A non-government entity
Medica Holding Company
Plan ID: H5264-5-0
Plan Summary PageDeanCare Gold Shared Value (Cost)
2025 DeanCare Gold Shared Value (Cost) H5264 — 005 — 0 is a Medicare Advantage plan . It has received a 5-out-of-5 star rating from CMS for 2025.
Learn more about DeanCare Gold Shared Value (Cost) H5264 - 005 - 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.
5 / 5 stars for 2025
$0.00 /mo
Monthly premium
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Plan Overview
2025 DeanCare Gold Shared Value (Cost) H5264 — 005 — 0 is a Cost offered in South Central Wisconsin by Medica Holding Company. It has a monthly premium of $118.00.
Premium Breakdown
Standard Part B Premium
$185.00
Part B premium reduction
- $0
Monthly Plan Premium
$118.00
Total Premium:
$303.00
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
No
Out-of-pocket maximum (In-Network)
N/A
Out-of-pocket maximum (Out-of-Network)
N/A
Out-of-pocket maximum (Combined)
N/A
Plan Organization:
Medica Holding Company
Plan Type:
Cost
Location:
South Central Wisconsin
Drugs Covered:
No
Drug Formulary:
Not yet released
Pharmacies:
Not yet released
Doctors Link:
Deductibles
The amount you must pay each year before your plan starts to pay for covered services or drugs.
Sign up for DeanCare Gold Shared Value (Cost)
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
DeanCare Gold Shared Value (Cost) does not provide drug coverage. If drug coverage is something you need, you should consider shopping for other plans that do provide cost sharing on drugs.
Additional Benefits
DeanCare Gold Shared Value (Cost) also provides the following benefits.
Prescription Drugs (Cost Plans Only)
Not covered.
Inpatient Hospital
Inpatient Hospital benefits are covered.
Inpatient Hospital-Acute
Inpatient Hospital-Acute benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Enhanced benefits
Non-Medicare-covered Stay, Upgrades
Do you charge the Medicare-defined cost share for tier 1?
No
Copayment for Medicare-covered stay
200.00
Periodicity
Original Medicare
Additional Days for Inpatient Hospital-Acute
Additional Days for Inpatient Hospital-Acute benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Number of day intervals for Additional Days
Zero (No Copayment per Day)
Non-Medicare-covered Stay for Inpatient Hospital-Acute
Non-Medicare-covered Stay for Inpatient Hospital-Acute benefits are covered.
Cost Sharing:
Upgrades for Inpatient Hospital-Acute
Not covered.
Inpatient Hospital Psychiatric
Inpatient Hospital Psychiatric benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Enhanced benefits (1b)
Non-Medicare-covered Stay
Do you charge the Medicare-defined cost share for tier 1?
No
Copayment for Medicare-covered stay
200.00
Periodicity
Original Medicare
Additional Days for Inpatient Hospital Psychiatric
Additional Days for Inpatient Hospital Psychiatric benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of Additional Days per benefit period
175
Number of day intervals for Additional Days
Zero (No Copayment per Day)
Non-Medicare-covered Stay for Inpatient Hospital Psychiatric
Not covered.
Outpatient Services
Outpatient Services benefits are covered.
All Outpatient Hospital Services
All Outpatient Hospital Services benefits are covered.
Outpatient Hospital Services
Outpatient Hospital Services benefits are covered.
Observation Services
Observation Services benefits are covered.
Ambulatory Surgical Center (ASC) Services
Ambulatory Surgical Center (ASC) Services benefits are covered.
Outpatient Substance Abuse Services
Outpatient Substance Abuse Services benefits are covered.
Individual Sessions for Outpatient Substance Abuse
Not covered.
Group Sessions for Outpatient Substance Abuse
Not covered.
Outpatient Blood Services
Outpatient Blood Services benefits are covered – including services not usually covered by Medicare plans.
More Details:
Enhanced benefit
Three (3) Pint Deductible Waived
Partial Hospitalization
Partial Hospitalization benefits are covered.
Ambulance and Transportation Services
Ambulance and Transportation Services benefits are covered.
All Ambulance Services
All Ambulance Services benefits are covered.
More Details:
Is there a coinsurance?
No
Is there a copayment ?
No
Ground Ambulance Services
Not covered.
Air Ambulance Services
Not covered.
Transportation Services
Transportation Services benefits are covered.
Transportation Services - Plan Approved Health-related Location
Not covered.
Transportation Services - Any Health-related Location
Not covered.
Emergency Services
Emergency Services benefits are covered.
Emergency Services
Emergency Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
No
Is there a copayment?
Yes
Is the copayment for Medicare-covered benefits waived if admitted to hospital?
Yes
Select either days or hours within which admission must occur for waiver
Days
Enter number of days or hours
3
Does the cost sharing count towards any plan-level deductible?
No
Urgently Needed Services
Urgently Needed Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
No
Is there a copayment?
Yes
Is the copayment for Medicare-covered benefits waived if admitted to hospital?
Yes
Select either days or hours within which admission must occur for waiver
Days
Enter number of days or hours
3
Does the cost sharing count towards any plan-level deductible?
No
Worldwide Emergency Services
Worldwide Emergency Services benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Worldwide Services have a Coinsurance
Worldwide Urgent Coverage, Worldwide Emergency Transportation
Is there a maximum plan benefit coverage?
Yes
Is the maximum plan benefit coverage amount unlimited?
No
Maximum amount
50000.00
Worldwide Emergency Coverage
Worldwide Emergency Coverage benefits are covered.
Cost Sharing:
Worldwide Urgent Coverage
Worldwide Urgent Coverage benefits are covered.
Cost Sharing:
Worldwide Emergency Transportation
Not covered.
Primary Care
Primary Care benefits are covered.
Primary Care Physician Services
Primary Care Physician Services benefits are covered.
Cost Sharing:
Chiropractic Services
Chiropractic Services benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Chiropractic Services have a Copayment
Routine Care, Other
Is there a maximum plan benefit coverage amount?
No
Routine Chiropractic Care
Routine Chiropractic Care benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
Yes
Occupational Therapy Services
Occupational Therapy Services benefits are covered.
More Details:
Is there a coinsurance?
No
Is there a copayment ?
No
Authorization required for this benefit?
No
Referral required for this benefit?
No
Physician Specialist Services
Physician Specialist Services benefits are covered.
Cost Sharing:
Mental Health Specialty Services
Mental Health Specialty Services benefits are covered.
Individual Sessions for Mental Health Specialty Services
Not covered.
Group Sessions for Mental Health Specialty Services
Not covered.
Podiatry Services
Not covered.
Other Health Care Professional
Other Health Care Professional benefits are covered.
Cost Sharing:
More Details:
Minimum copayment
10.00
Maximum copayment
10.00
Psychiatric Services
Psychiatric Services benefits are covered.
Individual Sessions for Psychiatric Services
Not covered.
Group Sessions for Psychiatric Services
Not covered.
Physical Therapy and Speech-Language Pathology Services
Physical Therapy and Speech-Language Pathology Services benefits are covered.
More Details:
Is there a coinsurance?
No
Is there a copayment ?
No
Authorization required for this benefit?
No
Referral required for this benefit?
No
Additional Telehealth Benefits
Not covered.
Opioid Treatment Program Services
Opioid Treatment Program Services benefits are covered.
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
Annual Physical Exam benefits are covered – including services not usually covered by Medicare plans.
More Details:
Is there a maximum plan benefit coverage amount?
No
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)
Not 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
Weight Management Programs benefits are 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
In-Home Support Services benefits are covered.
More Details:
Type of benefit for In-Home Support Services
Mandatory
Support for Caregivers of Enrollees
Not covered.
Additional Sessions of Smoking and Tobacco Cessation Counseling
Additional Sessions of Smoking and Tobacco Cessation Counseling benefits are covered.
More Details:
Number of visits
5
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.
Other Preventive Services
Other Preventive Services benefits are covered.
More Details:
Is a referral required for any Services?
No
Glaucoma Screening
Glaucoma Screening benefits are covered.
Diabetes Self-Management Training
Diabetes Self-Management Training benefits are covered.
Barium Enemas
Barium Enemas benefits are covered.
Digital Rectal Exams
Digital Rectal Exams benefits are covered.
EKG following Welcome Visit
EKG following Welcome Visit benefits are covered.
Hearing Services
Hearing Services benefits are covered.
Hearing Exams
Hearing Exams benefits are covered – including services not usually covered by Medicare plans.
More Details:
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
No
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?
No, indicate number
Number of visits
1
Periodicity
Every three years
Prescription Hearing Aids
Prescription Hearing Aids benefits are covered – including services not usually covered by Medicare plans.
More Details:
Service maximum plan benefit coverage
Yes
Select Coverage
Both ears combined
Maximum plan benefit coverage type
Plan-specified amount per period
Maximum amount
500.00
Periodicity
Every three years
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
1
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.
Vision Services
Vision Services benefits are covered.
Eye Exams
Eye Exams benefits are covered – including services not usually covered by Medicare plans.
More Details:
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.
More Details:
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
250.00
Periodicity
Every two years
Contact Lenses
Not covered.
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
Every two years
Eyeglass lenses
Not covered.
Eyeglass frames
Not covered.
Upgrades
Not covered.
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
300.00
Periodicity
Every year
Oral Exams
Oral Exams benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
2
Periodicity
Every year
Dental X-Rays
Dental X-Rays benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of X-Rays
1
Periodicity
Every year
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
2
Periodicity
Every year
Fluoride Treatment
Fluoride Treatment benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Every year
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.
Cost Sharing:
More Details:
Is this benefit unlimited?
Yes
Coinsurance percentage
50
Adjunctive General Services
Adjunctive General Services benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
Yes
Coinsurance percentage
50
Endodontics
Endodontics benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
Yes
Coinsurance percentage
50
Periodontics
Periodontics benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Periodontal cleanings - twice per year. Root planing/scaling - once per quadrant every 24 months. Full mouth debridement - once per lifetime. Periodontal surgical procedures - once per 36 months
Coinsurance percentage
50
Prosthodontics, removable
Prosthodontics, removable benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Services are limited to once in a five-year period.
Coinsurance percentage
50
Maxillofacial Prosthetics
Not covered.
Implant Services
Implant Services benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Services are limited to once per tooth per 5-year period
Coinsurance percentage
50
Prosthodontics, fixed
Prosthodontics, fixed benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Services are limited to once in a five-year period.
Coinsurance percentage
50
Oral and Maxillofacial Surgery
Oral and Maxillofacial Surgery benefits are covered.
Cost Sharing:
More Details:
Is this benefit unlimited?
Yes
Coinsurance percentage
50
Orthodontics
Not covered.
Home Infusion bundled Services
Not covered.
Dialysis Services
Dialysis Services benefits are covered.
Medical Equipment
Medical Equipment benefits are covered.
Durable Medical Equipment (DME)
Durable Medical Equipment (DME) benefits are covered.
More Details:
Is there a coinsurance?
No
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?
No
Is there a copayment ?
No
Authorization required for this benefit?
No
Prosthetic Devices
Not covered.
Medical Supplies
Not covered.
Diabetic Equipment
Diabetic Equipment benefits are covered.
More Details:
Do you limit Diabetic supplies and services to those from specified manufacturers
Yes
Diabetic Supplies
Not covered.
Diabetic Therapeutic Shoes/Inserts
Not covered.
Diagnostic and Radiological Services
Diagnostic and Radiological Services benefits are covered.
All Diagnostic services
All Diagnostic services benefits are covered.
More Details:
Is there a copayment?
No
Diagnostic Procedures/Tests
Not covered.
Lab Services
Not covered.
All Radiological Services
All Radiological Services benefits are covered.
More Details:
Is there a copayment?
No
Diagnostic Radiological Services
Not covered.
Therapeutic Radiological Services
Not covered.
Outpatient X-Ray Services
Not covered.
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?
No
Referral required for this benefit?
No
Additional Hours of Care
Not covered.
Personal Care Services
Not covered.
Cardiac Rehabilitation Services
Cardiac Rehabilitation Services benefits are covered.
Cardiac Rehabilitation Services
Not covered.
Intensive Cardiac Rehabilitation Services
Not covered.
Pulmonary Rehabilitation Services
Not covered.
SET for PAD Services
Not covered.
Skilled Nursing Facility (SNF)
Skilled Nursing Facility (SNF) benefits are covered.
More Details:
Does the plan provide Skilled Nursing Facility Services as a supplemental benefit under Part C?
Yes
Enhanced benefits (2)
Non-Medicare-covered stay (MMP Only)
Do you allow less than 3 day inpatient hospital stay prior to SNF admission?
No
Periodicity
Original Medicare
Additional Days beyond Medicare-covered for Skilled Nursing Facility (SNF)
Additional Days beyond Medicare-covered for Skilled Nursing Facility (SNF) benefits are covered.
More Details:
Number of Additional Days per benefit period
30
Is this benefit unlimited?
No, indicate number
Non-Medicare-covered Stay for Skilled Nursing Facility (SNF)
Not covered.
Other Services
Other Services benefits are covered.
Acupuncture
Acupuncture benefits are covered – including services not usually covered by Medicare plans.
More Details:
Is this benefit unlimited for Number of Treatments?
Yes
Is there a maximum plan benefit coverage amount?
No
Over-the-Counter (OTC) Items
Not covered.
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?
No
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.
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.
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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