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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 $105.00. 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 with a $0 deductible. During the initial coverage phase, you will pay a copay for your prescriptions. For a 30-day supply, you can expect to pay a $5 copay for preferred generics, $47 for standard generics, and $99 for preferred brand drugs. For non-preferred drugs, you will pay 33% coinsurance, and there is no copay for specialty tier drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase and pay nothing for your Part D covered drugs.
Additional Benefits
The Clever Care Value (HMO) plan offers a variety of benefits, including coverage for inpatient hospital stays with a copay, and outpatient services with copays ranging from $40 to $75. Emergency services have a $125 copay, and primary care services have copays between $0 and $40. Preventive services and home health services are covered with no copay. The plan also includes coverage for hearing exams, prescription hearing aids, and vision services, including routine eye exams and eyewear. Dental services cover a wide range of procedures. Other benefits include ambulance services, home infusion, dialysis, medical equipment, and diagnostic services, each with specific copays or coinsurance.
Inpatient Hospital See details
The Clever Care Value (HMO) plan covers inpatient hospital stays, including acute and psychiatric care. For Inpatient Hospital-Acute, you will pay a $100 copay for days 1-5, and no copay for days 6-90; for Inpatient Hospital Psychiatric, you will pay a $175 copay for days 1-7, and no copay for days 8-90. Additional days and non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services, Observation Services, Ambulatory Surgical Center (ASC) Services, Outpatient Substance Abuse Services, and Outpatient Blood Services. Outpatient Hospital and ASC services have a $75 copay, while individual and group sessions for outpatient substance abuse have a $40 copay.
Partial Hospitalization See details
Partial Hospitalization is covered under the Clever Care Value (HMO) plan, but requires prior authorization and a doctor's referral. The copay and coinsurance for this benefit are 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, including both ground and air ambulance services. 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 transportation, but transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Services, Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation are covered. Emergency Services have a $125 copay, and no coinsurance. 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 services, including primary care physician services, occupational therapy services, physician specialist services, mental health specialty services, psychiatric services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services are covered with a $5 copay for routine care, while individual and group sessions for mental health and psychiatric services have a $40 copay. Other health care professional services have a copay between $0 and $40, and opioid treatment program services have a 20% coinsurance. Podiatry services are not covered.
Preventive Services See details
The Clever Care Value (HMO) plan covers preventive services, including annual physical exams, with no copay or coinsurance. Additional preventive services are covered, as well as fitness benefits and remote access technologies, with a copay up to $40 for remote access technologies. Some services like health education and in-home safety assessments are not covered.
Hearing Services See details
The Clever Care Value (HMO) plan covers hearing exams, routine hearing exams (1 per year), and fitting/evaluation for hearing aids (3 per year), but requires prior authorization. Prescription hearing aids are covered up to $600 per ear every year, and OTC hearing aids are covered up to $50 every three months. Prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision services with Clever Care Value (HMO) include coverage for routine eye exams with one visit per year, and eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. Eyewear has a combined maximum benefit of $200 per year.
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 preventive dental services, and orthodontic services. The plan also covers restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, and oral and maxillofacial surgery, but does not cover orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Clever Care Value (HMO) plan, including Medicare Part B Insulin Drugs with a $35 copay and between 0-20% coinsurance. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are also covered with between 0-20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Clever Care Value (HMO) plan, but require prior authorization and a doctor's referral. The coinsurance for this benefit is 20%.
Medical Equipment See details
The Clever Care Value (HMO) plan covers medical equipment, including Durable Medical Equipment (DME) with a coinsurance between 0% and 20%, and Prosthetics/Medical Supplies with a coinsurance. Diabetic Equipment is also 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 Clever Care Value (HMO). Diagnostic services, including Diagnostic Procedures/Tests and Lab Services, are not covered, while Diagnostic Radiological Services have a copay of up to $75, and 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 require prior authorization and a referral. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but there is no copay or coinsurance information available. However, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Clever Care Value (HMO) plan, but require prior authorization and a doctor referral. For days 1-20, there is no copay, and for days 21-100, the copay is $214 per day; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The Clever Care Value (HMO) plan covers acupuncture with a maximum benefit coverage amount of $1000 per year, as well as over-the-counter (OTC) items with a maximum benefit coverage amount of $50 every three months, including nicotine replacement therapy and Naloxone. The plan also covers a meal benefit for a chronic illness, but requires prior authorization and a doctor referral. However, the plan does not cover 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.
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