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Imperial Giveback (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Imperial Giveback (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Imperial Giveback (HMO) in 2025, please refer to our full plan details page.
Imperial Giveback (HMO) is a HMO plan offered by Imperial Health Plan of California available for enrollment in 2025 to people living in Northern, Central and Southern California. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Imperial Giveback (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 Imperial Giveback (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 Imperial Giveback (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 $100.00. 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 $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 Imperial Giveback (HMO) plan has a $590 deductible for prescription drugs. After meeting the deductible, you'll pay the costs for your drugs based on the tier and pharmacy you use until your total drug costs reach $2000. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for your Part D covered drugs. If you qualify for the low-income subsidy, your Part D costs are $0.
Additional Benefits
The Imperial Giveback (HMO) plan offers a range of benefits with varying cost-sharing. Many services, including preventive services, home health, and diagnostic services, have no copay. Other services, such as outpatient services, primary care, and ambulance services, have a 20% coinsurance. The plan also includes coverage for hearing aids with a $500 annual maximum, vision services with a $500 annual maximum for eyewear, and dental services with a $500 annual maximum for other services and a $2,000 annual maximum for orthodontics. Additionally, the plan provides $75 every three months for over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital benefits are covered under the Imperial Giveback (HMO) plan, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, but the copay is not specified. Additional days, non-Medicare-covered stays, and upgrades for Inpatient Hospital-Acute and Additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
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 20% coinsurance, while individual and group sessions for outpatient substance abuse also have a 20% coinsurance. Outpatient Blood Services are not covered.
Partial Hospitalization See details
Partial hospitalization is covered with a 20% coinsurance, and requires prior authorization and a doctor's referral.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Imperial Giveback (HMO) plan. Ground and Air Ambulance Services have a 20% coinsurance, with no copay, while Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered by the Imperial Giveback (HMO) plan, with a 20% coinsurance, and no copay. Worldwide Emergency Services, including Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation, are not covered.
Primary Care See details
The Imperial Giveback (HMO) plan covers primary care physician services, chiropractic services, occupational therapy services, 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 with 20% coinsurance. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The Imperial Giveback (HMO) plan covers Medicare-covered preventive services with no copay, but requires a doctor referral. 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 with 20% coinsurance.
Hearing Services See details
Hearing services include hearing exams, routine hearing exams, and fitting/evaluation for hearing aids, all covered with no deductible. Prescription hearing aids are covered, with a maximum plan benefit of $500 every year, but inner ear, outer ear, and over-the-ear hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision services with the Imperial Giveback (HMO) plan include eye exams with 20% coinsurance and routine eye exams once per year. Eyewear is covered with a maximum plan benefit of $500 per year, and contact lenses and eyeglasses (lenses and frames) are covered once per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Imperial Giveback (HMO) plan offers dental services including oral exams, dental x-rays, prophylaxis (cleaning), fluoride treatment, restorative services, prosthodontics (removable and fixed), and oral and maxillofacial surgery. This plan offers a $500 maximum for Other Dental Services per year and a $2,000 maximum for orthodontic services per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. The coinsurance for Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs is between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Imperial Giveback (HMO) plan, but require prior authorization and a doctor's referral. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits are covered by the Imperial Giveback (HMO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, with no copay, and requires prior authorization. Prosthetic Devices have a 20% coinsurance, with no copay, and require prior authorization. Medical Supplies have a 20% coinsurance, with no copay, and require prior authorization. Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts each have a 20% coinsurance, with no copay, and require prior authorization. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including diagnostic procedures, lab services, diagnostic radiological services, therapeutic radiological services, and outpatient X-ray services, are covered by the Imperial Giveback (HMO) plan. All services have no copay, but you may have to pay up to 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the Imperial Giveback (HMO) 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 not covered under the Imperial Giveback (HMO) plan. Specifically, 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 are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but additional days beyond Medicare-covered and non-Medicare-covered stays are not covered. You will pay the Medicare-defined cost share for tier 1, and prior authorization and a doctor's referral are required.
Other Services See details
Other Services includes Over-the-Counter (OTC) Items, with a maximum benefit coverage of $75 every three months. Other services such as acupuncture and meal benefits are not covered.
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