A non-government entity
Sentara Medicare Value (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Sentara Medicare Value (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Sentara Medicare Value (HMO) in 2025, please refer to our full plan details page.
Sentara Medicare Value (HMO) is a HMO plan offered by Sentara Health Care (SHC) available for enrollment in 2025 to people living in State of North Carolina. The overall rating for this plan is not yet available for 2025.
It's important to know that Sentara Medicare 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 Sentara Medicare 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 Sentara Medicare Value (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. Additionally, this plan comes with a Part B Premium reduction of $0.40. 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 a $150.00 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 $3600.00 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 Sentara Medicare Value (HMO) plan has a $150 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, in the initial coverage phase, you may pay $20 for a preferred generic at a standard pharmacy, or $47 for a standard generic. The plan has no copay for preferred mail order generic drugs. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs.
Additional Benefits
The Sentara Medicare Value (HMO) plan provides coverage for a variety of services with varying cost-sharing. Inpatient hospital stays have a copay, while outpatient services and emergency services also have copays. The plan also covers primary care, preventive services, hearing, vision, and dental services, but with some limitations on coverage, such as routine services. Additional benefits include ambulance services, home health services, and skilled nursing facility care with copays and coinsurance requirements. The plan also covers certain diagnostic and radiological services, as well as home infusion and dialysis services. However, some services like outpatient substance abuse, worldwide emergency services, and other services are not covered.
Inpatient Hospital See details
Inpatient Hospital services are covered under the Sentara Medicare Value (HMO) plan, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For days 1-6, the copay is $250, and for days 7-90, there is no copay. Additional days for both Acute and Psychiatric services are covered with no copay. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services are covered by the Sentara Medicare Value (HMO) plan, including outpatient hospital services, observation services, and ambulatory surgical center services. Outpatient hospital and observation services have a $245 copay, while ambulatory surgical center services have a $200 copay. Outpatient substance abuse services and outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Sentara Medicare Value (HMO) plan with a $35 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Sentara Medicare Value (HMO) plan. Both ground and air ambulance services have a $265 copay, with no coinsurance, while transportation services to health-related locations are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services, are covered under the Sentara Medicare Value (HMO) plan. Emergency Services have a $140 copay and no coinsurance, while Urgently Needed Services have a $30 copay and no coinsurance. Worldwide Emergency Services are not covered.
Primary Care See details
The Sentara Medicare Value (HMO) plan covers primary care physician services, occupational therapy, physician specialist services, mental health specialty services, podiatry services, other health care professional services, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Chiropractic services are covered with a $20 copay, with routine care not covered; occupational therapy has a $25 copay. Physician specialist services have a $25 copay, and mental health specialty services, including individual and group sessions, have a minimum $25 copay. Podiatry services, including routine foot care, have a minimum $25 copay. Other health care professional services have a copay that ranges from $0 to $25, while psychiatric services, including individual and group sessions, have a minimum $25 copay. Physical therapy and speech-language pathology services have a $25 copay.
Preventive Services See details
The Sentara Medicare Value (HMO) plan covers preventive services, including Medicare-covered preventive services with prior authorization, with no copay. Additional preventive services are partially covered, excluding annual physical exams, health education, in-home safety assessments, medical nutrition therapy, 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, fitness benefit, enhanced disease management, telemonitoring services, remote access technologies, home and bathroom safety devices and modifications, and counseling services.
Hearing Services See details
Hearing services are covered, including hearing exams with a $25 copay, but routine hearing exams, fitting/evaluation for hearing aids, and all types of prescription hearing aids are not covered. OTC hearing aids are also not covered.
Vision Services See details
Vision services are partially covered by the Sentara Medicare Value (HMO) plan. Eye exams are covered, but routine eye exams are not. Eyewear is not covered, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
Dental Services are covered, but the plan does not cover Orthodontic Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable), Maxillofacial Prosthetics, Implant Services, Prosthodontics (fixed), Oral and Maxillofacial Surgery, and Orthodontics. Medicare Dental Services require prior authorization.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. 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 Sentara Medicare Value (HMO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment with 20% coinsurance and Prosthetic Devices and Medical Supplies with a 20% coinsurance, but Durable Medical Equipment for use outside the home is not covered. Diabetic Therapeutic Shoes/Inserts have a coinsurance of 20%, while 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 $0 and $85, and Diagnostic Radiological Services with a copay up to $275. Therapeutic Radiological Services have a copay up to $25 and a coinsurance of 20%, while Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Sentara Medicare Value (HMO) 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, but the plan does not cover any of the sub-services, including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Sentara Medicare 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, and non-Medicare-covered stays, are not covered.
Other Services See details
Other Services are not covered by the Sentara Medicare Value (HMO) plan, including acupuncture, over-the-counter items, meal benefits, dual eligible SNPs with highly integrated services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, private duty nursing services, case management, institution for mental disease services, services in an intermediate care facility, case management, tobacco cessation counseling, 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. No authorization or referral is required for these services.
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