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CareAdvantage (HMO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for CareAdvantage (HMO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on CareAdvantage (HMO D-SNP) in 2025, please refer to our full plan details page.
CareAdvantage (HMO D-SNP) is a HMO D-SNP plan offered by Health Plan of San Mateo available for enrollment in 2025 to people living in San Mateo County. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that CareAdvantage (HMO D-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
CareAdvantage (HMO D-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 CareAdvantage (HMO D-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 CareAdvantage (HMO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $29.70. 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 $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 CareAdvantage (HMO D-SNP) plan has an "Enhanced Alternative" drug benefit. The plan has a deductible of $590.00. During the initial coverage phase, after you meet your deductible, you pay 25% coinsurance for drugs in the Preferred Generic tier at Standard Pharmacies and Standard Mail. Once your total drug costs reach $2000.00, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The CareAdvantage (HMO D-SNP) plan offers a range of benefits, including inpatient hospital stays with a $1082 copay, and outpatient services with a 20% coinsurance. Emergency, urgent, and worldwide emergency services are covered, but may require coinsurance and have coverage limits. This plan includes coverage for primary care, preventive, hearing, vision, and dental services, though some services may have coinsurance or specific exclusions. Additional benefits include ambulance services with 20% coinsurance, dialysis services with 20% coinsurance, and home health services with no copay. Other services such as home infusion, medical equipment, and diagnostic services are covered with coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, there is a copay of $1082.00 for a Medicare-covered stay, with no deductible.
Outpatient Services See details
Outpatient services, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services, are covered under the CareAdvantage (HMO D-SNP) plan. Outpatient hospital services, observation services, and outpatient blood services have a 20% coinsurance, while individual and group sessions for outpatient substance abuse have a minimum coinsurance of 20% and a maximum coinsurance of 20%.
Partial Hospitalization See details
CareAdvantage (HMO D-SNP) covers partial hospitalization with a 20% coinsurance. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services, including services not usually covered by Medicare, are covered under the CareAdvantage (HMO D-SNP) plan. Ground and air ambulance services have a 20% coinsurance, and transportation services to a plan-approved health-related location are covered for 12 one-way trips per month. 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 CareAdvantage (HMO D-SNP) plan. For Emergency Services and Urgently Needed Services, there is a 20% coinsurance, and no copay, with the Emergency Services coinsurance waived if admitted to the hospital within 24 hours. Worldwide Emergency Services has a maximum plan benefit coverage of $25,000.
Primary Care See details
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 are covered under this plan. Primary Care Physician Services, Chiropractic Services, Physician Specialist Services, and Physical Therapy and Speech-Language Pathology Services have a 20% coinsurance, while Occupational Therapy Services, Mental Health Specialty Services, Psychiatric Services, and Opioid Treatment Program Services have a minimum and maximum coinsurance of 20%. Routine Chiropractic Care is not covered, and Podiatry Services are not covered.
Preventive Services See details
The CareAdvantage (HMO D-SNP) plan covers preventive services, including Medicare-covered services with no copay, and additional preventive services not usually covered by Medicare. Some services, such as annual physical exams, health education, in-home safety assessments, 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, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, remote access technologies, home and bathroom safety devices and modifications, and counseling services are not covered. Other preventive services such as Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit have a 20% coinsurance.
Hearing Services See details
Hearing Services are partially covered by the CareAdvantage (HMO D-SNP) plan. While hearing exams are covered, the plan has a coinsurance of at most 20% and does not have a deductible; however, routine hearing exams and fitting/evaluation for hearing aids are not covered.
Vision Services See details
The CareAdvantage (HMO D-SNP) plan covers vision services, including routine eye exams and eyewear. Routine eye exams and eyewear have a 20% coinsurance, with contact lenses covered. Eyeglasses (lenses and frames) are covered, while eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services are partially covered under the CareAdvantage (HMO D-SNP) plan. Medicare Dental Services are covered with a 20% coinsurance, while Orthodontic Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay, with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by CareAdvantage (HMO D-SNP). You will pay 20% coinsurance for these services.
Medical Equipment See details
The CareAdvantage (HMO D-SNP) plan covers Durable Medical Equipment (DME) with a 20% coinsurance and requires prior 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 some services, and Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the CareAdvantage (HMO D-SNP) plan. For Diagnostic Procedures/Tests and Lab Services, you will pay at most 20% coinsurance. For Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services, you will pay at most 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the CareAdvantage (HMO D-SNP) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the CareAdvantage (HMO D-SNP) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by CareAdvantage (HMO D-SNP), but require prior authorization. There is no copay for days 1-20, and a $214 copay 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 includes coverage for Over-the-Counter (OTC) items, with a maximum benefit of $95 every three months, but does not cover acupuncture, meal benefits, or Dual Eligible SNPs with Highly Integrated Services. Additionally, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, and other services are not covered.
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