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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. During the initial coverage phase, you'll pay a copay for your prescriptions, which varies depending on the drug tier and pharmacy type. For example, generic drugs have a $5 or $47 copay, while preferred brand drugs have a $99 copay. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you pay nothing for your Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
The Clever Care Value (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, but there is no copay for days 6-90. Outpatient services have a $75 copay, while emergency services have a $125 copay, waived if admitted to the hospital within 72 hours. The plan covers a variety of services, including primary care, preventive services, hearing, vision, and dental. Primary care services have copays between $0 and $40, while hearing aids are covered up to specific amounts per year. Vision benefits include eyewear coverage up to $200 per year, and dental services are comprehensive.
Inpatient Hospital See details
The Clever Care Value (HMO) plan covers Inpatient Hospital-Acute with a $100 copay for days 1-5, and no copay for days 6-90; Inpatient Hospital Psychiatric has a $175 copay for days 1-7, and no copay for days 8-90. Additional days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered stays and Upgrades are not covered.
Outpatient Services See details
Outpatient Services, including all outpatient hospital services, are covered with a $75 copay. Ambulatory Surgical Center (ASC) Services are covered with a $75 copay. Outpatient substance abuse services are covered with a $40 copay for both individual and group sessions.
Partial Hospitalization See details
Partial Hospitalization is covered by the Clever Care Value (HMO) plan, but requires both prior authorization and a doctor referral. There is no information about the cost of this benefit.
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 16 one-way trips per year via bus/subway or other modes of transportation. 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 under the Clever Care Value (HMO) plan. Emergency Services have a $125 copay, and there is no coinsurance; the copay is waived if admitted to the hospital within 72 hours.
Primary Care See details
The Clever Care Value (HMO) plan covers Primary Care Physician Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits and Opioid Treatment Program Services. Chiropractic Services are covered with a $5 copay, but routine chiropractic care is not covered. 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 20% coinsurance.
Preventive Services See details
Preventive services, including annual physical exams, are covered. Additional preventive services may have a copay, with coverage for Remote Access Technologies having a copay between $0 and $40. Some preventive services, such as Health Education, are not covered.
Hearing Services See details
The Clever Care Value (HMO) plan covers hearing exams, including routine hearing exams and fitting/evaluation for hearing aids, with prior authorization required. Prescription hearing aids are covered up to $600 per ear annually, and over-the-counter hearing aids are covered up to $50 every three months. Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, and Prescription Hearing Aids - Over the Ear are not covered.
Vision Services See details
The Clever Care Value (HMO) plan covers vision services including eye exams, routine eye exams (1 per 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
The Clever Care Value (HMO) plan covers dental services, including oral exams, dental x-rays, other diagnostic dental services, cleanings, fluoride treatments, and other preventive services. The plan also covers orthodontics, restorative services, adjunctive general services, endodontics, periodontics, removable prosthodontics, maxillofacial prosthetics, implant services, fixed prosthodontics, and oral and maxillofacial surgery.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay with coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Clever Care Value (HMO) plan, but require prior authorization and a doctor's referral. You will pay a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits under the Clever Care Value (HMO) plan include Durable Medical Equipment (DME) with 0% to 20% coinsurance, Prosthetics/Medical Supplies with coinsurance for Medicare-covered items, and Diabetic Therapeutic Shoes/Inserts with 20% coinsurance; however, Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by Clever Care Value (HMO), with no copay for all diagnostic services. 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 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, and copay information is available.
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's referral. There is no copay for days 1-20, and a $214 copay per day 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
Under the Clever Care Value (HMO) plan, acupuncture is covered with a maximum benefit coverage amount of $1,000 per year. Over-the-counter items, including nicotine replacement therapy and Naloxone, are covered with a maximum benefit coverage amount of $50 every three months.
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