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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 2026, 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 4 out of 5 stars in 2026.
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 $31.00. 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 a $200.00 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 $4500.00 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) prescription drug plan features an annual drug deductible of $200. Under this plan, there is no copay for Tier 1 preferred generic and Tier 2 generic drugs at standard pharmacies for one, two, or three-month supplies. Additionally, you will pay no copay for three-month supplies of these generic medications through standard mail order. For brand-name and specialty medications, your costs are determined by coinsurance. Tier 3 preferred brand drugs require a 25% coinsurance, Tier 4 non-preferred drugs require a 35% coinsurance, and Tier 5 specialty drugs require a 30% coinsurance. These coinsurance rates apply to standard pharmacy fills as well as three-month standard mail order fills.
Additional Benefits
The Clover Health Value (HMO) plan offers affordable healthcare coverage with no copays or coinsurance for primary care, specialist visits, telehealth, and preventive services. For hospital stays, members pay a daily copay of $275 for days 1 to 6 of acute inpatient care and a $250 copay for outpatient hospital services, both with no coinsurance. Emergency care is accessible with a $130 copay, while urgently needed services require a $25 copay, with both fees waived upon immediate hospitalization. This plan also features robust supplemental benefits, including routine dental, vision, and hearing exams with no copays, no deductibles, and no coinsurance. You will receive a $250 annual allowance for eyewear, up to $2,000 in yearly dental coverage with a $20 copay for most comprehensive services, and a $100 quarterly reimbursement for over-the-counter items. Additionally, home health services are covered with no copay, while durable medical equipment requires no copay and a 20% coinsurance.
Inpatient Hospital See details
Inpatient hospital care is covered by Clover Health Value (HMO) with no coinsurance, requiring a $275 daily copay for days 1 to 6 of acute stays and a $245 daily copay for days 1 to 6 of psychiatric stays, followed by no copay for subsequent days. Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Clover Health Value (HMO) covers outpatient hospital and observation services with a $250 copay and no coinsurance, and ambulatory surgical center services with a $150 copay and no coinsurance. Outpatient substance abuse sessions require a $10 copay with no coinsurance, while outpatient blood services are provided with no copay, no coinsurance, and no deductible.
Partial Hospitalization See details
Clover Health Value (HMO) covers partial hospitalization services with a $60.00 copay and no coinsurance. Prior authorization is required for some of these covered services.
Ambulance and Transportation Services See details
Clover Health Value (HMO) covers ground and air ambulance services with a $250 copay and no coinsurance, though prior authorization is required. Transportation services to health-related locations are not covered under this plan.
Emergency Services See details
Clover Health Value (HMO) covers emergency services with a $130 copay and urgently needed services with a $25 copay, both with no coinsurance and copays waived if admitted to the hospital within 24 hours. Worldwide emergency services are covered up to a $50,000 maximum with no coinsurance, carrying copays of $130 for emergency care, $40 for urgent care, and $250 for emergency transportation.
Primary Care See details
Clover Health Value (HMO) covers primary care, specialist, telehealth, and other healthcare professional services with no copay and no coinsurance. Mental health, psychiatric, opioid treatment, and physical, occupational, and speech therapies are covered with a $10 copay and no coinsurance, while chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered by Clover Health Value (HMO) with no copay and no coinsurance for covered benefits like annual physical exams, kidney disease education, and diabetes self-management. However, several additional benefits are not covered, including health education, in-home safety assessments, personal emergency response systems, and medical nutrition therapy.
Hearing Services See details
Clover Health Value (HMO) covers routine hearing exams and fitting evaluations with no deductible, no copay, and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from $499 to $999 for up to two aids per year, though OTC, inner ear, outer ear, and over-the-ear hearing aids are not covered.
Vision Services See details
Clover Health Value (HMO) offers partially covered vision services with no copay, no coinsurance, and no deductible, which includes one routine eye exam and a $250 yearly allowance for eyeglasses or contact lenses. Other eye exam services, separate eyeglass lenses, separate eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by Clover Health Value (HMO) up to a $2,000 annual maximum, featuring preventive care with no copay and no coinsurance. Most comprehensive services require a $20 copay and no coinsurance, while removable prosthodontics have no copay and 50% coinsurance, but orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Clover Health Value (HMO) with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy and other Part B drugs require a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Clover Health Value (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Clover Health Value (HMO) covers durable medical equipment and prosthetics with no copay and a 20% coinsurance, subject to prior authorization. Diabetic equipment is partially covered with no copay and no coinsurance, though diabetic supplies and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by Clover Health Value (HMO) with no coinsurance, though prior authorization is required. There is no copay for lab services, a $20 copay for outpatient X-rays, a $0 to $175 copay for diagnostic procedures, and minimum copays of $50 for diagnostic radiology and $60 for therapeutic radiology.
Home Health Services See details
Home health services are covered by the Clover Health Value (HMO) plan with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the Clover Health Value (HMO) plan with no coinsurance and require prior authorization. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered and require a $10 copay.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Clover Health Value (HMO) with no coinsurance, requiring prior authorization but no prior three-day hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, with additional days beyond the Medicare-covered limit not covered.
Other Services See details
Clover Health Value (HMO) partially covers other services, offering over-the-counter (OTC) items with no copay and no coinsurance up to a maximum of $100 every three months via reimbursement. Acupuncture, meal benefits, and nicotine replacement therapy are not covered under this plan.
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