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Capital Health Plan Advantage Plus (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Capital Health Plan Advantage Plus (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Capital Health Plan Advantage Plus (HMO) in 2025, please refer to our full plan details page.
Capital Health Plan Advantage Plus (HMO) is a HMO plan offered by Guidewell Mutual Holding Corporation available for enrollment in 2025 to people living in Leon and surrounding counties. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Capital Health Plan Advantage Plus (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 Capital Health Plan Advantage Plus (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 Capital Health Plan Advantage Plus (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $26.00. 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 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 $5500.00 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 Capital Health Plan Advantage Plus (HMO) plan has a $250 deductible for prescription drugs. In the initial coverage phase, you will pay a copay for your prescriptions. For preferred generics, the copay is $7.00 at standard and mail-order pharmacies. Standard generics have a $45 copay, and preferred brands have a $95 copay. Non-preferred drugs have 30% coinsurance, and specialty tier drugs have no copay. After your yearly out-of-pocket drug costs reach $2000, you will pay nothing for Medicare Part D covered drugs.
Additional Benefits
The Capital Health Plan Advantage Plus (HMO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay, while outpatient services have copays for specific services like outpatient hospital and substance abuse. Emergency, primary care, and hearing exams have copays, and vision services include coverage for eye exams and eyewear. This plan provides coverage for dental services, home infusion, and dialysis, with cost-sharing through copays or coinsurance. Durable medical equipment and home health services are covered, and there is coverage for cardiac rehabilitation and skilled nursing facilities. The plan also covers over-the-counter items and Naloxone.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric, are covered. For inpatient hospital stays, you'll pay a $250 copay for days 1-5 and no copay for days 6-90, with a service-specific out-of-pocket maximum of $1250. Additional days are covered, but non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services are covered, including outpatient hospital services with a $300 copay, observation services, ambulatory surgical center services with a $150 copay, and outpatient substance abuse services with a $30 copay for both individual and group sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Capital Health Plan Advantage Plus (HMO) plan, with a $40 copay. Prior authorization and a doctor's referral are required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Capital Health Plan Advantage Plus (HMO) plan, but Transportation Services are not covered. Ground and Air Ambulance Services have a $290 copay, and there is no coinsurance.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Capital Health Plan Advantage Plus (HMO) plan. Emergency Services have a $125 copay, Urgently Needed Services have a $20 copay, Worldwide Emergency Coverage has a $125 copay, Worldwide Urgent Coverage has a $20 copay, and Worldwide Emergency Transportation has a $290 copay, and all services have no coinsurance.
Primary Care See details
The Capital Health Plan Advantage Plus (HMO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, and occupational therapy services with a $20 copay. The plan also covers physician specialist services with a $30 copay, mental health and psychiatric services with a $30 copay, and physical therapy and speech-language pathology services with a $20 copay. Additional telehealth benefits are covered with a copay between $0 and $30, and opioid treatment program services are covered with a $30 copay.
Preventive Services See details
The Capital Health Plan Advantage Plus (HMO) plan covers preventive services, but does not cover annual physical exams, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, 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, enhanced disease management, telemonitoring services, home and bathroom safety devices and modifications, and counseling services. Kidney disease education services have a $10 copay. Other preventive services include glaucoma screenings with a $10-$30 copay, diabetes self-management training with a $10 copay, and barium enemas with a $10 copay.
Hearing Services See details
The Capital Health Plan Advantage Plus (HMO) plan covers hearing exams with a $30 copay, and covers prescription and OTC hearing aids, up to $600 per year, combined for both ears. Fitting/Evaluation for Hearing Aids, and Prescription Hearing Aids - Inner Ear, Outer Ear, and Over the Ear are not covered.
Vision Services See details
Vision services include coverage for eye exams with a copay of $10-$30, and eyewear, including contact lenses and eyeglasses (lenses and frames). Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $30 copay, and other services including oral exams, x-rays, and more, all of which are covered. There is a maximum plan benefit of $600 every year for these services.
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. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Capital Health Plan Advantage Plus (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
The Capital Health Plan Advantage Plus (HMO) plan covers Durable Medical Equipment (DME) with a 20% coinsurance and requires authorization, but does not cover Durable Medical Equipment for use outside the home. Prosthetics/Medical Supplies and Diabetic Equipment are covered, with a 20% coinsurance for Medicare-covered prosthetic devices, medical supplies, and diabetic therapeutic shoes/inserts. Diabetic supplies have a coinsurance between 0% and 20%, and the plan limits diabetic supplies and services to those from specified manufacturers.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Capital Health Plan Advantage Plus (HMO). Diagnostic services do not have a copay, but Diagnostic Procedures/Tests and Lab Services are not covered; Diagnostic Radiological Services have a copay of at most $100, and Therapeutic Radiological Services have a coinsurance of at most 20%; Outpatient X-Ray Services are not covered.
Home Health Services See details
Home Health Services are covered by the Capital Health Plan Advantage Plus (HMO) plan, with no copay or coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but not the specific services of 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. A doctor referral and prior authorization are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Capital Health Plan Advantage Plus (HMO) plan, requiring prior authorization and a doctor's referral. For days 1-20, the copay is $10, and for days 21-100, the copay is $200; additional and non-Medicare-covered SNF days are not covered.
Other Services See details
Other Services include coverage for over-the-counter items, with no maximum plan benefit coverage amount and coverage for Naloxone, but does not cover acupuncture or meal benefits. Additionally, this plan does not cover 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.
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