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Capital Health Plan Silver Advantage (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Capital Health Plan Silver Advantage (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 Silver Advantage (HMO) in 2025, please refer to our full plan details page.
Capital Health Plan Silver Advantage (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 Silver Advantage (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 Silver Advantage (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 Silver Advantage (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 $23.00. 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 no drug deductible. Your prescription medication coverage will start immediately.
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:
Sign up for Capital Health Plan Silver Advantage (HMO)
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Drug Coverage
The Capital Health Plan Silver Advantage (HMO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay a copay for your prescriptions depending on the drug tier and pharmacy you use. For example, preferred generic drugs have a $7 copay at preferred pharmacies and a $14 copay at standard pharmacies. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for covered Part D drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
The Capital Health Plan Silver Advantage (HMO) offers comprehensive coverage with a range of benefits. Inpatient hospital stays have a copay, and outpatient services have varying copays depending on the service. Emergency, primary care, hearing, vision, and dental services are also covered, with copays applying to some services. The plan also includes coverage for preventive services, home health, and medical equipment. Additionally, there is coverage for home infusion and dialysis, though coinsurance or copays may apply. The plan also offers coverage for over-the-counter items, and skilled nursing facility stays with a copay.
Inpatient Hospital See details
Inpatient hospital services are covered, including acute and psychiatric care. For days 1-6, there is a $275 copay, and for days 7-90, there is no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute are not covered, as are Non-Medicare-covered stays for Inpatient Hospital Psychiatric.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered by Capital Health Plan Silver Advantage (HMO). Outpatient hospital services have a $350 copay, while Ambulatory Surgical Center (ASC) Services have a $250 copay, and Individual and Group Sessions for Outpatient Substance Abuse services have a $30 copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Capital Health Plan Silver Advantage (HMO) with a $40 copay, but requires prior authorization and a doctor's referral.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Capital Health Plan Silver Advantage (HMO). Ground and Air Ambulance Services have a $290 copay, and there is no coinsurance. 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 under the Capital Health Plan Silver Advantage (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $125 copay, Urgently Needed Services and Worldwide Urgent Coverage have a $20 copay, and Worldwide Emergency Transportation has a $290 copay; all services have no coinsurance.
Primary Care See details
The Capital Health Plan Silver Advantage (HMO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay (routine care not covered), occupational therapy services with a $30 copay, physician specialist services with a $30 copay, and mental health specialty services with a $30 copay. The plan also covers other health care professionals, psychiatric services, physical therapy and speech-language pathology services with a $30 copay, and additional telehealth benefits with a copay between $0 and $30.
Preventive Services See details
Preventive Services are covered, including services not usually covered by Medicare plans. Medicare-covered preventive services, Health Education, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, Remote Access Technologies, Glaucoma Screening, Diabetes Self-Management Training, Digital Rectal Exams, and EKG following Welcome Visit are covered. Kidney Disease Education Services have a $10 copay. Other covered preventive services include Barium Enemas, which require a referral. Annual Physical Exams, 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, Alternative Therapies, 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
The Capital Health Plan Silver Advantage (HMO) plan covers hearing exams with a $30 copay, and covers prescription hearing aids up to $200 per year, and OTC hearing aids up to $200 per year. Fitting/Evaluation for 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 coverage for eye exams with a copay of $10-$30, and coverage for contact lenses and eyeglasses (lenses and frames). Eyeglasses 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 dental services with a $200 maximum benefit per year. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. 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 under the Capital Health Plan Silver Advantage (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment is covered by the Capital Health Plan Silver Advantage (HMO), including Durable Medical Equipment (DME) with 20% coinsurance, Prosthetic Devices with 20% coinsurance, Medical Supplies with 20% coinsurance, Diabetic Supplies with 0-20% coinsurance, and Diabetic Therapeutic Shoes/Inserts with 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by the Capital Health Plan Silver Advantage (HMO), with no copay for all diagnostic services. Diagnostic procedures/tests, lab services, and outpatient X-Ray services are not covered; however, diagnostic radiological services have a copay of up to $100, and therapeutic radiological services have a coinsurance of up to 20%.
Home Health Services See details
Home Health Services are covered by the Capital Health Plan Silver Advantage (HMO) with no copay or coinsurance, but a referral is required. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization and a doctor referral are required, and you may have a copay for some services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Capital Health Plan Silver Advantage (HMO) plan, but require prior authorization and a doctor's referral. The copay is $10 for days 1-20 and $200 for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include Over-the-Counter (OTC) Items, which are covered, but acupuncture, meal benefits, and several other services are not covered. The plan provides OTC items as a supplemental benefit and covers all drugs on the CMS OTC list.
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