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Clever Care Value (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Clever Care Value (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Clever Care Value (HMO) in 2025, please refer to our full plan details page.
Clever Care Value (HMO) is a HMO plan offered by Clever Care Health Plan, Inc. available for enrollment in 2025 to people living in Southern California. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that Clever Care Value (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 Clever Care Value (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 Clever Care Value (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 $110.00. 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 $2900.00 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 Clever Care Value (HMO) plan has an enhanced alternative drug benefit. There is no deductible for prescription drugs. In the initial coverage phase, you will pay a copay depending on the drug tier and pharmacy type. For example, preferred generic drugs have a $5 copay at standard and mail order pharmacies. After your yearly out-of-pocket drug costs reach $2000, you will pay nothing for covered drugs.
Additional Benefits
The Clever Care Value (HMO) plan offers a range of benefits, including coverage for inpatient hospital stays, outpatient services, and emergency services with varying copays. The plan includes coverage for primary care, vision, dental, and hearing services, and also offers coverage for ambulance and transportation services. Additional benefits include home health services with no copay, and medical equipment with coinsurance. The plan also covers diagnostic and radiological services, dialysis services, and skilled nursing facility stays. Other services include acupuncture, over-the-counter items, and a meal benefit.
Inpatient Hospital See details
Inpatient Hospital benefits with the Clever Care Value (HMO) plan include coverage for Inpatient Hospital-Acute with a $100 copay for days 1-5, and no copay for days 6-90, and Inpatient Hospital Psychiatric with a $175 copay for days 1-7, and no copay for days 8-90. Additional days and upgrades for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services are covered, including outpatient hospital services with a $75 copay, ambulatory surgical center services with a $75 copay, and outpatient substance abuse services, which includes individual and group sessions with a copay between $40 and $40. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Clever Care Value (HMO) plan, but requires prior authorization and a doctor's referral. The cost of services is not mentioned in the provided information.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Clever Care Value (HMO) plan. Ground ambulance services have a $200 copay, while air ambulance services have a 20% coinsurance. Transportation services to a plan-approved health-related location are covered for 16 one-way trips per year via bus/subway or other modes of transportation, while transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Clever Care Value (HMO) plan. Emergency Services have a $125 copay and no coinsurance, and the copay is waived if admitted to the hospital within 72 hours. Worldwide Emergency Services have a maximum plan benefit coverage of $55,000.
Primary Care See details
The Clever Care Value (HMO) plan covers primary care physician services, occupational therapy, physician specialist services, mental health specialty services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services are partially covered, but routine care is not covered. Other health care professional services have a copay between $0 and $40, while individual and group mental health and psychiatric sessions have a $40 copay. Physical therapy, speech-language pathology, and physician specialist services have a $5 copay. Opioid treatment program services have a 20% coinsurance.
Preventive Services See details
Preventive Services, including Medicare-covered services, are covered by the Clever Care Value (HMO) plan. Additional preventive services include a Fitness Benefit (Memory Fitness) with a maximum plan benefit coverage amount of $50.00 every three months, and Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline) with a copay ranging from $0.00 to $40.00. Health Education, In-Home Safety Assessment, Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, 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, Counseling Services, are not covered.
Hearing Services See details
Hearing services include routine hearing exams with 1 visit per year and fitting/evaluation for hearing aids with 3 visits per year, as well as coverage for prescription hearing aids up to $600 per year per ear. Over-the-counter hearing aids are covered up to $50 every three months, while prescription hearing aids for the inner and outer ear are not covered.
Vision Services See details
Vision services include coverage for routine eye exams, with one exam covered every year, and eyewear. Eyewear has a combined maximum plan benefit coverage amount of $200.00 every year, and contact lenses, eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
The Clever Care Value (HMO) plan covers dental services, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, and other preventative dental services, all of which require prior authorization. The plan also covers orthodontic services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, and oral and maxillofacial surgery, though orthodontics is not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Clever Care Value (HMO) plan and require prior authorization. The plan covers Medicare Part B Insulin Drugs with a $35 copay and between 0% and 20% coinsurance, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Clever Care Value (HMO) plan and require prior authorization and a doctor's referral. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include coverage for Durable Medical Equipment (DME) with a coinsurance between 0% and 20%, and Prosthetics/Medical Supplies with a coinsurance, but Durable Medical Equipment for use outside the home is not covered. Diabetic Equipment is covered, but Diabetic Supplies are not covered, and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Clever Care Value (HMO) plan, but diagnostic procedures, tests, and lab services are not covered. Diagnostic Radiological Services have a copay of up to $75, while Therapeutic Radiological Services have a coinsurance of 20%.
Home Health Services See details
Home Health Services are covered by the Clever Care Value (HMO) plan with no copay and no coinsurance, but prior authorization and a referral are required. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover the sub-services of 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. A copay applies, but the exact amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Clever Care Value (HMO), but require prior authorization and a doctor's referral. There is no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered, and non-Medicare-covered stays, are not covered.
Other Services See details
Other Services include acupuncture, over-the-counter (OTC) items, and a meal benefit. Acupuncture has a maximum plan benefit coverage amount of $1000 per year. OTC items are covered with a maximum plan benefit coverage amount of $50 every three months, and the plan also provides nicotine replacement therapy and Naloxone coverage. The meal benefit requires prior authorization and a doctor referral.
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