A non-government entity
NEIGHBORHOOD HEALTH PLAN OF RHODE ISLAND
Plan ID: H9576-1-0
Plan Summary PageNeighborhood INTEGRITY (Medicare-Medicaid Plan)
2025 Neighborhood INTEGRITY (Medicare-Medicaid Plan) H9576 — 001 — 0 is a Medicare Advantage plan with drug coverage. 0
Learn more about Neighborhood INTEGRITY (Medicare-Medicaid Plan) H9576 - 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.
$0.00 /mo
Monthly premium
$0
Drug deductible
Enroll online
Call to enroll
OR
Get personalized help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week!
Plan Overview
2025 Neighborhood INTEGRITY (Medicare-Medicaid Plan) H9576 — 001 — 0 is a Medicare-Medicaid Plan offered in State of Rhode Island by NEIGHBORHOOD HEALTH PLAN OF RHODE ISLAND. It has a monthly premium of $0.00.
Premium Breakdown
Standard Part B Premium
$185.00
Part B premium reduction
- $0
Monthly Plan Premium
$0.00
Total Premium:
$185.00
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:
NEIGHBORHOOD HEALTH PLAN OF RHODE ISLAND
Plan Type:
Medicare-Medicaid Plan
Location:
State of Rhode Island
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
$0
Sign up for Neighborhood INTEGRITY (Medicare-Medicaid Plan)
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
Neighborhood INTEGRITY (Medicare-Medicaid Plan) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Benefit Type
Enhanced Alternative
Prescription drug deductible
$0
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 |
|---|---|
$0.00 | $0.00 |
Initial Coverage Phase
After you pay your $0.00 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.
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.
Additional Benefits
Neighborhood INTEGRITY (Medicare-Medicaid Plan) also provides the following benefits.
Inpatient Hospital
Inpatient Hospital benefits are covered.
Inpatient Hospital-Acute
Inpatient Hospital-Acute benefits are covered – including services not usually covered by Medicare plans. Prior Authorization is required.
More Details:
Enhanced benefits
Non-Medicare-covered Stay, Upgrades
Periodicity
Annual
Do you charge cost sharing on the day of discharge?
No
Additional Days for Inpatient Hospital-Acute
Additional Days for Inpatient Hospital-Acute benefits are covered.
More Details:
Is this benefit unlimited?
Yes
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.
More Details:
Enhanced benefits (1b)
Additional Days, Non-Medicare-covered Stay
Periodicity
Annual
Do you charge cost sharing on the day of discharge?
No
Additional Days for Inpatient Hospital Psychiatric
Additional Days for Inpatient Hospital Psychiatric benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Non-Medicare-covered Stay for Inpatient Hospital Psychiatric
Non-Medicare-covered Stay for Inpatient Hospital Psychiatric benefits are covered.
Cost Sharing:
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. Prior Authorization is required.
Observation Services
Observation Services benefits are covered.
Ambulatory Surgical Center (ASC) Services
Ambulatory Surgical Center (ASC) Services benefits are covered. Prior Authorization is required.
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. Prior Authorization is required.
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.
More Details:
Is there a coinsurance?
No
Is there a copayment?
No
Urgently Needed Services
Urgently Needed Services benefits are covered.
More Details:
Is there a coinsurance?
No
Is there a copayment?
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.
Primary Care
Primary Care benefits are covered.
Primary Care Physician Services
Primary Care Physician Services benefits are covered.
Chiropractic Services
Chiropractic Services benefits are covered. Prior Authorization is required.
Routine Chiropractic Care
Not covered.
Occupational Therapy Services
Occupational Therapy Services benefits are covered.
More Details:
Is there a coinsurance?
No
Is there a coinsurance?
No
Is there a copayment ?
No
Is there a copayment ?
No
Authorization required for this benefit?
Yes
Referral required for this benefit?
No
Does this plan provide Non-Medicare-covered Occupational Therapy Services?
Yes
Enter name of Non-Medicare-covered Occupational Therapy Service
Outpatient Hospital Occupational Therapy Services
Is there a service specific maximum plan benefit coverage amount?
No
Authorization required for this benefit?
Yes
Referral required for this benefit?
No
Physician Specialist Services
Physician Specialist Services benefits are covered.
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
Podiatry Services benefits are covered – including services not usually covered by Medicare plans.
More Details:
Enhanced benefits (7f)
Routine Foot Care
Is this benefit unlimited?
Yes
Is there a maximum plan benefit coverage amount?
No
Other Health Care Professional
Other Health Care Professional benefits are covered.
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 coinsurance?
No
Is there a copayment ?
No
Is there a copayment?
No
Authorization required for this benefit?
Yes
Referral required for this benefit?
No
Does this plan provide Non-Medicare-covered Physical and/or Speech Therapy services?
Yes
Non-Medicare-covered Physical and/or Speech Therapy Services
Other 1, Other 2
Is there a maximum plan benefit coverage amount?
No
Authorization required for this benefit?
Yes
Referral required for this benefit?
No
Other 1 for PT and SP Services
Other 1 for PT and SP Services benefits are covered.
More Details:
Enter name of Other 1 Service
Physical Therapy Evaluation
Other 2 for PT and SP Services
Other 2 for PT and SP Services benefits are covered.
More Details:
Enter name of Other 2 Service
Preventive Physical Therapy Services
Additional Telehealth Benefits
Additional Telehealth Benefits benefits are covered – including services not usually covered by Medicare plans. Prior Authorization is required.
More Details:
Medicare-covered benefits that may have Additional Telehealth Benefits available
4b: Urgently Needed Services, 7a: Primary Care Physician Services, 7c: Occupational Therapy Services, 7d: Physician Specialist Services, 7e1: Individual Sessions for Mental Health Specialty Services, 7e2: Group Sessions for Mental Health Specialty Services, 7g: Other Health Care Professional, 7h1: Individual Sessions for Psychiatric Services, 7h2: Group Sessions for Psychiatric Services, 7i: Physical Therapy and Speech-Language Pathology Services, 9c1: Individual Sessions for Outpatient Substance Abuse, 9c2: Group Sessions for Outpatient Substance Abuse, 14d: Kidney Disease Education Services, 14e2: Diabetes Self-Management Training
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
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
Health Education benefits are 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
Weight Management Programs benefits are covered.
Alternative Therapies
Not covered.
Therapeutic Massage
Not covered.
Adult Day Health Services
Not covered.
Nutritional/Dietary Benefit
Nutritional/Dietary Benefit benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Setting for Nutritional/Dietary Benefit
Both Sessions (Individual and Group)
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
9999
Fitness Benefit
Fitness Benefit benefits are covered.
More Details:
Type of Fitness Benefit offered
Physical Fitness, 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?
Yes
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.
More Details:
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
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 two years
Other Eye Exam Services
Other Eye Exam Services benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Service Name
Medically Necessary Optometry Services
Eyewear
Eyewear benefits are covered – including services not usually covered by Medicare plans. Prior Authorization is required.
More Details:
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
No
Contact Lenses
Contact Lenses benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of pairs
1
Periodicity
Every two years
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
Eyeglass lenses benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of pairs
1
Periodicity
Every two years
Eyeglass frames
Eyeglass frames benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of eyeglass frames
1
Periodicity
Every two years
Upgrades
Not covered.
Dental Services
Dental Services benefits are covered.
Medicare Dental Services
Medicare Dental Services benefits are covered. Prior Authorization is required.
Other Dental Services
Other Dental Services benefits are covered.
More Details:
Is there a maximum plan benefit coverage?
Yes
Maximum amount
1250.00
Periodicity
Other, Describe
Description
Benefit covers 2 cleanings, 1 Exam, 1 Bitewing X-Ray, 1 Adult Fluoride Treatment annually, 1 Full-Mouth X-Ray every 5 years, Single X-Rays as needed, and other benefits as needed
Oral Exams
Not covered.
Dental X-Rays
Not covered.
Prophylaxis (Cleaning)
Not covered.
Fluoride Treatment
Not covered.
Other Preventive Dental Services
Other Preventive Dental Services benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
9999
Periodicity
Every year
Orthodontic Services
Orthodontic Services benefits are covered.
More Details:
Is there a maximum plan benefit coverage?
No
Restorative Services
Not covered.
Adjunctive General Services
Not covered.
Endodontics
Not covered.
Periodontics
Not covered.
Prosthodontics, removable
Prosthodontics, removable benefits are covered. Prior Authorization is required.
More Details:
Is this benefit unlimited?
Yes
Maxillofacial Prosthetics
Maxillofacial Prosthetics benefits are covered. Prior Authorization is required.
More Details:
Is this benefit unlimited?
Yes
Implant Services
Not covered.
Prosthodontics, fixed
Prosthodontics, fixed benefits are covered. Prior Authorization is required.
More Details:
Is this benefit unlimited?
Yes
Oral and Maxillofacial Surgery
Oral and Maxillofacial Surgery benefits are covered. Prior Authorization is required.
More Details:
Is this benefit unlimited?
Yes
Orthodontics
Not covered.
Home Infusion bundled Services
Home Infusion bundled Services benefits are covered. Prior Authorization is required.
More Details:
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 B, Part B to Part D, Part D to Part B
Does the plan provide Part D home infusion drugs as part of a bundled service as a mandatory supplemental benefit?
No
Does the plan pay for Part D home infusion services and supplies as a Medicaid benefit?
No
Insulin
Insulin benefits are covered.
Medicare Part B Insulin Drugs
Medicare Part B Insulin Drugs benefits are covered.
Medicare Part B Chemotherapy/Radiation Drugs
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 coinsurance?
No
Is there a copayment ?
No
Is there a copayment ?
No
Are there preferred vendors/manufacturers for Durable Medical Equipment (DME)?
No
Authorization required for this benefit?
Yes
Does this plan provide Non-Medicare-covered Durable Medical Equipment?
Yes
Non-Medicare-covered Durable Medical Equipment
Other 1, Other 2
Is there a maximum plan benefit coverage amount?
No
Authorization required for this benefit?
Yes
Durable Medical Equipment for use outside the home
Not covered.
Other 1 for Durable Medical Equipment
Other 1 for Durable Medical Equipment benefits are covered.
More Details:
Enter name of Other 1 Service
Minor Environmental Modifications
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 coinsurance?
No
Is there a copayment ?
No
Is there a copayment ?
No
Authorization required for this benefit?
Yes
Does this plan provide Non-Medicare-covered Prosthetics/Medical Supplies?
Yes
Enter name of Non-Medicare-covered Service
Non-Medicare Prosthetics/Medical Supplies
Is there a maximum plan benefit coverage amount?
No
Authorization required for this benefit?
Yes
Prosthetic Devices
Not covered.
Medical Supplies
Not covered.
Diabetic Equipment
Diabetic Equipment benefits are covered. Prior Authorization is required.
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. Prior Authorization is required.
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. Prior Authorization is required.
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 an enrollee Coinsurance?
No
Is there a copayment ?
No
Is there an enrollee Copayment?
No
Authorization required for this benefit?
Yes
Referral required for this benefit?
No
Is there a limit on the services provided?
No
Does this plan provide Non-Medicare-covered Home Health Services?
Yes
Non-Medicare-covered Home Health Services
Personal Care Services, Other 2
Is there a maximum plan benefit coverage amount?
No
Does any service require qualification for and enrollment in a state-operated waiver program?
No
Authorization required for this benefit?
Yes
Referral required for this benefit?
No
Additional Hours of Care
Not covered.
Personal Care Services
Not covered.
Other 1 for Home Health Services
Other 1 for Home Health Services benefits are covered.
More Details:
Enter name of Other 1 Service
Home Care Services
Cardiac Rehabilitation Services
Cardiac Rehabilitation Services benefits are covered – including services not usually covered by Medicare plans.
Cardiac Rehabilitation Services
Cardiac Rehabilitation Services benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Intensive Cardiac Rehabilitation Services
Intensive Cardiac Rehabilitation Services benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Pulmonary Rehabilitation Services
Pulmonary Rehabilitation Services benefits are covered.
More Details:
Is this benefit unlimited?
Yes
SET for PAD Services
Not covered.
Skilled Nursing Facility (SNF)
Skilled Nursing Facility (SNF) benefits are covered. Prior Authorization is required.
More Details:
Does the plan provide Skilled Nursing Facility Services as a supplemental benefit under Part C?
Yes
Enhanced benefits (2)
Additional days beyond Medicare-covered, Non-Medicare-covered stay (MMP Only)
Do you allow less than 3 day inpatient hospital stay prior to SNF admission?
Yes
Days
Zero
Periodicity
Annual
Do you charge cost sharing on the day of discharge?
No
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:
Is this benefit unlimited?
Yes
Non-Medicare-covered Stay for Skilled Nursing Facility (SNF)
Non-Medicare-covered Stay for Skilled Nursing Facility (SNF) benefits are covered.
Cost Sharing:
Other Services
Other Services benefits are covered.
Acupuncture
Not covered.
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
Immediately following surgery or inpatient hospitilization, For a chronic illness
Is there a maximum plan benefit coverage amount?
Yes
Maximum plan benefit coverage amount
9999.00
Periodicity
Other, Describe
Description
14 Home Delivered Meals, up to 2 times per year, not to exceed a maximum of 28 meals, offered to members as needed after inpatient hospitalization or surgery.
Other 2
Other 2 benefits are covered. Prior Authorization is required.
More Details:
Service Name
Homemaker Services
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:
Does the plan provide Additional Services?
Yes
Additional Services
13h2: Tobacco Cessation Counseling for Pregnant Women, 13h4: Respiratory Care Services, 13h5: Family Planning Services, 13h6: Nursing Home Services, 13h8: Personal Care Services, 13h10: Private Duty Nursing Services, 13h11: Case Management (Long Term Care), 13h15: Other 1, 13h16: Other 2, 13h17: Other 3, 13h18: Other 4, 13h19: Other 5, 13h20: Other 6, 13h21: Other 7, 13h22: Other 8, 13h23: Other 9, 13h24: Other 10, 13h25: Other 11, 13h26: Other 12, 13h27: Other 13, 13h28: Other 14, 13h29: Other 15, 13h30: Other 16, 13h31: Other 17, 13h32: Other 18, 13h33: Other 19, 13h34: Other 20, 13h35: Other 21, 13h36: Other 22, 13h37: Other 23, 13h38: Other 24, 13h39: Other 25, 13h40: Other 26
Is there a limit on the Additional Services provided?
Yes
Additional Services where a limit applies
13h40: Other 26
Is there a maximum plan benefit coverage amount?
Yes
Additional Services have a Maximum Plan Benefit Coverage Amount
13h23: Other 9, 13h39: Other 25
Does any service require qualification for and enrollment in a state-operated waiver program?
Yes
Services that require qualification for and enrollment in a state-operated waiver program
13h8: Personal Care Services, 13h10: Private Duty Nursing Services, 13h11: Case Management (Long Term Care), 13h23: Other 9, 13h24: Other 10, 13h26: Other 12, 13h27: Other 13, 13h28: Other 14, 13h29: Other 15, 13h30: Other 16, 13h31: Other 17, 13h32: Other 18, 13h33: Other 19, 13h34: Other 20, 13h35: Other 21, 13h36: Other 22
Is a beneficiary receiving any benefit subject to a state-required monthly payment amount that is based on his or her financial resources (for example: a "patient pay amount")?
Yes
Benefits subject to a state-required monthly payment amount that is based on his or her financial resources (for example: a "patient pay amount")
13h6: Nursing Home Services, 13h36: Other 22, 13h35: Other 21, 13h34: Other 20, 13h33: Other 19, 13h32: Other 18, 13h31: Other 17, 13h30: Other 16, 13h29: Other 15, 13h28: Other 14, 13h27: Other 13, 13h26: Other 12, 13h24: Other 10, 13h23: Other 9, 13h11: Case Management (Long Term Care), 13h10: Private Duty Nursing Services, 13h8: Personal Care Services
Is Authorization required for one or more Additional Services?
Yes
Which Additional Services need an Authorization
13h6: Nursing Home Services, 13h8: Personal Care Services, 13h16: Other 2, 13h24: Other 10, 13h25: Other 11, 13h34: Other 20, 13h35: Other 21
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
Private Duty Nursing Services benefits are covered.
More Details:
Minimum
0.00
Maximum
5000.00
Case Management (Long Term Care)
Case Management (Long Term Care) benefits are covered.
More Details:
Minimum
0.00
Maximum
5000.00
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.
Other 1
Other 1 benefits are covered.
More Details:
Enter name of Other 1 Service
Care Management
Other 2
Other 2 benefits are covered.
More Details:
Enter name of Other 2 Service
Adult Day Health
Other 3
Other 3 benefits are covered.
More Details:
Enter name of Other 3 Service
Special Medical Equipment/Minor Assistive Devices
Other 4
Other 4 benefits are covered.
More Details:
Enter name of Other 4 Service
HIV/AIDS Non-Medical Targeted & AIDS Medical Case Management
Other 5
Other 5 benefits are covered.
More Details:
Enter name of Other 5 Service
Criminal & Civil Court-Ordered Mental Health & Substance Abuse Treatment
Tobacco Cessation Counseling for Pregnant Women
Not covered.
Other 6
Other 6 benefits are covered.
More Details:
Enter name of Other 6 Service
Assertive Community Treatment (ACT)
Other 7
Other 7 benefits are covered.
More Details:
Enter name of Other 7 Service
Integrated Health Home (IHH)
Other 8
Other 8 benefits are covered.
More Details:
Enter name of Other 8 Service
Non-Traditional Clinical Behavioral Health Services
Other 9
Other 9 benefits are covered.
More Details:
Enter name of Other 9 Service
Respite (LTSS)
Maximum plan benefit coverage amount
3000.00
Periodicity
Every year
Minimum
0.00
Maximum
5000.00
Other 10
Other 10 benefits are covered.
More Details:
Enter name of Other 10 Service
Homemaker Services (LTSS)
Minimum
0.00
Maximum
5000.00
Other 11
Other 11 benefits are covered.
More Details:
Enter name of Other 11 Service
Environmental Mods/Home Accessibility Adaptations
Other 12
Other 12 benefits are covered.
More Details:
Enter name of Other 12 Service
Skilled Nursing Services/LPN (LTSS)
Minimum
0.00
Maximum
5000.00
Other 13
Other 13 benefits are covered.
More Details:
Enter name of Other 13 Service
Community Transition Services (LTSS)
Minimum
0.00
Maximum
5000.00
Other 14
Other 14 benefits are covered.
More Details:
Enter name of Other 14 Service
Residential Supports (LTSS)
Minimum
0.00
Maximum
5000.00
Other 15
Other 15 benefits are covered.
More Details:
Enter name of Other 15 Service
Day Supports (LTSS)
Minimum
0.00
Maximum
5000.00
Freestanding Birth Center Services
Not covered.
Other 16
Other 16 benefits are covered.
More Details:
Enter name of Other 16 Service
Supported Employment (LTSS)
Minimum
0.00
Maximum
5000.00
Other 17
Other 17 benefits are covered.
More Details:
Enter name of Other 17 Service
RIte @ Home/Supported - Shared Living Arrangements (LTSS)
Minimum
0.00
Maximum
5000.00
Other 18
Other 18 benefits are covered.
More Details:
Enter name of Other 18 Service
Self-Directed Supports and Services (LTSS)
Minimum
0.00
Maximum
5000.00
Other 19
Other 19 benefits are covered.
More Details:
Enter name of Other 19 Service
Senior Companion/Adult Companion Services (LTSS)
Minimum
0.00
Maximum
5000.00
Other 20
Other 20 benefits are covered.
More Details:
Enter name of Other 20 Service
Assisted Living (LTSS)
Minimum
0.00
Maximum
5000.00
Other 21
Other 21 benefits are covered.
More Details:
Enter name of Other 21 Service
Rehabilitation Services
Minimum
0.00
Maximum
5000.00
Other 22
Other 22 benefits are covered.
More Details:
Enter name of Other 22 Service
Mental Health Psychiatric Rehabilitation Residences
Minimum
0.00
Maximum
5000.00
Other 23
Other 23 benefits are covered.
More Details:
Enter name of Other 23 Service
Outpatient Mental Health and Substance Use Disorder Treatment
Other 24
Other 24 benefits are covered.
More Details:
Enter name of Other 24 Service
Opioid Treatment Program (OTP) Health Home Services
Other 25
Other 25 benefits are covered.
More Details:
Enter name of Other 25 Service
Healthy Food and Nutrition Benefit
Maximum plan benefit coverage amount
75.00
Periodicity
Other, Describe
Description
Monthly, Non-Rolling
Respiratory Care Services
Not covered.
Other 26
Other 26 benefits are covered.
More Details:
Enter name of Other 26 Service
Doula Services
Units
Visits
Numerical limit
7
Periodicity
Every Pregnancy
Family Planning Services
Not covered.
Nursing Home Services
Nursing Home Services benefits are covered.
More Details:
Minimum
0.00
Maximum
5000.00
Home and Community Based Services
Not covered.
Personal Care Services
Personal Care Services benefits are covered.
More Details:
Minimum
0.00
Maximum
5000.00
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
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
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.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
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.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved