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Medica Advantage Solution H8889-009 (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medica Advantage Solution H8889-009 (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Medica Advantage Solution H8889-009 (PPO) in 2025, please refer to our full plan details page.
Medica Advantage Solution H8889-009 (PPO) is a PPO plan offered by Medica Holding Company available for enrollment in 2025 to people living in Select counties in IA, MN, NE, ND and SD. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Medica Advantage Solution H8889-009 (PPO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Medica Advantage Solution H8889-009 (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 Medica Advantage Solution H8889-009 (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 $85.00. 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.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $4900.00 (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 $4900.00 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
Prescription drugs are not covered by Medica Advantage Solution H8889-009 (PPO).
Additional Benefits
The Medica Advantage Solution H8889-009 (PPO) plan offers a range of benefits, including inpatient hospital stays with a copay, outpatient services, and coverage for emergency services. It also provides coverage for preventive, hearing, vision, dental, and home health services. The plan also offers coverage for medical equipment, diagnostic and radiological services, and skilled nursing facilities. This plan also offers additional benefits such as ambulance services, partial hospitalization, and home infusion services. Primary care, including specialist visits, mental health services, and therapy, are covered with copays. Additionally, the plan covers services such as dialysis and cardiac rehabilitation.
Inpatient Hospital See details
Inpatient hospital services are covered, with a copay of $350 for days 1-6, and no copay for days 7-90. Additional days for Inpatient Hospital-Acute are covered, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered. Inpatient Hospital Psychiatric services are covered, with a copay of $350 for days 1-6, and no copay for days 7-90; however, Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services include coverage for all outpatient hospital services, observation services, ambulatory surgical center (ASC) services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services have a copay between $0 and $395, and observation services have a $350 copay. Ambulatory surgical center (ASC) services have no copay, and individual and group outpatient substance abuse sessions have copays of $35 and $25, respectively.
Partial Hospitalization See details
Partial Hospitalization is covered by this plan, but requires prior authorization. You will have a $95 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Mediac Advantage Solution H8889-009 (PPO) plan. Ground Ambulance Services have a $325 copay, and Air Ambulance Services have a $375 copay, with no coinsurance for either service. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered by the Medica Advantage Solution H8889-009 (PPO) plan, with a $125 copay, and no coinsurance. Urgently Needed Services have a copay between $0 and $45, and no coinsurance. Worldwide Emergency Services are covered, with 20% coinsurance for Worldwide Emergency Coverage and Worldwide Emergency Transportation. Worldwide Urgent Coverage is not covered.
Primary Care See details
The "Medica Advantage Solution H8889-009 (PPO)" plan covers Primary Care Physician Services, Chiropractic Services with a $20 copay, Occupational Therapy Services with a $35 copay, Physician Specialist Services with a $35 copay, and Mental Health and Psychiatric Services with a $25-$35 copay. This plan also covers Physical Therapy and Speech-Language Pathology Services with a $35 copay, Additional Telehealth Benefits with a $0-$45 copay, and Opioid Treatment Program Services with a $35 copay. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
The "Medica Advantage Solution H8889-009 (PPO)" plan covers a variety of preventive services, including Medicare-covered preventive services, annual physical exams, and additional preventive services. Additional services such as health education, in-home safety assessments, and others are not covered.
Hearing Services See details
Hearing services include routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids (all types) are covered with a copay between $549 and $1299. 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
The Medcia Advantage Solution H8889-009 (PPO) plan covers vision services including routine eye exams with a copay of $0-$35, and eyewear with a combined maximum benefit of $200 per year. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a copay between $0 and $35, and other services with a $1,000 annual maximum. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable), maxillofacial prosthetics, implant services, prosthodontics (fixed), and oral and maxillofacial surgery are covered. Orthodontics is not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for this benefit.
Dialysis Services See details
Dialysis Services are covered by the plan with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment is covered under the Medica Advantage Solution H8889-009 (PPO) plan. Durable Medical Equipment (DME) and Prosthetics/Medical Supplies have a 20% coinsurance, with no copay; however, Durable Medical Equipment for use outside the home is not covered. Diabetic Equipment has a coinsurance, with no copay, and a 0-20% coinsurance for Diabetic Supplies, and a 20% coinsurance for Diabetic Therapeutic Shoes/Inserts.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with prior authorization required. Diagnostic Procedures/Tests have a maximum copay of $85, while Lab Services are not covered. Diagnostic Radiological Services have a maximum copay of $85, Therapeutic Radiological Services have a copay of $80, and Outpatient X-Ray Services have a copay of $20.
Home Health Services See details
Home Health Services are covered by the Medica Advantage Solution H8889-009 (PPO) plan with no copay and no coinsurance. However, additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by Medica Advantage Solution H8889-009 (PPO), but 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. The copay information can be found below.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Medica Advantage Solution H8889-009 (PPO) plan. There is no copay for days 1-20 and days 44-100, but there is a $214 copay for days 21-43.
Other Services See details
Other Services include coverage for over-the-counter (OTC) items with a maximum benefit of $75.00 every six months. 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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