 20%, Therapeutic Radiological Services with a coinsurance of at most 20%, and Outpatient X-Ray Services with a $25 copay. Prior authorization is required for all diagnostic and radiological services.
Home Health Services See details
Home Health Services are covered by the Clear Spring Health Essential (HMO C-SNP) plan 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 Clear Spring Health Essential (HMO C-SNP) plan. This includes Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Clear Spring Health Essential (HMO C-SNP) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $167.
Other Services See details
The Clear Spring Health Essential (HMO C-SNP) plan covers Over-the-Counter (OTC) items with a maximum benefit of $60.00 per month. 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.
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