A non-government entity
Intermountain Health Care, Inc.
Plan ID: H1994-15-0
Plan Summary PageSelect Health Medicare Dual (HMO D-SNP)
2026 Select Health Medicare Dual (HMO D-SNP) H1994 — 015 — 0 is a Medicare Advantage plan with drug coverage. It has received a 3.5-out-of-5 star rating from CMS for 2026.
Learn more about Select Health Medicare Dual (HMO D-SNP) H1994 - 015 - 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 / 5 stars for 2026
$37.60 /mo
Monthly premium
$615.00
Drug deductible
$8850.00
Out-of-pocket maximum (Out-of-Network)
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week!
About This Plan
The Select Health Medicare Dual (HMO D-SNP) plan offers comprehensive coverage with no copay for primary care visits, home health services, and select preventive care. For inpatient hospital stays, members pay a $410 copay per day for the first four days and no copay for days five through 90. Outpatient services generally feature no copays, though coinsurance rates between 20% and 30% apply to most procedures. This plan also includes valuable everyday benefits, such as dental care with no copay or coinsurance up to a $1,500 annual limit, and vision coverage featuring a $200 yearly allowance for eyewear. Additionally, members can access unlimited one-way transportation to plan-approved health locations with no copay. Durable medical equipment, dialysis, and diagnostic tests are also covered with no copay, though coinsurance still applies to these services.
The Select Health Medicare Dual (HMO D-SNP) plan features an annual prescription drug deductible of $615. This deductible is the amount you must pay out-of-pocket for your medications before the plan begins to cover its share of the costs. Specific drug coverage tier details, such as copayments and coinsurance for individual tiers, are currently unavailable for this plan. You can review the plan's formulary to see how your specific prescription medications are classified and covered.
Plan data sourced from the official CMS 2026 public benefit files. Reviewed by Walt Whitney. How we source and review plan information.
Plan Overview
2026 Select Health Medicare Dual (HMO D-SNP) H1994 — 015 — 0 is a HMO D-SNP offered in Davis, Iron, Salt Lake, Utah, Washington, Weber by Intermountain Health Care, Inc.. It has a monthly premium of $37.60.
Important:
2026 Select Health Medicare Dual (HMO D-SNP) H1994 — 015 — 0 is a Dual-Eligible Special Needs Type plan. You can only enroll in this plan if you meet specific criteria.
Premium Breakdown
Monthly plan premium
$37.60
Standard Part B premium
$202.90
Note:
The standard Medicare Part B premium for 2026 is $202.90. Your actual Part B premium may differ based on income (IRMAA), late enrollment penalties, Medicaid assistance, disability status, or other factors. 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)
$8850.00
Out-of-pocket maximum (Combined)
N/A
Conditions Covered
None
Plan Organization:
Intermountain Health Care, Inc.
Plan Type:
HMO D-SNP
Location:
Davis, Iron, Salt Lake, Utah, Washington, Weber
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
$615
Note:
This plan does not charge an annual deductible for all drugs. The $615.00 annual deductible only applies to drugs in certain tiers.
Sign up for Select Health Medicare Dual (HMO D-SNP)
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
Select Health Medicare Dual (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
$615.00
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 |
|---|---|
$37.60 | $37.60 |
Initial Coverage Phase
After you pay your $615.00 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 $2100.00. Once you reach that amount, you will enter the next coverage phase.
Tier | Preferred Pharmacy | Standard Pharmacy | Preferred Mail | Standard Mail |
|---|
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2100.00, 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
Select Health Medicare Dual (HMO D-SNP) 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.
Cost Sharing:
| Days 1-4: | Days 5-90: | |
|---|---|---|
| Copayment | 410.00 | 0.00 |
More Details:
Enhanced benefits
Non-Medicare-covered Stay
Do you charge the Medicare-defined cost share for tier 1?
No
Copayment for Medicare-covered stay
0.00
Periodicity
Per Admission or Per Stay
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
Not covered.
Upgrades for Inpatient Hospital-Acute
Not covered.
Inpatient Hospital Psychiatric
Inpatient Hospital Psychiatric benefits are covered. Prior Authorization is required.
Cost Sharing:
| Days -: | Days 5-90: | |
|---|---|---|
| Copayment | 410.00 | 0.00 |
| Begin Day | 1 | - |
| End Day | 4 | - |
| Copayment | 0.00 | - |
| Begin Day | 1 | - |
| End Day | 60 | - |
More Details:
Do you charge the Medicare-defined cost share for tier 1?
No
Copayment for Medicare-covered stay
0.00
Periodicity
Per Admission or Per Stay
Do you charge cost sharing on the day of discharge?
No
Additional Days for Inpatient Hospital Psychiatric
Not covered.
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.
Cost Sharing:
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. Prior Authorization is required.
Cost Sharing:
Observation Services
Observation Services benefits are covered.
Cost Sharing:
Ambulatory Surgical Center (ASC) Services
Ambulatory Surgical Center (ASC) Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Outpatient Substance Abuse Services
Outpatient Substance Abuse Services benefits are covered. Prior Authorization is required.
Cost Sharing:
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.
More Details:
Is there a deductible?
No
Do you waive the deductible for the first three pints of blood?
Yes
Partial Hospitalization
Partial Hospitalization benefits are covered.
Partial Hospitalization
Partial Hospitalization benefits are covered. Prior Authorization is required.
Cost Sharing:
Partial Hospitalization
Partial Hospitalization benefits are covered. Prior Authorization is required.
Cost Sharing:
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:
Air Ambulance Services
Air Ambulance Services benefits are covered.
Cost Sharing:
Transportation Services
Transportation Services benefits are covered – including services not usually covered by Medicare plans. Prior Authorization is required.
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
Bus/Subway, Medical Transport, Other, Describe
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
Hours
Enter number of days or hours
24
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?
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
40.00
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 Emergency Coverage, Worldwide Emergency Transportation
Which Worldwide Services have a Copayment
Worldwide Urgent Coverage
Is there a maximum plan benefit coverage?
No
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
Worldwide Emergency Transportation benefits are covered.
Cost Sharing:
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.
Cost Sharing:
More Details:
Which Chiropractic Services have a Copayment
Routine Care
Routine Chiropractic Care
Not covered.
Occupational Therapy Services
Occupational Therapy Services benefits are covered. Prior Authorization is required.
Cost Sharing:
Physician Specialist Services
Physician Specialist Services benefits are covered.
Cost Sharing:
Mental Health Specialty Services
Mental Health Specialty Services benefits are covered.
Cost Sharing:
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
30
Maximum coinsurance
30
Group Sessions for Mental Health Specialty Services
Group Sessions for Mental Health Specialty Services benefits are covered.
More Details:
Minimum coinsurance
30
Maximum coinsurance
30
Podiatry Services
Podiatry Services benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Enhanced benefits (7f)
Routine Foot Care
Is this benefit unlimited?
No
Visits
6
Periodicity
Every year
Which Podiatry Services have a Coinsurance
Medicare-covered Podiatry Services, Routine Foot Care
Minimum coinsurance
30
Maximum coinsurance
30
Minimum coinsurance
30
Maximum coinsurance
30
Is there a maximum plan benefit coverage amount?
No
Other Health Care Professional
Other Health Care Professional benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
0
Maximum coinsurance
30
Psychiatric Services
Psychiatric Services benefits are covered.
Cost Sharing:
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
30
Maximum coinsurance
30
Group Sessions for Psychiatric Services
Group Sessions for Psychiatric Services benefits are covered.
More Details:
Minimum coinsurance
30
Maximum coinsurance
30
Physical Therapy and Speech-Language Pathology Services
Physical Therapy and Speech-Language Pathology Services benefits are covered. Prior Authorization is required.
Cost Sharing:
Additional Telehealth Benefits
Additional Telehealth Benefits benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Medicare-covered benefits that may have Additional Telehealth Benefits available
4b: Urgently Needed Services, 7a: Primary Care Physician Services, 7d: Physician Specialist Services
Opioid Treatment Program Services
Opioid Treatment Program Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
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
In-Home Safety Assessment benefits are covered.
Personal Emergency Response System (PERS)
Not covered.
Medical Nutrition Therapy (MNT)
Medical Nutrition Therapy (MNT) benefits are covered.
More Details:
Do you offer Additional Sessions for Medicare-covered diseases?
Yes
Limit for additional sessions
Sessions
Numerical limit
999
Do you offer Coverage for Non-Medicare-covered diseases?
Yes
Numerical limit
Sessions
Limit for additional sessions
999
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
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
Not covered.
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.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Other Preventive Services
Other Preventive Services benefits are covered.
Cost Sharing:
More Details:
Which Services have a Coinsurance
Medicare-covered Digital Rectal Exams
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.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
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.
Cost Sharing:
More Details:
Which Hearing Exam Benefits have a Coinsurance
Routine Hearing Exams
Minimum coinsurance
30
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 year
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
2
Periodicity
Every year
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.
Cost Sharing:
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
Other Eye Exam Services
Other Eye Exam Services benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
1
Periodicity
Every year
Service Name
Determination of Refraction
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
200.00
Periodicity
Every year
Contact Lenses
Contact Lenses benefits are covered.
More Details:
Is this benefit unlimited?
Yes
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 year
Eyeglass lenses
Not covered.
Eyeglass frames
Not covered.
Upgrades
Upgrades benefits are covered.
Dental Services
Dental Services benefits are covered.
Medicare Dental Services
Medicare Dental Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Coinsurance percentage
30
Other Dental Services
Other Dental Services benefits are covered.
More Details:
Is there a maximum plan benefit coverage?
Yes
Maximum amount
1500.00
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
Every six 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 six months
Prophylaxis (Cleaning)
Prophylaxis (Cleaning) benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Every six months
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
1
Periodicity
Every six months
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?
Yes
Adjunctive General Services
Adjunctive General Services benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Endodontics
Endodontics benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Periodontics
Periodontics benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Prosthodontics, removable
Prosthodontics, removable benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Maxillofacial Prosthetics
Maxillofacial Prosthetics benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Implant Services
Not covered.
Prosthodontics, fixed
Prosthodontics, fixed benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Oral and Maxillofacial Surgery
Oral and Maxillofacial Surgery benefits are covered.
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.
Cost Sharing:
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 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?
Yes
Insulin
Insulin benefits are covered.
Medicare Part B Insulin Drugs
Medicare Part B Insulin Drugs benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
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
Dialysis Services
Dialysis Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Medical Equipment
Medical Equipment benefits are covered.
Durable Medical Equipment (DME)
Durable Medical Equipment (DME) benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Are there preferred vendors/manufacturers for Durable Medical Equipment (DME)?
No
Prosthetics/Medical Supplies - Non-Medicare benefit
Prosthetics/Medical Supplies - Non-Medicare benefit benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Prosthetics/Medical Supplies have a Coinsurance
Medicare-covered Prosthetic Devices, Medicare-covered Medical Supplies
Prosthetic Devices
Prosthetic Devices benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Medical Supplies
Medical Supplies benefits are covered.
Cost Sharing:
Diabetic Equipment
Diabetic Equipment benefits are covered. Prior Authorization is required.
Cost Sharing:
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
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:
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:
More Details:
Minimum coinsurance
0
Lab Services
Lab Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
All Radiological Services
All Radiological Services benefits are covered. Prior Authorization is required.
Cost Sharing:
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:
More Details:
Minimum coinsurance
20
Therapeutic Radiological Services
Therapeutic Radiological Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Outpatient X-Ray Services
Outpatient X-Ray Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
30
Home Health Services
Home Health Services benefits are covered. Prior Authorization is required.
Cardiac Rehabilitation Services
Cardiac Rehabilitation Services benefits are covered. Prior Authorization is required.
Cost Sharing:
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.
Skilled Nursing Facility (SNF)
Skilled Nursing Facility (SNF) benefits are covered. Prior Authorization is required.
Cost Sharing:
| Days 1-20: | Days 21-65: | Days 66-100: | |
|---|---|---|---|
| Copayment | 0.00 | 218.00 | 0.00 |
More Details:
Does the plan provide Skilled Nursing Facility Services as a supplemental benefit under Part C?
Yes
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.
Other Services
Other Services benefits are covered.
Acupuncture
Not covered.
Over-the-Counter (OTC) Items
Not covered.
Meal Benefit
Meal Benefit benefits are covered. Prior Authorization is required.
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.
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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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.
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