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Medica Advantage with SSM Value (HMO-POS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medica Advantage with SSM Value (HMO-POS). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Medica Advantage with SSM Value (HMO-POS) in 2025, please refer to our full plan details page.
Medica Advantage with SSM Value (HMO-POS) is a HMO-POS plan offered by Medica Holding Company available for enrollment in 2025 to people living in St. Louis Metro Area. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that Medica Advantage with SSM Value (HMO-POS) 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 Medica Advantage with SSM Value (HMO-POS).
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 Medica Advantage with SSM Value (HMO-POS), 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 $35.00. 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 combined Maximum Out-Of-Pocket cost of $8000.00 (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 $8000.00 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 Medica Advantage with SSM Value (HMO-POS) plan has no deductible for prescription drugs. In the initial coverage phase, you'll pay a copay or coinsurance depending on the drug tier and pharmacy you use. For example, preferred generic drugs have an $8 copay at preferred pharmacies. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for 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 Medica Advantage with SSM Value (HMO-POS) plan offers comprehensive coverage, including inpatient and outpatient hospital services, with varying copays. You'll find no copay for many services, such as ambulatory surgical center services, and lab services. Primary care, specialist visits, vision, and dental services are also covered, with routine eye exams and some dental work available. This plan provides coverage for emergency services, ambulance, and transportation services, with a $300 copay for ambulance services and coverage for 24 transportation trips per year. It also covers hearing services, home health services, and skilled nursing facility stays, with different copays depending on the specific service. Additionally, the plan includes benefits like home infusion, medical equipment, and various diagnostic and radiological services.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you'll pay a $325 copay for days 1-7, and no copay for days 8-90. For Inpatient Hospital Psychiatric, you'll pay a $310 copay for days 1-7, and no copay for days 8-90. Additional days and upgrades for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered. Non-Medicare-covered stays are not covered.
Outpatient Services See details
Outpatient services include coverage for outpatient hospital services with a copay between $0 and $300, observation services with a $300 copay, ambulatory surgical center services with no copay, and outpatient substance abuse services with a copay of $35 for individual sessions and $25 for group sessions. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered with a $100 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Medica Advantage with SSM Value (HMO-POS) plan. Ground and air ambulance services each have a $300 copay, with no coinsurance. Transportation services to any health-related location are covered for 24 one-way trips per year via bus or subway.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the plan. Emergency Services and Worldwide Emergency Coverage have a $140 copay, while Urgently Needed Services have a copay between $0 and $40; all services have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Medica Advantage with SSM Value (HMO-POS) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $35 copay, specialist services with a copay between $0 and $35, and mental health specialty services with a copay between $25 and $35. Podiatry services and other healthcare professional services have a $35 copay, and physical therapy and speech-language pathology services have a $40 copay. This plan also covers additional telehealth benefits with a copay between $0 and $35, and opioid treatment program services with a $35 copay.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services, annual physical exams, and additional preventive services, while health education, in-home safety assessments, and other services are not covered. Additional sessions of smoking and tobacco cessation counseling, a fitness benefit, remote access technologies, glaucoma screening, and other preventive services are covered.
Hearing Services See details
Hearing services include routine hearing exams with a $35 copay. Fitting/evaluation for hearing aids are covered, and prescription hearing aids are covered, but inner ear, outer ear, and over the ear prescription hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision Services includes coverage for routine eye exams once per year, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades. There is no deductible or coinsurance for any of these services.
Dental Services See details
Dental Services includes coverage for Medicare Dental Services with a $40 copay, as well as other dental services with a $300 maximum benefit per year. This plan also covers Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), and Fluoride Treatments. Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Implant Services, and Oral and Maxillofacial Surgery are covered with 50% coinsurance. Maxillofacial Prosthetics and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, the copay is $30-$35. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, the coinsurance ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by the Medica Advantage with SSM Value (HMO-POS) plan. The coinsurance for dialysis services is between 20% and 20%.
Medical Equipment See details
Medical Equipment is covered by the Medica Advantage with SSM Value (HMO-POS) plan, with Durable Medical Equipment (DME) subject to a 0-20% coinsurance and requiring authorization, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices and Medical Supplies have a 20% coinsurance, and Diabetic Therapeutic Shoes/Inserts are covered with a 20% coinsurance, but Diabetic Supplies are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for diagnostic procedures/tests with a copay between $10 and $20, and lab services with no copay. Diagnostic Radiological Services have a copay of at most $200, Therapeutic Radiological Services have a copay of at most $75 (minimum $20), and Outpatient X-Ray Services have a $20 copay.
Home Health Services See details
Home Health Services are covered with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Medica Advantage with SSM Value (HMO-POS) plan. The plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Medica Advantage with SSM Value (HMO-POS) plan, but require prior authorization. For days 1-20, the copay is $10 per day, and for days 21-100, the copay is $214 per day. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Under the "Other Services" benefit, Acupuncture is not covered, while Over-the-Counter (OTC) Items are covered with a maximum plan benefit of $50.00 every three months. The plan also covers a meal benefit for a chronic illness, and "Other 1" services, such as ambulance services for non-transport, have a copay of $300.00. However, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), and other services listed are not covered.
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