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WellSense Choice (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for WellSense Choice (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on WellSense Choice (HMO) in 2025, please refer to our full plan details page.
WellSense Choice (HMO) is a HMO plan offered by BMC Health System, Inc. available for enrollment in 2025 to people living in All Counties_Choice. This plan received an overall rating of 2.5 out of 5 stars in 2025.
It's important to know that WellSense Choice (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 WellSense Choice (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 WellSense Choice (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $29.00. 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 $3900.00 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 WellSense Choice (HMO) plan has an "Enhanced Alternative" drug benefit. The plan has no deductible. In the initial coverage phase, you'll pay different copays or coinsurance amounts depending on the drug tier and pharmacy. For example, in the initial coverage phase, you'll pay $5.00 for a preferred generic at a standard pharmacy, or a $0 copay if you use the standard mail order option. For non-preferred drugs, you will pay 33% 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 WellSense Choice (HMO) plan offers a range of benefits, including coverage for inpatient hospital stays with a $395 copay for the first six days and no copay for the remainder. Outpatient services have varying copays, and emergency services have a $140 copay. This plan includes coverage for primary care, vision, and dental services, with copays for specialist visits, eye exams, and dental procedures. Additionally, it provides coverage for home health services with no copay, along with coverage for over-the-counter items, and a meal benefit for chronic illness.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric, are covered under the WellSense Choice (HMO) plan. For days 1-6, there is a $395 copay, and for days 7-90, there is no copay.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $380, Observation Services with a $395 copay, Ambulatory Surgical Center (ASC) Services with a $300 copay, and Outpatient Substance Abuse Services with a $45 copay for both Individual and Group Sessions. Outpatient Blood Services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the WellSense Choice (HMO) plan, but requires prior authorization. You will have a $130 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the WellSense Choice (HMO) plan. Ground ambulance services have a $295 copay, while air ambulance services have a 50% coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the WellSense Choice (HMO) plan, with a $140 copay for Emergency Services and Worldwide Emergency Coverage, and a $40 copay for Urgently Needed Services. Worldwide Emergency Transportation is not covered.
Primary Care See details
The WellSense Choice (HMO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $55 copay, physician specialist services with a $20 copay, mental health specialty services with a $70 copay for individual and group sessions, other health care professional services with a copay between $0 and $80, psychiatric services with a $70 copay for individual and group sessions, physical therapy and speech-language pathology services with an $80 copay, additional telehealth benefits, and opioid treatment program services with a copay between $0 and $70. Routine chiropractic care and podiatry services are not covered.
Preventive Services See details
The WellSense Choice (HMO) plan covers preventive services, including an annual physical exam, with no copay. Additional preventive services like health education, in-home safety assessments, and more are not covered.
Hearing Services See details
Hearing Services with the WellSense Choice (HMO) plan include routine hearing exams for a $20 copay, and fitting/evaluation for hearing aids with no copay; these benefits are available once per year. Prescription hearing aids (all types) are covered with a copay between $699 and $999, but prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
The WellSense Choice (HMO) plan covers vision services including eye exams with a $20 copay. Eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames, are also covered, with a combined maximum benefit of $200 every year.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $20 copay, and other dental services such as oral exams (2 visits per year), dental x-rays (2 per year), other diagnostic services (1 visit per year), prophylaxis, fluoride treatments (2 per year), and other preventive services (1 every 3 years per tooth on unrestored perm molars). Orthodontic Services are covered up to a maximum of $5000 per year, and restorative, adjunctive general, endodontics, periodontics, removable prosthodontics, fixed prosthodontics, and oral and maxillofacial surgery services are covered with a 10% coinsurance. However, maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the WellSense Choice (HMO) plan. There is a 20% coinsurance for these services.
Medical Equipment See details
The WellSense Choice (HMO) plan covers Durable Medical Equipment, Prosthetics/Medical Supplies, and Diabetic Equipment. Durable Medical Equipment has a 20% coinsurance, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices have a 20% coinsurance, and Medical Supplies have a 20% coinsurance. Diabetic Supplies have between 0% and 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures/tests with a copay between $0 and $10, and lab services with no copay. Diagnostic radiological services have a copay up to $350, therapeutic radiological services have a coinsurance of at least 20%, and outpatient X-rays have a copay of $80.
Home Health Services See details
Home Health Services are covered by the WellSense Choice (HMO) 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
WellSense Choice (HMO) does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. There is a copay for some Cardiac and Pulmonary Rehabilitation Services, but the specific copay details are not provided.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the WellSense Choice (HMO) plan, 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 for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The WellSense Choice (HMO) plan does not cover acupuncture, 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, or Self-Directed Personal Assistance Services. The plan covers Over-the-Counter (OTC) Items with a maximum benefit of $125 every three months, including Nicotine Replacement Therapy (NRT) and Naloxone coverage. The plan also covers a Meal Benefit for a chronic illness.
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