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FirstMedicare Direct POS Standard (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for FirstMedicare Direct POS Standard (HMO-POS). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on FirstMedicare Direct POS Standard (HMO-POS) in 2025, please refer to our full plan details page.
FirstMedicare Direct POS Standard (HMO-POS) is a HMO-POS plan offered by The Carle Foundation available for enrollment in 2025 to people living in Sandhills and Wake Counties. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that FirstMedicare Direct POS Standard (HMO-POS) 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 POS Standard (HMO-POS).
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 POS Standard (HMO-POS), 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 combined Maximum Out-Of-Pocket cost of $8950.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $8950.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
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 POS Standard (HMO-POS) plan has an enhanced alternative drug benefit with no deductible. During the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, you will pay a $15 copay for preferred generic drugs at a standard or mail pharmacy. After your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs. If you qualify for the low-income subsidy, you will pay $0.00 for Part D drugs.
Additional Benefits
The FirstMedicare Direct POS Standard (HMO-POS) plan offers comprehensive coverage, including inpatient hospital stays with a copay, outpatient services, and ambulance services. You can expect copays for services like primary care visits, specialist visits, mental health services, and hearing exams, while preventive services and home health services have no copay. The plan also includes coverage for vision and dental services, with varying copays and coinsurance for different procedures, and offers additional benefits like acupuncture, an OTC allowance, and a meal benefit.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you pay a $300 copay for days 1-10, and no copay for days 11-90, while for Inpatient Hospital Psychiatric, you pay a $160 copay for days 1-10, and no copay for days 11-90. Upgrades, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay between $0 and $300, Ambulatory Surgical Center (ASC) Services with no copay, and outpatient substance abuse services with a $35 copay for both individual and group sessions. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization. You will have a $40 copay for this benefit.
Ambulance and Transportation Services See details
The FirstMedicare Direct POS Standard (HMO-POS) plan covers ambulance services with no coinsurance, but has a $350 copay for ground ambulance services and a $450 copay for air ambulance services. Transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services have a $140 copay, and Urgently Needed Services have a $20 copay; both have no coinsurance. Worldwide Emergency Coverage has a $140 copay, Worldwide Urgent Coverage has a $20 copay, and Worldwide Emergency Transportation has a $350 - $450 copay; all three have no coinsurance.
Primary Care See details
Primary Care benefits include coverage for Primary Care Physician Services with a $5 copay, Chiropractic Services with a $20 copay, Occupational Therapy Services with a $30 copay, Physician Specialist Services with a $30 copay, Mental Health Specialty Services with a $35 copay for individual or group sessions, Other Health Care Professional visits with a $30 copay, Psychiatric Services with a $35 copay for individual or group sessions, Physical Therapy and Speech-Language Pathology Services with a $30 copay, Additional Telehealth Benefits with a $0-$35 copay, and Opioid Treatment Program Services with a $35 copay. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
Preventive services, including annual physical exams, are covered with no copay. Other services, such as Health Education, In-Home Safety Assessment, and Personal Emergency Response System (PERS), are not covered.
Hearing Services See details
Hearing Services include routine hearing exams with a $35 copay and fitting/evaluation for hearing aids, both covered. Prescription hearing aids are covered, with a copay between $495 and $1695, but inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
Vision services include eye exams and eyewear. Routine eye exams are covered once per year. Eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades, are covered with a 20% coinsurance for contact lenses and a combined maximum benefit of $200 per year.
Dental Services See details
Dental services include a $35 copay for Medicare dental services, and other dental services are covered up to $2,000 per year. Restorative, Adjunctive General Services, Endodontics, Periodontics, and Oral and Maxillofacial Surgery have a 15% coinsurance, and Prosthodontics, removable, Maxillofacial Prosthetics, Implant Services, and Prosthodontics, fixed, have a 40% coinsurance. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), and other preventive dental services are covered with no copay or coinsurance. Fluoride treatment and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. Medicare Part B Insulin Drugs have a $35 copay and between 0% and 20% coinsurance, while the other drugs have between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the FirstMedicare Direct POS Standard (HMO-POS) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a coinsurance between 0% and 20%, and Prosthetic Devices and Medical Supplies with a 20% coinsurance. Diabetic Supplies have a coinsurance between 0% and 20%, while Diabetic Therapeutic Shoes/Inserts have 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 covered. Diagnostic Procedures/Tests have no copay, while Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $275, Therapeutic Radiological Services have a copay of at most $60, and Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the FirstMedicare Direct POS Standard (HMO-POS) plan with no copay and no coinsurance. However, Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but none of the sub-services are covered, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. This means that the plan does not cover any cardiac rehabilitation services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, with a copay of $10 for days 1-20 and $214 for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The FirstMedicare Direct POS Standard (HMO-POS) plan covers acupuncture with a $30 copay per visit, up to 15 treatments per year. This plan also covers Over-the-Counter (OTC) items, offering a $35 allowance every three months. Additionally, the plan provides a meal benefit for chronic or medical conditions requiring the member to stay home. However, other services like Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and others are not covered.
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