A non-government entity
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 2026, 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 2026.
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 $12.00. 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 $615.00 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 $9250.00 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 CareAdvantage (HMO D-SNP)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The CareAdvantage (HMO D-SNP) plan offers an Enhanced Alternative drug benefit with an annual prescription drug deductible of $615.00. After meeting this deductible, you will pay a 25% coinsurance for Tier 1 preferred generic drugs at standard retail pharmacies and standard mail order services. If you qualify for the low-income subsidy, your Part D premium may be reduced to $12.00. Once your yearly out-of-pocket drug costs reach $2,100.00, you enter the catastrophic coverage phase and will have no copay for covered Medicare Part D drugs. However, you may still pay a share of the cost for excluded drugs covered under any enhanced benefits. You should check the plan's formulary to confirm specific drug coverage and costs.
Additional Benefits
CareAdvantage (HMO D-SNP) offers comprehensive coverage where most outpatient, emergency, primary care, and diagnostic services feature no copay and a standard 20% coinsurance. For inpatient hospital stays, members pay a $1,157 copay per stay with no deductible or coinsurance, while skilled nursing facility care is covered with no copay for the first 20 days. This plan also includes valuable extra benefits like a $75 quarterly over-the-counter allowance alongside limited vision, dental, and medical transportation services. However, it is important to note that hearing services, cardiac rehabilitation, and restorative dental procedures are not covered under this plan.
Inpatient Hospital See details
Inpatient hospital services are partially covered by CareAdvantage (HMO D-SNP) and require a $1,157 copay per Medicare-covered acute or psychiatric stay, with no deductible and no coinsurance. Prior authorization is required, and sub-services such as additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
CareAdvantage (HMO D-SNP) covers outpatient services, including outpatient hospital, observation, ambulatory surgical center, substance abuse, and blood services, with no copay and a 20% coinsurance. Prior authorization is required for outpatient hospital, observation, and ambulatory surgical center services.
Partial Hospitalization See details
Partial hospitalization benefits are covered by CareAdvantage (HMO D-SNP) with no copay and a 20% coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
CareAdvantage (HMO D-SNP) covers ambulance services with a 20% coinsurance and no copay, with prior authorization required. Transportation services are partially covered, offering up to 12 one-way trips per month to plan-approved health-related locations, while transportation to any health-related location is not covered.
Emergency Services See details
CareAdvantage (HMO D-SNP) covers emergency and urgently needed services with a 20% coinsurance and no copay, with the coinsurance waived if you are admitted to the hospital within 24 hours. Worldwide emergency, urgent, and transportation services are also covered up to a maximum benefit limit of $25,000.
Primary Care See details
CareAdvantage (HMO D-SNP) primary care benefits are partially covered with no copay and a 20% coinsurance for most services, including physician, specialist, and physical therapy visits. Podiatry services and routine chiropractic care are not covered.
Preventive Services See details
CareAdvantage (HMO D-SNP) covers Medicare-covered zero-dollar preventive services, personal emergency response systems, and memory fitness with no copay and no coinsurance. Kidney disease education and other select preventive screenings are covered with no copay and a 20% coinsurance. Annual physical exams and various additional services, such as health education and in-home safety assessments, are not covered.
Hearing Services See details
Hearing Services are not covered under CareAdvantage (HMO D-SNP), as routine hearing exams, fitting and evaluation services, prescription hearing aids, and over-the-counter hearing aids are all excluded from coverage.
Vision Services See details
CareAdvantage (HMO D-SNP) partially covers vision services, offering one annual routine eye exam and eyewear like contact lenses and eyeglasses with no copay, no deductible, and a 20% coinsurance up to a $175 yearly limit. Individual eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services are partially covered by CareAdvantage (HMO D-SNP), with covered Medicare dental services requiring a 20% coinsurance and no copay. Orthodontic, restorative, endodontic, periodontic, prosthodontic, implant, and oral surgery services are not covered.
Home Infusion bundled Services See details
CareAdvantage (HMO D-SNP) covers Home Infusion bundled services under prior authorization, featuring a $35 copay and no coinsurance to 20% coinsurance for Medicare Part B insulin. Other covered Part B chemotherapy, radiation, and miscellaneous drugs have no copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the CareAdvantage (HMO D-SNP) plan with no copay and a 20% coinsurance.
Medical Equipment See details
CareAdvantage (HMO D-SNP) covers medical equipment, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment, with a 20% coinsurance and no copay. Prior authorization is required for these services, and diabetic supplies are limited to specified manufacturers.
Diagnostic and Radiological Services See details
CareAdvantage (HMO D-SNP) covers diagnostic and radiological services, including lab tests, therapeutic radiology, and outpatient X-rays, with no copay and a 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the CareAdvantage (HMO D-SNP) plan, though prior authorization is required before you can receive these services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by CareAdvantage (HMO D-SNP), which includes no coverage for sub-services such as intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD).
Skilled Nursing Facility (SNF) See details
CareAdvantage (HMO D-SNP) partially covers Skilled Nursing Facility (SNF) services, offering no copay for days 1 to 20 and a $218 daily copay for days 21 to 100, with no coinsurance required. Prior authorization is required, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
CareAdvantage (HMO D-SNP) partially covers Other Services, which includes an Over-the-Counter (OTC) benefit of $75 every three months with no copay or coinsurance. Acupuncture, meal benefits, and highly integrated services for dual-eligible SNPs are not covered under this plan.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved