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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 a $0 deductible for prescription drugs. In the initial coverage phase, you will pay a copay for your prescriptions depending on the drug tier and whether you use a preferred or standard pharmacy. For example, the copay for preferred generic drugs is $5.00 at a standard pharmacy, while the copay for standard generic drugs is $47.00. Once your total drug costs reach $2000.00, you enter the catastrophic coverage phase and pay nothing for covered drugs.
Additional Benefits
The Clever Care Value (HMO) plan offers a range of benefits, including inpatient hospital stays with a copay, outpatient services, and emergency services with a copay. The plan also covers primary care, preventive services, hearing, vision, and dental services, with varying cost-sharing structures. Additional benefits include ambulance and transportation services, home infusion, dialysis, medical equipment, and home health services. You'll find coverage for services like diagnostic and radiological services, cardiac rehabilitation, and skilled nursing facility stays. The plan also offers other services such as acupuncture, over-the-counter items, and a meal benefit.
Inpatient Hospital See details
The Clever Care Value (HMO) plan covers Inpatient Hospital services, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you have a $100 copay for days 1-5, and no copay for days 6-90; for Inpatient Hospital Psychiatric, you have a $175 copay for days 1-7, and no copay for days 8-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Additional Days for 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 with a $40 copay for both individual and group sessions. 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 referral.
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 20% coinsurance. Transportation services to a plan-approved health-related location are covered for up to 16 one-way trips per year, and transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services, Worldwide Emergency Services, Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation, are covered by the Clever Care Value (HMO) plan. Emergency Services have a $125 copay, but there is no coinsurance.
Primary Care See details
The Clever Care Value (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 and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services require a $5 copay, while routine chiropractic care is not covered. Individual and group sessions for mental health and psychiatric services have a $40 copay. Physical therapy and speech-language pathology services have a $5 copay, and opioid treatment program services have 20% coinsurance.
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, and some services require a copay, like Remote Access Technologies, which has a copay between $0-$40.
Hearing Services See details
The Clever Care Value (HMO) plan covers hearing exams, including routine hearing exams and fitting/evaluation for hearing aids, with no copay. Prescription hearing aids are covered with a maximum benefit of $600 per year per ear, and OTC hearing aids are covered with a maximum benefit of $50 every three months. However, prescription hearing aids for inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision Services includes coverage for routine eye exams, with one exam covered every year, and eyewear. Eyewear has a combined maximum benefit of $200 per year, and includes coverage for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
Dental Services are covered, with a maximum benefit of $200 every three months. Oral exams are limited to 2 visits per year, dental x-rays are limited to 1 per year, and prophylaxis (cleaning) is limited to 2 per year. Orthodontics is not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and 0-20% coinsurance, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by the Clever Care Value (HMO) plan, but require prior authorization and a doctor's referral. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered by the Clever Care Value (HMO) plan, with Durable Medical Equipment (DME) and Prosthetics/Medical Supplies covered, and a 0%-20% coinsurance for DME, and Medicare-covered Prosthetic Devices, and Medicare-covered Medical Supplies. Diabetic Equipment is covered, but Diabetic Supplies are not covered, and there is a 20% coinsurance for Diabetic Therapeutic Shoes/Inserts.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, though Diagnostic Procedures/Tests and Lab Services are not covered. Diagnostic Radiological Services have a copay of up to $75, and Therapeutic Radiological Services have 20% coinsurance.
Home Health Services See details
Home Health Services are covered by Clever Care Value (HMO) with no copay or 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 the plan does not cover Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. Prior authorization and a doctor's referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Clever Care Value (HMO) plan, but require prior authorization and a doctor's referral. There is no copay for days 1-20, but there is a $214 copay for days 21-100; additional days beyond Medicare-covered SNF stays 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 is covered with a maximum plan benefit of $1,000 per year, while OTC items have a maximum benefit of $50 every three months. The meal benefit requires prior authorization and a doctor's referral.
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