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Community Health Plan of WA MA Plan 4 (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Community Health Plan of WA MA Plan 4 (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Community Health Plan of WA MA Plan 4 (HMO) in 2025, please refer to our full plan details page.
Community Health Plan of WA MA Plan 4 (HMO) is a HMO plan offered by Community Health Plan of Washington available for enrollment in 2025 to people living in Eastern and Western Washington State. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that Community Health Plan of WA MA Plan 4 (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 Community Health Plan of WA MA Plan 4 (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 Community Health Plan of WA MA Plan 4 (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $107.00. 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 no drug deductible. Your prescription medication coverage will start immediately.
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 Community Health Plan of WA MA Plan 4 (HMO)
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Drug Coverage
The Community Health Plan of WA MA Plan 4 (HMO) has an enhanced alternative drug benefit. The plan has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, preferred generic drugs have a $10 copay at preferred pharmacies. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for Part D covered drugs.
Additional Benefits
The Community Health Plan of WA MA Plan 4 (HMO) offers a range of benefits with varying costs. For inpatient hospital stays, you'll pay a copay, but the copay is waived after a few days. Outpatient services, including emergency services, have copays, while some services like vision and dental have coinsurance. This plan also covers primary care visits, hearing exams, and medical equipment with copays or coinsurance. Additionally, it includes preventive services like alternative therapies and fitness benefits. This plan also offers other services like dialysis services, cardiac rehabilitation, and skilled nursing facility services.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you pay a $500 copay for days 1-4, and no copay for days 5-90; for Inpatient Hospital Psychiatric, you pay a $175 copay for days 1-10, and no copay for days 11-90. Additional Days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered. Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services, observation services, and ambulatory surgical center services, each have a copay of $325.00, and outpatient substance abuse services have a 20% coinsurance for both individual and group sessions. Outpatient blood services are also covered, with a waived three-pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered under the Community Health Plan of WA MA Plan 4 (HMO) with a 20% coinsurance. Prior authorization and a doctor referral are required to receive this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Community Health Plan of WA MA Plan 4 (HMO), including ground and air ambulance services with a $325 copay, and no coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered, including emergency services, urgently needed services, and worldwide emergency services. Emergency services have a $100 copay, while worldwide emergency services have a 20% coinsurance and a maximum plan benefit of $25,000. Urgently needed services have no copay or coinsurance.
Primary Care See details
Community Health Plan of WA MA Plan 4 (HMO) covers primary care physician services, chiropractic services with a $15 copay, occupational therapy services with a $30 copay, physician specialist services with a $40 copay, mental health specialty services with a $30 copay, podiatry services, other health care professional services with a copay between $0 and $30, psychiatric services with a $30 copay, physical therapy and speech-language pathology services with a $30 copay, additional telehealth benefits with a 20% coinsurance and a copay between $0 and $40, and opioid treatment program services with a 20% coinsurance.
Preventive Services See details
Preventive Services include coverage for Medicare-covered preventive services with a doctor referral, along with additional preventive services that are not typically covered by Medicare, such as Alternative Therapies (12 visits), Additional Sessions of Smoking and Tobacco Cessation Counseling (8 visits), Fitness Benefit, and Remote Access Technologies. Annual Physical Exams, Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Enhanced Disease Management, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing Services are partially covered by Community Health Plan of WA MA Plan 4 (HMO). Hearing exams require a $20 copay, while routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids (all types, inner ear, outer ear, and over the ear), and OTC hearing aids are not covered.
Vision Services See details
Vision services include coverage for eye exams with a $40 copay, and eyewear with 20% coinsurance. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered with no coinsurance.
Dental Services See details
Dental services include coverage for Medicare dental services with 20% coinsurance, and other services such as oral exams, dental x-rays, and orthodontics are covered. Orthodontic services have a maximum plan benefit of $500 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. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Community Health Plan of WA MA Plan 4 (HMO) with a doctor referral required. This plan has a coinsurance of 20% for dialysis services.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME) with 20% coinsurance and Prosthetics/Medical Supplies with 20% coinsurance, but Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered. There is no copay for any of these services.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures/tests with a coinsurance of at most 20% and lab services with no coinsurance. Diagnostic radiological services and therapeutic radiological services have a coinsurance of at most 20%, and outpatient X-ray services have a $15 copay.
Home Health Services See details
Home Health Services are covered by the Community Health Plan of WA MA Plan 4 (HMO) with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization and a referral are required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but not Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization and a doctor referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Community Health Plan of WA MA Plan 4 (HMO). There is no copay for days 1-20, and a $200 copay for days 21-100.
Other Services See details
The Community Health Plan of WA MA Plan 4 (HMO) plan covers acupuncture with a limit of 12 treatments per year, while over-the-counter items, 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. The plan also covers a meal benefit, with a doctor referral required.
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