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Clear Spring Health Essential (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Clear Spring Health Essential (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Clear Spring Health Essential (HMO) in 2025, please refer to our full plan details page.
Clear Spring Health Essential (HMO) is a HMO plan offered by Group 1001 available for enrollment in 2025 to people living in Select Colorado Counties. The overall rating for this plan is not yet available for 2025.
It's important to know that Clear Spring Health Essential (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 Clear Spring Health Essential (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 Clear Spring Health Essential (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 $4.00. 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 $3400.00 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 Clear Spring Health Essential (HMO) plan has a $0 deductible for prescription drugs. In the initial coverage phase, you will pay varying copays for your prescriptions depending on the drug tier and pharmacy. For example, preferred generic drugs have no copay, while standard generic drugs have a $42 copay at a preferred pharmacy. After your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for your Part D covered drugs. If you qualify for the low-income subsidy, you may have your premium reduced. Please refer to the plan's formulary for a complete list of covered drugs.
Additional Benefits
The Clear Spring Health Essential (HMO) plan offers a range of benefits, including inpatient hospital stays with a copay, outpatient services, and partial hospitalization. It also covers ambulance and transportation services, emergency services, and a variety of primary care services, such as chiropractic, mental health, and physical therapy. The plan provides coverage for hearing and vision services, with copays for hearing exams and no copay for routine eye exams. This plan includes dental services with copays, home infusion services, dialysis services with coinsurance, and medical equipment with coinsurance. Additionally, it covers home health services with no copay and skilled nursing facility services with copays. The plan also offers an over-the-counter (OTC) items benefit.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered. For acute care, you will pay a $150 copay for days 1-5, and no copay for days 6-90, and an $800 copay for days 1-60; additional days, and non-medicare covered stays are not covered.
Outpatient Services See details
Outpatient services are covered, including outpatient hospital services with a copay between $40 and $150, observation services with a $150 copay, ambulatory surgical center services with a $40 copay, and outpatient substance abuse services with a $40 copay for both individual and group sessions. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Clear Spring Health Essential (HMO) plan with a $55 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Clear Spring Health Essential (HMO) plan, including ground and air ambulance services with a $200 copay. The plan also covers transportation services to a plan-approved health-related location, offering 12 one-way trips per year, but transportation services to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Clear Spring Health Essential (HMO) plan. Emergency Services have a $90 copay and no coinsurance, while Urgently Needed Services have a $35 copay and no coinsurance. Worldwide Emergency Services are not covered.
Primary Care See details
The Clear Spring Health Essential (HMO) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, other health care professional services, psychiatric services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services have a $20 copay, while individual and group sessions for mental health specialty services have a $20 copay, and individual and group sessions for psychiatric services have a $30 copay. The plan has a $40 copay for physical therapy and speech-language pathology services, and a $25 copay for other health care professional services and opioid treatment program services. Physician specialist services have a copay between $0 and $20. Routine Chiropractic care and podiatry services are not covered.
Preventive Services See details
The Clear Spring Health Essential (HMO) plan covers preventive services, including Medicare-covered services at no copay. Annual physical exams, health education, in-home safety assessments, 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, enhanced disease management, telemonitoring services, home and bathroom safety devices and modifications, and counseling services are not covered. Kidney Disease Education Services are covered with 20% coinsurance. Other services covered include Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit.
Hearing Services See details
Hearing services include coverage for hearing exams with a $30 copay, routine hearing exams (1 visit per year), and fitting/evaluation for hearing aids (1 visit per year). Prescription hearing aids are covered up to a maximum of $500 per year, with 2 hearing aids covered per year. OTC hearing aids, and prescription hearing aids for the inner and outer ear are not covered.
Vision Services See details
Vision services include routine eye exams with no copay, and one exam is covered every year. Eyewear is covered with a combined maximum benefit of $200.00 per year, but contact lenses, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services are covered, including Medicare Dental Services with a $30 copay. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, and other preventive dental services are covered, with limitations on the number of visits per year. Orthodontic Services are covered up to a maximum of $2000 per year. Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable), Maxillofacial Prosthetics, Implant Services, Prosthodontics (fixed), Oral and Maxillofacial Surgery, and Orthodontics are also covered with a limit of 2 visits per year.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered. You will pay a $35 copay for Medicare Part B Insulin Drugs, with a coinsurance between 0% and 20% for the other drugs.
Dialysis Services See details
Dialysis Services are covered by the Clear Spring Health Essential (HMO) plan with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance and no copay, Prosthetics/Medical Supplies with a 20% coinsurance and no copay, and Diabetic Equipment. Some services are covered, but Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered. Diagnostic Procedures/Tests, Lab Services, and Outpatient X-Ray Services are not covered. Diagnostic Radiological Services have a copay between $20 and $175, and Therapeutic Radiological Services have a coinsurance of 20%.
Home Health Services See details
Home Health Services are covered under the Clear Spring Health Essential (HMO) plan, with no copay or coinsurance. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Clear Spring Health Essential (HMO) 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, but require prior authorization. You will have no copay for days 1-20, and a $178 copay for days 21-100. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Clear Spring Health Essential (HMO) plan covers Over-the-Counter (OTC) Items with a monthly benefit of $60.00. Acupuncture, Meal Benefit, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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