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Clover Health Classic (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Clover Health Classic (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Clover Health Classic (HMO) in 2025, please refer to our full plan details page.
Clover Health Classic (HMO) is a HMO plan offered by Clover Health Holdings, Inc. available for enrollment in 2025 to people living in Select NJ Counties. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Clover Health Classic (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 Clover Health Classic (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 Clover Health Classic (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.
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 $8550.00 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 Clover Health Classic (HMO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you'll pay different copays depending on the drug tier and pharmacy. For example, you'll pay an $8 copay for a standard generic drug, and a $100 copay for a preferred brand drug. 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 Clover Health Classic (HMO) plan offers coverage for a range of services with varying cost-sharing. You'll find no copay for primary care physician services, preventive services, and home health services. For other services, you can expect to pay copays, such as $10 for routine eye exams, $30 for outpatient x-rays, and $350 for ground ambulance services. The plan also covers inpatient hospital stays with copays of $375 or $320 depending on the service, along with outpatient services and emergency services with various copays. Additionally, it includes dental, vision, and hearing benefits, along with coverage for medical equipment and home infusion services.
Inpatient Hospital See details
Inpatient Hospital services are covered by the Clover Health Classic (HMO) plan, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you'll pay a $375 copay for days 1-6, and no copay for days 7-90, while for Inpatient Hospital Psychiatric, you'll pay a $320 copay for days 1-6 and no copay for days 7-90.
Outpatient Services See details
Outpatient Services are covered under the Clover Health Classic (HMO) plan. Outpatient Hospital Services and Observation Services have a $350 copay, while Ambulatory Surgical Center (ASC) Services have a $200 copay. Outpatient Substance Abuse Services, including individual and group sessions, have a copay ranging from $25 to $25.
Partial Hospitalization See details
Partial Hospitalization is covered by the Clover Health Classic (HMO) plan, with a $60 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Clover Health Classic (HMO) plan. Medicare-covered ground and air ambulance services have a $350 copay, with no coinsurance, while transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services and Worldwide Emergency Services, are covered under the Clover Health Classic (HMO) plan. Emergency Services have a $100 copay, and Urgently Needed Services have a $25 copay, while Worldwide Emergency Coverage has a $100 copay, Worldwide Urgent Coverage has a $40 copay, and Worldwide Emergency Transportation has a $350 copay; all services have no coinsurance.
Primary Care See details
Primary Care includes coverage for Primary Care Physician Services with no copay, Chiropractic Services with a $15 copay, Occupational Therapy Services with a $15 copay, Physician Specialist Services with a $10 copay, and Mental Health Specialty Services with a $25 copay for individual or group sessions. Also covered are Other Health Care Professional services with a copay of $0-$10, Psychiatric Services with a $25 copay for individual or group sessions, Physical Therapy and Speech-Language Pathology Services with a $15 copay, Additional Telehealth Benefits with a copay of $0-$10, and Opioid Treatment Program Services with a $25 copay. Routine Chiropractic Care is not covered, and Podiatry Services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services, Annual Physical Exams, and other preventive services, with no copay or coinsurance. However, Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, 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, and Counseling Services are not covered.
Hearing Services See details
Hearing exams are covered with a $10 copay, and routine hearing exams are limited to one per year. Prescription hearing aids are covered, with a copay between $699 and $999, and are limited to two per year; however, prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision services are covered, including eye exams and eyewear. Routine eye exams have a $10 copay, while eyewear has a combined maximum benefit of $200 every year, and contact lenses and eyeglasses (lenses and frames) are each limited to one per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $10 copay, and other services with a $1,250 annual maximum. Restorative, Adjunctive General Services, Endodontics, Periodontics, Maxillofacial Prosthetics, Implant Services, Prosthodontics (fixed), and Oral and Maxillofacial Surgery have a $30 copay. Prosthodontics (removable) has 50% coinsurance, and 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 Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with a coinsurance between 0% and 20%. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered under the Clover Health Classic (HMO) plan. You will pay a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME) with 20% coinsurance and Prosthetics/Medical Supplies with 20% coinsurance. This plan does not cover Durable Medical Equipment for use outside the home, Diabetic Supplies, or Diabetic Therapeutic Shoes/Inserts.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Clover Health Classic (HMO) plan. Diagnostic Procedures/Tests have a minimum copay of $0 and a maximum copay of $175, while Lab Services have no copay. Diagnostic Radiological Services have a minimum copay of $50 and a maximum copay of $175, Therapeutic Radiological Services have a copay of $60, and Outpatient X-Ray Services have a copay of $30.
Home Health Services See details
Home Health Services are covered by the Clover Health Classic (HMO) plan with no copay and no coinsurance, but prior authorization is required. Additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Clover Health Classic (HMO) plan. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Clover Health Classic (HMO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $203 per day; additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Clover Health Classic (HMO) plan does not cover acupuncture, meal benefits, or Dual Eligible SNPs with Highly Integrated Services. Over-the-Counter (OTC) Items are covered up to $85 every three months, and the plan does not offer Nicotine Replacement Therapy (NRT) but does offer Naloxone coverage. Many other services are not covered, including 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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