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inurance organization provider

BlueCross BlueShield of Tennessee

Plan ID: H3015-1-0

Shared Health Dual Plus (HMO D-SNP)

2025 Shared Health Dual Plus (HMO D-SNP) H3015001 0 is a Medicare Advantage plan with drug coverage. It has received a 3-out-of-5 star rating from CMS for 2025.

Learn more about Shared Health Dual Plus (HMO D-SNP) H3015 - 001 - 0, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.

3 / 5 stars for 2025

$39.10 /mo

Monthly premium

$590.00

Drug deductible

$9350.00

Out-of-pocket maximum (Out-of-Network)

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Overview Icon

Plan Overview

2025 Shared Health Dual Plus (HMO D-SNP) H3015001 0 is a HMO D-SNP offered in Mississippi by BlueCross BlueShield of Tennessee. It has a monthly premium of $39.10.

Important:

2025 Shared Health Dual Plus (HMO D-SNP) H3015001 0 is a Dual-Eligible Special Needs Type plan. You can only enroll in this plan if you meet specific criteria.

Premium Breakdown

Standard Part B Premium

$185.00

Part B premium reduction

- $0

Monthly Plan Premium

$39.10

Total Premium:

$224.10

Note:

The standard Medicare Part B premium for 2025 is $185.00. Your premium may differ based on factors like late enrollment, income (IRMAA), or disability status. Most people enrolled in Medicare Part B are required to pay this premium.

Special needs plan type

Yes

Out-of-pocket maximum (In-Network)

N/A

Out-of-pocket maximum (Out-of-Network)

$9350.00

Out-of-pocket maximum (Combined)

N/A

Conditions Covered

None

Plan Organization:

BlueCross BlueShield of Tennessee

Plan Type:

HMO D-SNP

Location:

Mississippi

Drugs Covered:

Yes

Drug Formulary:

Pharmacies:

Doctors Link:

Deductibles

The amount you must pay each year before your plan starts to pay for covered services or drugs.

Drug deductible

$590

Note:

This plan does not charge an annual deductible for all drugs. The $590.00 annual deductible only applies to drugs in certain tiers.

Sign up for Shared Health Dual Plus (HMO D-SNP)

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Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week

Drug Coverage Icon

Drug Coverage

Shared Health Dual Plus (HMO D-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Benefit Type

Defined Standard

Prescription drug deductible

$590.00

Part D Premium Reduction

This plan's premium may be reduced for you if you qualify for the low-income subsidy (also known as LIS or "Extra help"). The following is what you'll pay for with LIS.

Part D

LIS Full

$39.10

$39.10

Initial Coverage Phase

After you pay your $590.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2000.00. Once you reach that amount, you will enter the next coverage phase.

30 Days
60 Days
90 Days

Tier

Preferred Pharmacy

Standard Pharmacy

Preferred Mail

Standard Mail

1. Preferred Generic

-

-

-

-

2. Standard Generic

-

-

-

-

3. Preferred Brand

-

-

-

-

4. Non-Preferred Drug

-

-

-

-

5. Specialty Tier

-

-

-

-

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.

Nursing Icon

Additional Benefits

Shared Health Dual Plus (HMO D-SNP) also provides the following benefits.

Additional Coverage Icon

Hearing Services

Hearing Services benefits are covered.

Hearing Exams

Hearing Exams benefits are covered – including services not usually covered by Medicare plans.

Cost Sharing:

- Coinsurance: At most 20%. See below for more coinsurance info.

More Details:

Which Hearing Exam Benefits have a Coinsurance

Routine Hearing Exams

Minimum coinsurance

20

Is there a deductible?

No

Is there a deductible?

No

Is there a maximum plan benefit coverage?

Yes

Maximum amount

0.00

Periodicity

Other, Describe

Description

Benefit includes 1 routine hearing exam annually at $0 cost-sharing.

Routine Hearing Exams

Routine Hearing Exams benefits are covered.

More Details:

Is this benefit unlimited?

No, indicate number

Number of visits

1

Periodicity

Every year

Fitting/Evaluation for Hearing Aid

Fitting/Evaluation for Hearing Aid benefits are covered.

More Details:

Is this benefit unlimited?

Yes

Prescription Hearing Aids

Prescription Hearing Aids benefits are covered – including services not usually covered by Medicare plans.

Cost Sharing:

- Service-specific out-of-pocket maximum: $0.00.

More Details:

Maximum enrollee out-of-pocket cost type

Plan-specified amount per period

Periodicity

Other, Describe

Description

1 hearing aid per ear every 3 years.

Service maximum plan benefit coverage

No

Prescription Hearing Aids (all types)

Prescription Hearing Aids (all types) benefits are covered.

More Details:

Is this benefit unlimited?

No, indicate number

Number of visits

2

Periodicity

Every three years

Prescription Hearing Aids - Inner Ear

Not covered.

Prescription Hearing Aids - Outer Ear

Not covered.

Prescription Hearing Aids - Over the Ear

Not covered.

OTC Hearing Aids

Not covered.

Additional Coverage Icon

Vision Services

Vision Services benefits are covered.

Eye Exams

Eye Exams benefits are covered – including services not usually covered by Medicare plans.

Cost Sharing:

- Coinsurance: 20%.

More Details:

Which Eye Exams have a Coinsurance

Routine Eye Exams

Is there a deductible?

No

Is there a deductible?

No

Is there a maximum plan benefit coverage?

No

Routine Eye Exams

Routine Eye Exams benefits are covered.

More Details:

Is this benefit unlimited?

No, indicate number

Number of visits

1

Periodicity

Every year

Eyewear

Eyewear benefits are covered – including services not usually covered by Medicare plans.

Cost Sharing:

- Coinsurance: 20%.

More Details:

Which Eyewear Benefits have a Coinsurance

Contact lenses

Is there a deductible?

No

Is there a deductible?

No

Is there a maximum plan benefit coverage?

Yes

Maximum plan benefit coverage type

Plan-specified amount per period

Do you offer a Combined Max Plan Benefit Coverage Amount for all Eyewear?

Yes

Combined maximum amount

300.00

Periodicity

Every year

Contact Lenses

Contact Lenses benefits are covered.

More Details:

Is this benefit unlimited?

No, indicate number

Number of pairs

1

Periodicity

Other, Describe

Description

$300 allowance per year for glasses and/or contact lenses and fittings.

Eyeglasses (lenses and frames)

Eyeglasses (lenses and frames) benefits are covered.

More Details:

Is this benefit unlimited?

No, indicate number

Number of pairs

1

Periodicity

Other, Describe

Description

$300 allowance per year for glasses and/or contact lenses and fittings.

Eyeglass lenses

Eyeglass lenses benefits are covered.

More Details:

Is this benefit unlimited?

No, indicate number

Number of pairs

1

Periodicity

Other, Describe

Description

$300 allowance per year for glasses and/or contact lenses and fittings.

Eyeglass frames

Eyeglass frames benefits are covered.

More Details:

Is this benefit unlimited?

No, indicate number

Number of eyeglass frames

1

Periodicity

Other, Describe

Description

$300 allowance per year for glasses and/or contact lenses and fittings.

Upgrades

Not covered.

Additional Coverage Icon

Dental Services

Dental Services benefits are covered.

Medicare Dental Services

Medicare Dental Services benefits are covered.

Other Dental Services

Other Dental Services benefits are covered.

More Details:

Is there a maximum plan benefit coverage?

Yes

Maximum amount

4000.00

Periodicity

Every year

Oral Exams

Oral Exams benefits are covered.

More Details:

Is this benefit unlimited?

No

Number of visits

1

Periodicity

Every six months

Dental X-Rays

Dental X-Rays benefits are covered.

More Details:

Is this benefit unlimited?

No

Number of X-Rays

1

Periodicity

Other, Describe

Description

No more than one full mouth set of X-rays every 36 months. No more than four bitewing films every 12 months.

Other Diagnostic Dental Services

Other Diagnostic Dental Services benefits are covered.

More Details:

Is this benefit unlimited?

No

Number of visits

1

Periodicity

Every year

Prophylaxis (Cleaning)

Prophylaxis (Cleaning) benefits are covered.

More Details:

Is this benefit unlimited?

No

Number of visits

1

Periodicity

Every six months

Fluoride Treatment

Fluoride Treatment benefits are covered.

More Details:

Is this benefit unlimited?

No

Number of visits

1

Periodicity

Every six months

Other Preventive Dental Services

Other Preventive Dental Services benefits are covered.

More Details:

Is this benefit unlimited?

No

Number of visits

1

Periodicity

Other, Describe

Description

No more than one recementation every 12 months. No more than one sealant per tooth per lifetime.

Orthodontic Services

Orthodontic Services benefits are covered.

More Details:

Is there a maximum plan benefit coverage?

Yes

Maximum plan benefit coverage type

Covered under Diagnostic and Preventive Dental (16b)

Restorative Services

Restorative Services benefits are covered.

More Details:

Is this benefit unlimited?

No

Number of visits

1

Periodicity

Other, Describe

Description

No more than one amalgam or resin restoration per tooth surface every 12 months.

Adjunctive General Services

Not covered.

Endodontics

Endodontics benefits are covered.

More Details:

Is this benefit unlimited?

No

Number of visits

1

Periodicity

Other, Describe

Description

For primary teeth only.

Periodontics

Periodontics benefits are covered.

More Details:

Is this benefit unlimited?

No

Number of visits

1

Periodicity

Other, Describe

Description

No more than one periodontal scaling and root planing per quadrant every 24 months. No more than one full mouth debridement per lifetime. No more than one cleaning or periodontal maintenance procedure

Prosthodontics, removable

Prosthodontics, removable benefits are covered.

More Details:

Is this benefit unlimited?

No

Number of visits

1

Periodicity

Other, Describe

Description

Replacement of removable dentures covered only after 60 months from the date of initial placement.

Maxillofacial Prosthetics

Not covered.

Implant Services

Not covered.

Prosthodontics, fixed

Prosthodontics, fixed benefits are covered.

More Details:

Is this benefit unlimited?

No

Number of visits

1

Periodicity

Other, Describe

Description

Crown and bridge repair and recementation covered separately only after 12 months from the date of initial placement. Denture adjustments are covered separately from the denture only after 6 months.

Oral and Maxillofacial Surgery

Oral and Maxillofacial Surgery benefits are covered.

More Details:

Is this benefit unlimited?

Yes

Orthodontics

Not covered.

Additional Coverage Icon

Home Infusion bundled Services

Home Infusion bundled Services benefits are covered.

Cost Sharing:

- Coinsurance: See below for more coinsurance info.

More Details:

Which Medicare Part B Rx Drugs have a Coinsurance

Medicare Part B Chemotherapy/Radiation Drugs, Other Medicare Part B Drugs

Does this plan have a service specific maximum enrollee out-of-pocket cost (MOOP)?

No

Does the plan offer step therapy?

Yes

Does the benefit step from?

Part B to Part D

Does the plan provide Part D home infusion drugs as part of a bundled service as a mandatory supplemental benefit?

No

Insulin

Insulin benefits are covered.

Medicare Part B Insulin Drugs

Medicare Part B Insulin Drugs benefits are covered.

Cost Sharing:

- Copay: $35.00.

More Details:

Does the Part B drugs - Insulin cost sharing count towards any plan-level deductible?

No

Medicare Part B Chemotherapy/Radiation Drugs

Medicare Part B Chemotherapy/Radiation Drugs benefits are covered.

More Details:

Minimum coinsurance

0

Maximum coinsurance

20

Other Medicare Part B Drugs

Other Medicare Part B Drugs benefits are covered.

More Details:

Minimum coinsurance

0

Maximum coinsurance

20

Additional Coverage Icon

Preventive Services

Preventive Services benefits are covered.

Medicare-covered Zero Dollar Preventive Services

Medicare-covered Zero Dollar Preventive Services benefits are covered.

Annual Physical Exam

Not covered.

Additional Preventive Services

Additional Preventive Services benefits are covered – including services not usually covered by Medicare plans.

More Details:

Is there a service-specific Maximum Plan Benefit Coverage amount for Other Defined Supplemental Benefits?

No

Health Education

Not covered.

In-Home Safety Assessment

Not covered.

Personal Emergency Response System (PERS)

Personal Emergency Response System (PERS) benefits are covered.

Medical Nutrition Therapy (MNT)

Not covered.

Post discharge In-Home Medication Reconciliation

Not covered.

Re-admission Prevention

Not covered.

Wigs for Hair Loss Related to Chemotherapy

Not covered.

Weight Management Programs

Not covered.

Alternative Therapies

Not covered.

Therapeutic Massage

Not covered.

Adult Day Health Services

Not covered.

Nutritional/Dietary Benefit

Not covered.

Home-Based Palliative Care

Not covered.

In-Home Support Services

Not covered.

Support for Caregivers of Enrollees

Not covered.

Additional Sessions of Smoking and Tobacco Cessation Counseling

Not covered.

Fitness Benefit

Fitness Benefit benefits are covered.

More Details:

Type of Fitness Benefit offered

Memory Fitness

Enhanced Disease Management

Not covered.

Telemonitoring Services

Not covered.

Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)

Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline) benefits are covered.

Home and Bathroom Safety Devices and Modifications

Not covered.

Counseling Services

Not covered.

Kidney Disease Education Services

Kidney Disease Education Services benefits are covered.

Cost Sharing:

- Coinsurance: See below for more coinsurance info.

More Details:

Minimum coinsurance

20

Maximum coinsurance

20

Other Preventive Services

Other Preventive Services benefits are covered.

Cost Sharing:

- Coinsurance: See below for more coinsurance info.

More Details:

Which Services have a Coinsurance

Medicare-covered Glaucoma Screening, Medicare-covered Diabetes Self-Management Training, Medicare-covered Barium Enemas, Medicare-covered Digital Rectal Exams, Medicare-covered EKG following Welcome Visit

Is a referral required for any Services?

No

Glaucoma Screening

Glaucoma Screening benefits are covered.

More Details:

Minimum coinsurance

20

Maximum coinsurance

20

Diabetes Self-Management Training

Diabetes Self-Management Training benefits are covered.

More Details:

Minimum coinsurance

20

Maximum coinsurance

20

Barium Enemas

Barium Enemas benefits are covered.

More Details:

Minimum coinsurance

20

Maximum coinsurance

20

Digital Rectal Exams

Digital Rectal Exams benefits are covered.

More Details:

Minimum coinsurance

20

Maximum coinsurance

20

EKG following Welcome Visit

EKG following Welcome Visit benefits are covered.

More Details:

Minimum coinsurance

20

Maximum coinsurance

20

Other Services

Other Services benefits are covered.

Acupuncture

Acupuncture benefits are covered – including services not usually covered by Medicare plans.

Cost Sharing:

- Coinsurance: 20%.

More Details:

Is this benefit unlimited for Number of Treatments?

No

Limit for Number of Treatments

20

Periodicity

Every year

Is there a maximum plan benefit coverage amount?

No

Over-the-Counter (OTC) Items

Over-the-Counter (OTC) Items benefits are covered.

More Details:

Does the plan provide Over-The-Counter (OTC) Items as a supplemental benefit under Part C?

Yes

Is there a maximum plan benefit coverage amount?

Yes

Maximum plan benefit coverage amount

200.00

Periodicity

Every month

Does your Maximum Plan Benefit Coverage amount carry forward to the next period if it is unused?

No

Plan offers Nicotine Replacement Therapy (NRT) as a Part C OTC benefit?

Yes

The Nicotine Replacement Therapy (NRT) being offered does not duplicate any Part D OTC or formulary drugs.

The Nicotine Replacement Therapy (NRT) being offered does not duplicate any Part D OTC or formulary drugs.

Plan offers Naloxone coverage as a Part C OTC benefit?

Yes

Does this cover all of the drugs on the CMS OTC list which may be found in Chapter 4 of the Medicare Managed Care Manual

Yes

Meal Benefit

Meal Benefit benefits are covered.

More Details:

Does the plan provide a limited duration Meal Benefit as a supplemental benefit under Part C? Note: Only primarily health-related meals offered in accordance with Chapter 4 of the MMCM should be entered in this section.

Yes

Type of primarily health related meals benefit offered

For a chronic illness

Is there a maximum plan benefit coverage amount?

Yes

Maximum plan benefit coverage amount

0.00

Periodicity

Other, Describe

Description

Our plan covers 14 meals following an acute inpatient or SNF discharge stay to a home setting. There is not a limit to the number of discharges for meals. Must use designated vendor.

Dual Eligible SNPs with Highly Integrated Services

Not covered.

Other Services

Other Services benefits are covered.

More Details:

Is Authorization required for one or more Additional Services?

No

Is a referral required for one or more Additional Services?

No

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services

Not covered.

Private Duty Nursing Services

Not covered.

Case Management (Long Term Care)

Not covered.

Institution for Mental Disease Services for Individuals 65 or Older

Not covered.

Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities

Not covered.

Case Management

Not covered.

Tobacco Cessation Counseling for Pregnant Women

Not covered.

Freestanding Birth Center Services

Not covered.

Respiratory Care Services

Not covered.

Family Planning Services

Not covered.

Nursing Home Services

Not covered.

Home and Community Based Services

Not covered.

Personal Care Services

Not covered.

Self-Directed Personal Assistance Services

Not covered.

Dialysis Services

Dialysis Services benefits are covered.

Cost Sharing:

- Coinsurance: See below for more coinsurance info.

More Details:

Minimum coinsurance

20

Maximum coinsurance

20

Additional Coverage Icon

Medical Equipment

Medical Equipment benefits are covered.

Durable Medical Equipment (DME)

Durable Medical Equipment (DME) benefits are covered.

More Details:

Is there a coinsurance?

Yes

Minimum coinsurance

20

Maximum coinsurance

20

Is there a copayment ?

No

Are there preferred vendors/manufacturers for Durable Medical Equipment (DME)?

No

Authorization required for this benefit?

No

Durable Medical Equipment for use outside the home

Not covered.

Prosthetics/Medical Supplies - Non-Medicare benefit

Prosthetics/Medical Supplies - Non-Medicare benefit benefits are covered.

More Details:

Is there a coinsurance?

Yes

Which Prosthetics/Medical Supplies have a Coinsurance

Medicare-covered Prosthetic Devices, Medicare-covered Medical Supplies

Is there a copayment ?

No

Authorization required for this benefit?

No

Prosthetic Devices

Prosthetic Devices benefits are covered.

More Details:

Minimum coinsurance

20

Maximum coinsurance

20

Medical Supplies

Medical Supplies benefits are covered.

Cost Sharing:

- Coinsurance: 20%.

Diabetic Equipment

Diabetic Equipment benefits are covered.

Cost Sharing:

- Coinsurance: See below for more coinsurance info.

More Details:

Which Diabetic Supplies and Services have a Coinsurance

Medicare-covered Diabetic Supplies, Medicare-covered Diabetic Therapeutic Shoes or Inserts

Do you limit Diabetic supplies and services to those from specified manufacturers

Yes

Diabetic Supplies

Diabetic Supplies benefits are covered.

More Details:

Minimum coinsurance

20

Maximum coinsurance

20

Diabetic Therapeutic Shoes/Inserts

Diabetic Therapeutic Shoes/Inserts benefits are covered.

More Details:

Minimum coinsurance

20

Maximum coinsurance

20

Additional Coverage Icon

Ambulance and Transportation Services

Ambulance and Transportation Services benefits are covered.

All Ambulance Services

All Ambulance Services benefits are covered. Prior Authorization is required.

More Details:

Is there a coinsurance?

Yes

Which Services have a Coinsurance

Medicare-covered Ground Ambulance Services, Medicare-covered Air Ambulance Services

Is this Coinsurance waived if admitted to hospital?

No

Is there a copayment ?

No

Ground Ambulance Services

Ground Ambulance Services benefits are covered.

Cost Sharing:

- Coinsurance: 20%.

Air Ambulance Services

Air Ambulance Services benefits are covered.

Cost Sharing:

- Coinsurance: 20%.

Transportation Services

Transportation Services benefits are covered – including services not usually covered by Medicare plans.

More Details:

Enhanced benefit (10b)

Plan Approved Health-related Location

Is there a service specific maximum plan benefit coverage amount?

No

Transportation Services - Plan Approved Health-related Location

Transportation Services - Plan Approved Health-related Location benefits are covered.

More Details:

Is this benefit unlimited?

Yes

Type of transportation

One-way

Mode of Transportation

Rideshare Services, Bus/Subway, Van, Medical Transport, Other, Describe

Transportation Services - Any Health-related Location

Not covered.

Additional Coverage Icon

Outpatient Services

Outpatient Services benefits are covered.

All Outpatient Hospital Services

All Outpatient Hospital Services benefits are covered.

Cost Sharing:

- Coinsurance: See below for more coinsurance info.

More Details:

Which Services have a Coinsurance

Medicare-covered Outpatient Hospital Services, Medicare-covered Observation Services

Outpatient Hospital Services

Outpatient Hospital Services benefits are covered.

Cost Sharing:

- Coinsurance: 20%.

Observation Services

Observation Services benefits are covered.

Cost Sharing:

- Coinsurance: 20%.

Ambulatory Surgical Center (ASC) Services

Ambulatory Surgical Center (ASC) Services benefits are covered.

Cost Sharing:

- Coinsurance: See below for more coinsurance info.

More Details:

Minimum coinsurance

20

Maximum coinsurance

20

Outpatient Substance Abuse Services

Outpatient Substance Abuse Services benefits are covered.

Cost Sharing:

- Coinsurance: See below for more coinsurance info.

More Details:

Which Outpatient Substance Abuse services have a Coinsurance

Medicare-covered Individual Sessions, Medicare-covered Group Sessions

Individual Sessions for Outpatient Substance Abuse

Individual Sessions for Outpatient Substance Abuse benefits are covered.

More Details:

Minimum coinsurance

20

Maximum coinsurance

20

Group Sessions for Outpatient Substance Abuse

Group Sessions for Outpatient Substance Abuse benefits are covered.

More Details:

Minimum coinsurance

20

Maximum coinsurance

20

Outpatient Blood Services

Outpatient Blood Services benefits are covered – including services not usually covered by Medicare plans.

Cost Sharing:

- Coinsurance: 20%.

More Details:

Enhanced benefit

Three (3) Pint Deductible Waived

Additional Coverage Icon

Diagnostic and Radiological Services

Diagnostic and Radiological Services benefits are covered.

All Diagnostic services

All Diagnostic services benefits are covered. Prior Authorization is required.

Cost Sharing:

- Coinsurance: See below for more coinsurance info.

More Details:

Which Outpatient Diagnostic Procedures/Tests/Lab Services have a Coinsurance

Medicare-covered Diagnostic Procedures/Tests, Medicare-covered Lab Services

Is there a copayment?

No

Diagnostic Procedures/Tests

Diagnostic Procedures/Tests benefits are covered.

Cost Sharing:

- Coinsurance: At most 20%. See below for more coinsurance info.

More Details:

Minimum coinsurance

20

Lab Services

Lab Services benefits are covered.

Cost Sharing:

- Coinsurance: At most 20%. See below for more coinsurance info.

More Details:

Minimum coinsurance

20

All Radiological Services

All Radiological Services benefits are covered.

Cost Sharing:

- Coinsurance: See below for more coinsurance info.

More Details:

Which Outpatient Diagnostic/Therapeutic Radiological Services have a Coinsurance

Medicare-covered Diagnostic Radiological Services, Medicare-covered Therapeutic Radiological Services, Medicare-covered X-Ray Services

Is there a copayment?

No

Diagnostic Radiological Services

Diagnostic Radiological Services benefits are covered.

Cost Sharing:

- Coinsurance: At most 20%. See below for more coinsurance info.

More Details:

Minimum coinsurance

20

Therapeutic Radiological Services

Therapeutic Radiological Services benefits are covered.

Cost Sharing:

- Coinsurance: At most 20%. See below for more coinsurance info.

More Details:

Minimum coinsurance

20

Outpatient X-Ray Services

Outpatient X-Ray Services benefits are covered.

Cost Sharing:

- Coinsurance: At most 20%. See below for more coinsurance info.

More Details:

Minimum coinsurance

20

Additional Coverage Icon

Primary Care

Primary Care benefits are covered.

Primary Care Physician Services

Primary Care Physician Services benefits are covered.

Cost Sharing:

- Coinsurance: 20%.

Chiropractic Services

Chiropractic Services benefits are covered – including services not usually covered by Medicare plans. Prior Authorization is required.

Cost Sharing:

- Coinsurance: 20%.

More Details:

Which Chiropractic Services have a Coinsurance

Routine Care

Is there a maximum plan benefit coverage amount?

No

Routine Chiropractic Care

Routine Chiropractic Care benefits are covered.

More Details:

Is this benefit unlimited?

No, indicate number

Visits

12

Periodicity

Every year

Occupational Therapy Services

Occupational Therapy Services benefits are covered.

More Details:

Is there a coinsurance?

Yes

Minimum coinsurance

20

Maximum coinsurance

20

Is there a copayment ?

No

Authorization required for this benefit?

Yes

Referral required for this benefit?

No

Physician Specialist Services

Physician Specialist Services benefits are covered.

Cost Sharing:

- Coinsurance: 20%.

Mental Health Specialty Services

Mental Health Specialty Services benefits are covered.

Cost Sharing:

- Coinsurance: See below for more coinsurance info.

More Details:

Which Mental Health Specialty Services have a Coinsurance

Medicare-covered Individual Sessions, Medicare-covered Group Sessions

Individual Sessions for Mental Health Specialty Services

Individual Sessions for Mental Health Specialty Services benefits are covered.

More Details:

Minimum coinsurance

20

Maximum coinsurance

20

Group Sessions for Mental Health Specialty Services

Group Sessions for Mental Health Specialty Services benefits are covered.

More Details:

Minimum coinsurance

20

Maximum coinsurance

20

Podiatry Services

Podiatry Services benefits are covered – including services not usually covered by Medicare plans.

Cost Sharing:

- Coinsurance: See below for more coinsurance info.

More Details:

Enhanced benefits (7f)

Routine Foot Care

Is this benefit unlimited?

No

Visits

6

Periodicity

Every year

Which Podiatry Services have a Coinsurance

Routine Foot Care

Minimum coinsurance

20

Maximum coinsurance

20

Is there a maximum plan benefit coverage amount?

No

Other Health Care Professional

Other Health Care Professional benefits are covered.

Cost Sharing:

- Coinsurance: See below for more coinsurance info.

More Details:

Minimum coinsurance

20

Maximum coinsurance

20

Psychiatric Services

Psychiatric Services benefits are covered.

Cost Sharing:

- Coinsurance: See below for more coinsurance info.

More Details:

Which Psychiatric Services have a Coinsurance

Medicare-covered Individual Sessions, Medicare-covered Group Sessions

Individual Sessions for Psychiatric Services

Individual Sessions for Psychiatric Services benefits are covered.

More Details:

Minimum coinsurance

20

Maximum coinsurance

20

Group Sessions for Psychiatric Services

Group Sessions for Psychiatric Services benefits are covered.

More Details:

Minimum coinsurance

20

Maximum coinsurance

20

Physical Therapy and Speech-Language Pathology Services

Physical Therapy and Speech-Language Pathology Services benefits are covered.

Cost Sharing:

- Coinsurance: 20%.

More Details:

Is there a coinsurance?

Yes

Is there a copayment ?

No

Authorization required for this benefit?

Yes

Referral required for this benefit?

No

Additional Telehealth Benefits

Additional Telehealth Benefits benefits are covered.

Opioid Treatment Program Services

Opioid Treatment Program Services benefits are covered.

Cost Sharing:

- Coinsurance: See below for more coinsurance info.

More Details:

Minimum coinsurance

20

Maximum coinsurance

20

Home Health Services

Home Health Services benefits are covered.

More Details:

Is there a coinsurance?

No

Is there a copayment ?

No

Authorization required for this benefit?

Yes

Referral required for this benefit?

No

Additional Hours of Care

Not covered.

Personal Care Services

Not covered.

Partial Hospitalization

Partial Hospitalization benefits are covered. Prior Authorization is required.

Cost Sharing:

- Coinsurance: 20%.

Emergency Services

Emergency Services benefits are covered.

Emergency Services

Emergency Services benefits are covered.

Cost Sharing:

- Coinsurance: 20%.

More Details:

Is there a coinsurance?

Yes

Is the coinsurance for Medicare-covered benefits waived if admitted to hospital?

Yes

Select either days or hours within which admission must occur for waiver

Hours

Enter number of days or hours

24

Is there a copayment?

No

Maximum per visit amount

110.00

Does the cost sharing count towards any plan-level deductible?

No

Urgently Needed Services

Urgently Needed Services benefits are covered.

Cost Sharing:

- Coinsurance: 20%.

More Details:

Is there a coinsurance?

Yes

Is the coinsurance for Medicare-covered benefits waived if admitted to hospital?

No

Is there a copayment?

No

Maximum per visit amount

45.00

Does the cost sharing count towards any plan-level deductible?

No

Worldwide Emergency Services

Worldwide Emergency Services benefits are covered.

Worldwide Emergency Coverage

Not covered.

Worldwide Urgent Coverage

Not covered.

Worldwide Emergency Transportation

Not covered.

Additional Coverage Icon

Cardiac Rehabilitation Services

Cardiac Rehabilitation Services benefits are covered.

Cost Sharing:

- Coinsurance: See below for more coinsurance info.

More Details:

Which Cardiac and Pulmonary Rehabilitation Services have a Coinsurance

Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, Additional Cardiac Rehabilitation Services

Cardiac Rehabilitation Services

Not covered.

Intensive Cardiac Rehabilitation Services

Not covered.

Pulmonary Rehabilitation Services

Not covered.

SET for PAD Services

Not covered.

Additional Coverage Icon

Skilled Nursing Facility (SNF)

Skilled Nursing Facility (SNF) benefits are covered. Prior Authorization is required.

Cost Sharing:

- Copay: See below for more copay info.
Days 1-20: Days 21-100:
Copayment0.00214.00

More Details:

Does the plan provide Skilled Nursing Facility Services as a supplemental benefit under Part C?

No

Do you allow less than 3 day inpatient hospital stay prior to SNF admission?

Yes

Days

Zero

Do you charge the Medicare-defined cost share for tier 1?

No

Periodicity

Original Medicare

Additional Days beyond Medicare-covered for Skilled Nursing Facility (SNF)

Not covered.

Non-Medicare-covered Stay for Skilled Nursing Facility (SNF)

Not covered.

Additional Coverage Icon

Inpatient Hospital

Inpatient Hospital benefits are covered.

Inpatient Hospital-Acute

Inpatient Hospital-Acute benefits are covered. Prior Authorization is required.

Cost Sharing:

- Copay: See below for more copay info.

More Details:

Do you charge the Medicare-defined cost share for tier 1?

No

Copayment for Medicare-covered stay

2045.00

Periodicity

Original Medicare

Additional Days for Inpatient Hospital-Acute

Not covered.

Non-Medicare-covered Stay for Inpatient Hospital-Acute

Not covered.

Upgrades for Inpatient Hospital-Acute

Not covered.

Inpatient Hospital Psychiatric

Inpatient Hospital Psychiatric benefits are covered. Prior Authorization is required.

Cost Sharing:

- Copay: See below for more copay info.

More Details:

Do you charge the Medicare-defined cost share for tier 1?

No

Copayment for Medicare-covered stay

2036.00

Periodicity

Original Medicare

Additional Days for Inpatient Hospital Psychiatric

Not covered.

Non-Medicare-covered Stay for Inpatient Hospital Psychiatric

Not covered.

Overview Icon

Plan Providers

Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.

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Get Personalized Help from a licensed insurance agent

1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week

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Every year, Medicare evaluates plans based on a 5-star rating system.

Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.

* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.

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We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.

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