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FirstMedicare Direct SmartHMO (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for FirstMedicare Direct SmartHMO (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on FirstMedicare Direct SmartHMO (HMO) in 2025, please refer to our full plan details page.
FirstMedicare Direct SmartHMO (HMO) is a HMO plan offered by The Carle Foundation available for enrollment in 2025 to people living in Wake County. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that FirstMedicare Direct SmartHMO (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 FirstMedicare Direct SmartHMO (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 FirstMedicare Direct SmartHMO (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.
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 $2400.00 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 FirstMedicare Direct SmartHMO (HMO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you'll pay a copay or coinsurance depending on the drug tier and pharmacy type. For example, you'll pay a $10 copay for preferred generic drugs at a standard or mail-order pharmacy. For standard generic drugs, you'll pay 25% coinsurance, and for preferred brand drugs, you'll pay 50% coinsurance. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The FirstMedicare Direct SmartHMO (HMO) plan offers a range of benefits to help cover your healthcare costs. This plan includes coverage for inpatient and outpatient services, with copays varying by service. You'll also find coverage for primary care, preventive services, hearing and vision services, dental, and home health services. The plan also covers ambulance services, with copays of $100 for ground and $400 for air, and offers transportation to health-related locations. Additionally, there is coverage for medical equipment, diagnostic and radiological services, cardiac rehabilitation, and skilled nursing facility stays. The plan also includes an over-the-counter (OTC) benefit.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, there is a $150 copay for days 1-5, and no copay for days 6-90. For Inpatient Hospital Psychiatric, there is a $295 copay for days 1-5, and no copay for days 6-90.
Outpatient Services See details
Outpatient Services are covered under the FirstMedicare Direct SmartHMO (HMO) plan, including outpatient hospital services with a $150 copay, observation services, and ambulatory surgical center services with a $100 copay. Additionally, outpatient substance abuse services are covered with a $40 copay for both individual and group sessions, and outpatient blood services are covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the FirstMedicare Direct SmartHMO (HMO) plan with a $40 copay, and requires prior authorization and a doctor referral.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the FirstMedicare Direct SmartHMO (HMO) plan, with prior authorization required for all ambulance services. Ground ambulance services have a $100 copay, while air ambulance services have a $400 copay; there is no coinsurance for any ambulance services. Transportation services to plan-approved health-related locations are covered for up to 24 one-way trips per year, and other transportation services are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered under the FirstMedicare Direct SmartHMO (HMO) plan. Emergency Services and Worldwide Emergency Coverage have an $80 copay, while Urgently Needed Services have no copay; all three have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The FirstMedicare Direct SmartHMO (HMO) plan covers primary care physician services with no copay. Chiropractic services have a $10 copay, while occupational therapy services have a $10 copay. Physician specialist services have a $20 copay, and individual and group sessions for mental health specialty services have a $40 copay. Podiatry services have a copay of $10-$30. Physical therapy and speech-language pathology services have a $10 copay. Individual and group sessions for psychiatric services have a $40 copay. Opioid treatment program services have a 20% coinsurance.
Preventive Services See details
The FirstMedicare Direct SmartHMO (HMO) plan covers preventive services, including annual physical exams, health education, re-admission prevention, and a fitness benefit with memory fitness, with no copay or coinsurance. Additional preventive services like in-home safety assessment, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, 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, telemonitoring services, remote access technologies, home and bathroom safety devices and modifications, and counseling services are not covered. Kidney disease education services, glaucoma screenings, diabetes self-management training, digital rectal exams, and EKGs following a Welcome Visit are covered. Barium enemas require prior authorization.
Hearing Services See details
Hearing Services are partially covered by the FirstMedicare Direct SmartHMO (HMO) plan. Hearing exams are covered with no copay, but 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 eye exams with a copay between $0 and $45, as well as coverage for eyewear with a combined maximum benefit of $75 every two years, and coverage for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Routine eye exams are covered with a copay between $0 and $45.
Dental Services See details
Dental Services include coverage for Medicare Dental Services, 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, and Oral and Maxillofacial Surgery with copays ranging from $0 to $425. Orthodontics is not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and coinsurance between 0% and 20%, Medicare Part B Chemotherapy/Radiation Drugs with coinsurance between 0% and 20%, and Other Medicare Part B Drugs with coinsurance between 0% and 20%. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered under the FirstMedicare Direct SmartHMO (HMO) plan, with a copay of $30.00. Prior authorization and a doctor referral are required for coverage.
Medical Equipment See details
Medical Equipment benefits are covered, including Durable Medical Equipment (DME) with a 20% coinsurance and Prosthetics/Medical Supplies with a 20% coinsurance. Diabetic equipment is covered, including Diabetic Supplies with a coinsurance between 0% and 20%, and Diabetic Therapeutic Shoes/Inserts with a 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 under the FirstMedicare Direct SmartHMO (HMO) plan. There is no copay for any of the services, but Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, and Outpatient X-Ray Services are not covered. Therapeutic Radiological Services are covered with at most 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the FirstMedicare Direct SmartHMO (HMO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services, including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services, are covered with a $10 copay for Cardiac, Intensive Cardiac, and Pulmonary Rehabilitation Services, and no copay for SET for PAD Services. A doctor referral and prior authorization are required for these services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the FirstMedicare Direct SmartHMO (HMO) plan. For days 1-20, there is no copay, and for days 21-100, the copay is $100. Additional days beyond Medicare-covered for SNF are also covered, with no copay. Non-Medicare-covered stays are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) Items, with a maximum benefit of $95 every three months, and Nicotine Replacement Therapy (NRT) is offered as a Part C OTC benefit. Acupuncture, Meal Benefit, Dual Eligible SNPs with Highly Integrated Services, and other services are not covered.
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