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Clear Spring Health Essential (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Clear Spring Health Essential (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Clear Spring Health Essential (PPO) in 2025, please refer to our full plan details page.
Clear Spring Health Essential (PPO) is a PPO plan offered by Group 1001 available for enrollment in 2025 to people living in Metro Denver, Boulder, Fort Collins. The overall rating for this plan is not yet available for 2025.
It's important to know that Clear Spring Health Essential (PPO) 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 Clear Spring Health Essential (PPO).
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 Clear Spring Health Essential (PPO), 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 $2.50. 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 combined Maximum Out-Of-Pocket cost of $8950.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $8950.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
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 Clear Spring Health Essential (PPO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, preferred generic drugs have no copay at preferred pharmacies and preferred mail-order pharmacies. For standard generic drugs, you will pay a $42 copay at preferred pharmacies and $47 at standard pharmacies. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Clear Spring Health Essential (PPO) plan offers a range of benefits with varying costs. Inpatient hospital stays have copays, while outpatient services and emergency services have copays ranging from $30 to $340. The plan also covers primary care, preventive, hearing, vision, dental, and home health services, with specific copays and limitations on coverage for certain services like hearing aids and eyewear. Additional benefits include coverage for ambulance, home infusion, and dialysis services, each with its own cost structure. The plan provides coverage for medical equipment, diagnostic and radiological services, and skilled nursing facilities, with copays and coinsurance applicable. Furthermore, the plan offers a $60 monthly allowance for over-the-counter items, but certain services like acupuncture and private duty nursing are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered under the Clear Spring Health Essential (PPO) plan. For Inpatient Hospital-Acute, you will pay a $300 copay for days 1-5, and no copay for days 6-90. For Inpatient Hospital Psychiatric, you will pay a $275 copay for days 1-6, and no copay for days 7-90. Additional Days, Non-Medicare-covered Stay, and Upgrades for Inpatient Hospital-Acute and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services, including outpatient hospital services and observation services, are covered with copays ranging from $45 to $340 and $300, respectively. Ambulatory Surgical Center (ASC) services and both individual and group outpatient substance abuse sessions are covered with copays of $45 and $40, respectively, while outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization. You will have a $55 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Clear Spring Health Essential (PPO) plan, with a $270 copay for both ground and air ambulance services; however, transportation services to any health-related location are not covered. There is no coinsurance for ambulance services.
Emergency Services See details
Emergency Services, Urgent Care, and Worldwide Emergency Services are covered by the Clear Spring Health Essential (PPO) plan. Emergency Services have a $90 copay and no coinsurance, while Urgently Needed Services have a $30 copay and no coinsurance. Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation are not covered.
Primary Care See details
The Clear Spring Health Essential (PPO) plan covers primary care physician services, occupational therapy services, physician specialist services, mental health specialty services, other health care professional services, psychiatric services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services are covered with a $20 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 and opioid treatment program services have a $25 copay, and physical therapy and speech-language pathology services have a $40 copay.
Preventive Services See details
The Clear Spring Health Essential (PPO) plan covers preventive services, including Medicare-covered services with no copay. The plan does not cover annual physical exams. Additional preventive services are covered, but not health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, 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, or counseling services. The plan also covers re-admission prevention, fitness benefits, remote access technologies, kidney disease education services (with prior authorization), and other preventive services like glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit.
Hearing Services See details
Hearing Services include coverage for hearing exams, routine hearing exams (1 per year), and fitting/evaluation for hearing aids (1 per year). Prescription hearing aids are covered up to $500 per ear per year, and prescription hearing aids (all types) are covered for 2 visits per year. However, prescription hearing aids - inner ear, prescription hearing aids - outer ear, prescription hearing aids - over the ear, and OTC hearing aids are not covered.
Vision Services See details
The Clear Spring Health Essential (PPO) plan covers vision services, including routine eye exams once per year and eyeglasses (lenses and frames) once per year, with a combined maximum benefit of $150 per year for eyewear. Contact lenses, eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are covered, with a $30 copay for Medicare dental services. Oral exams are covered with a copay of $30 per visit every six months, dental x-rays are covered with a copay of $30 per two x-rays every year, and other diagnostic dental services are covered with a $30 copay for two visits every year. Prophylaxis (cleaning) is covered with a copay of $30 for one visit every six months, fluoride treatment is covered with a copay of $30 for one visit every year, and other preventive dental services are covered with a $30 copay for two visits every year. Orthodontic services are covered up to a maximum of $1500 per year. Restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable), maxillofacial prosthetics, implant services, prosthodontics (fixed), oral and maxillofacial surgery, and orthodontics are covered with a $30 copay for two visits every year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Clear Spring Health Essential (PPO) plan, and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, with a coinsurance between 0% and 20%. 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 by the Clear Spring Health Essential (PPO) plan with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME) with 20% coinsurance and Prosthetics/Medical Supplies, also with 20% coinsurance; however, Durable Medical Equipment for use outside the home, Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered. There is no copay for any of these services.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. Diagnostic Procedures/Tests and Lab Services are not covered. Diagnostic Radiological Services have a copay of at most $175, with a minimum of $20. Therapeutic Radiological Services have a coinsurance of at most 20%, with a minimum of 20. Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered by the Clear Spring Health Essential (PPO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the Clear Spring Health Essential (PPO) plan, but the specific services are not covered. Prior authorization is required for Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Clear Spring Health Essential (PPO) plan, requiring prior authorization. For days 1-20, there is no copay, while days 21-100 have a $178 copay. Additional days beyond Medicare coverage and non-Medicare-covered stays are not covered.
Other Services See details
Other Services includes coverage for over-the-counter items with a $60 monthly allowance, while 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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