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Clover Health Value (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Clover Health Value (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Clover Health Value (HMO) in 2025, please refer to our full plan details page.
Clover Health Value (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 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 Clover Health 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 Clover Health Value (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $39.30. 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 a $280.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $8300.00 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 Value (HMO) plan has an enhanced alternative drug benefit. The plan includes a $280 deductible. In the initial coverage phase, after your deductible is met, you will pay a copay or coinsurance for your prescriptions. For example, you will pay an $8.00 copay for preferred generic drugs at a standard pharmacy, and 25% coinsurance for standard generic drugs.
Additional Benefits
The Clover Health Value (HMO) plan offers a range of healthcare benefits. The plan covers inpatient and outpatient services, including emergency care, with varying copays. Primary care, preventive, hearing, vision, and dental services are also included, with specific copays and annual maximums for some services. Additional benefits include home health, dialysis, medical equipment, and diagnostic services. The plan also covers ambulance services, skilled nursing facilities, and cardiac rehabilitation, but some services require prior authorization or have limitations. The plan also offers coverage for prescription hearing aids, as well as an OTC benefit.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $340 copay for days 1-6 and no copay for days 7-90, while for Inpatient Hospital Psychiatric, you will pay a $310 copay for days 1-6 and no copay for days 7-90. Additional days, upgrades, and non-Medicare covered stays for both are not covered.
Outpatient Services See details
Outpatient Services are covered by the Clover Health Value (HMO) plan, including Outpatient Hospital Services with a $325 copay, Observation Services with a $325 copay, Ambulatory Surgical Center (ASC) Services with a $200 copay, Individual and Group Sessions for Outpatient Substance Abuse with a $10 copay, and Outpatient Blood Services.
Partial Hospitalization See details
Partial Hospitalization is covered by the Clover Health Value (HMO) plan, with a $60 copay. Prior authorization is required for coverage.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Clover Health Value (HMO) plan. Ground and Air Ambulance Services have a $250 copay, and there is no coinsurance. 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 Clover Health Value (HMO) plan. Emergency Services and Worldwide Emergency Coverage have a $100 copay, Urgently Needed Services has a $25 copay, Worldwide Urgent Coverage has a $40 copay, and Worldwide Emergency Transportation has a $250 copay.
Primary Care See details
The Clover Health Value (HMO) plan covers primary care physician services, chiropractic services with a $10 copay, occupational therapy services with a $10 copay, physician specialist services with a $5 copay, and mental health specialty services with a $10 copay for individual and group sessions. The plan also covers other health care professionals with a copay between $0 and $5, psychiatric services with a $10 copay for individual and group sessions, physical therapy and speech-language pathology services with a $10 copay, additional telehealth benefits with a copay between $0 and $5, and opioid treatment program services with a $10 copay. Routine chiropractic care is not covered.
Preventive Services See details
Preventive Services are covered by the Clover Health Value (HMO) plan, including Medicare-covered preventive services, annual physical exams, and other preventive services. Additional services such as Health Education, In-Home Safety Assessment, and Personal Emergency Response System (PERS) are not covered.
Hearing Services See details
Hearing services include hearing exams, routine hearing exams, and fitting/evaluation for hearing aids, each of which is covered. Routine hearing exams are limited to one visit per year, and there is a $5 copay for hearing exams. Prescription hearing aids (all types) are covered with a copay between $699 and $999, but prescription hearing aids - inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are also not covered.
Vision Services See details
Vision services include routine eye exams with a $5 copay, and eyewear with a combined maximum benefit of $250 every year, including one pair of contact lenses and one pair of eyeglasses (lenses and frames) per year. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services are covered, including Medicare Dental Services with a $5 copay and other dental services with a $1,500 annual maximum. Oral exams, dental x-rays, and other diagnostic dental services are covered with a limit of one visit per year, while prophylaxis (cleaning), fluoride treatment, and other preventative dental services are covered with a limit of two visits per year. Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Maxillofacial Prosthetics, Implant Services, Prosthodontics fixed, and Oral and Maxillofacial Surgery are covered with a $20 copay and a limit of one visit per year, while Prosthodontics, removable has a 50% coinsurance. Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Clover Health Value (HMO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits are covered, with Durable Medical Equipment (DME) subject to 20% coinsurance and no copay, but DME for use outside the home is not covered. Prosthetics and medical supplies have a 20% coinsurance, with no copay, and Diabetic Equipment is covered, but Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. Diagnostic Procedures/Tests have a copay between $0 and $175, while Lab Services have no copay. Diagnostic Radiological Services have a copay of at most $175 (minimum of $50), Therapeutic Radiological Services have a copay of at most $60, and Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered by the Clover Health Value (HMO) plan with no copay and no coinsurance; however, additional hours of care and personal care services are not covered. A referral is not required, but authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Clover Health Value (HMO) plan, but the specific services listed are not covered. Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Clover Health Value (HMO) plan, but require prior authorization. There is no copay for days 1-20, and a $203 copay 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
Other Services include Over-the-Counter (OTC) Items, with a maximum benefit of $85 every three months, but acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, 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 are not covered.
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