KelseyCare Advantage Essential (HMO)

Medicare Advantage Plan (Part C)

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PARTC

Plan Summary

Insurance Type
Medicare Advantage Plan (Part C)
Insurance Provider
KelseyCare Advantage
CMS Rating
Plan Type
HMO
Annual Deductible
$0.00

What To Know About This Plan

  • This is a health coverage only plan with no drug coverage
  • This plan is available for 2015. see plan

Why We Like This Plan

  • has been rated 5 stars by CMS
  • has no additional premium costs outside of your Medicare Part B premium
  • Primary care physician office visit copay of $5

Plan Details

Costs and Other Important Information

Plan Year:
2014
Optional Supplemental Benefits?
No
Choice of Doctors?
Plan Doctors Only
Prescription Drugs Covered?
No
Out-Of-Pocket Spending Limit
$3,400 In-Network
Other Deductibles?
In Network: No. Out of Network: No
Health Plan Deductible
$0
Monthly Drug Plan Premium
Not Applicable
Monthly Health Plan Premium
$0.00

Benefits

Service
In Network
Out of Network
Inpatient Hospital Care
$500 copay
Not Applicable
Inpatient Mental Health Care
$500 copay
Not Applicable
Skilled Nursing Facility (SNF)
Days 1-20: $0 copay per day. Days 21-100: $125 copay per day
Not Applicable
Home Health Care
$10 maximum per visit
Not Applicable
Doctor Office Visits
$5 maximum per visit
Not Applicable
Outpatient Services
$250 maximum per visit
Not Applicable
Ambulance Services
$100 maximum
Not Applicable
Emergency Care
$65 maximum per visit
Not Applicable
Durable Medical Equipment
20% maximum per item
Not Applicable
Kidney Disease and Conditions
$25 maximum per visit
Not Applicable
Specialist Office Visit
$20 maximum per visit
Not Applicable

Prescription Drug Coverage

Drugs Covered under Medicare Part B

General

Most drugs not covered.

20% of the cost for Medicare Part B chemotherapy drugs and other Part B drugs.


Drugs Covered under Medicare Part D

General

This plan does not offer prescription drug coverage.


Optional Supplemental Benefits

Other Services

Inpatient Care

Doctor and Hospital Choice



In-Network

You must go to network doctors, specialists, and hospitals.

Referral required for network hospitals and specialists (for certain benefits).


,

Inpatient Hospital Care



In-Network

Plan covers 90 days each benefit period.

$500 copay for each Medicare-covered hospital stay

Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day.

Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.


Outpatient Care

Inpatient Mental Health Care



In-Network

You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.

$500 copay for each Medicare-covered hospital stay.

Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day.

Except in an emergency, your doctor must tell the plan that you are going to be admitted to the hospital.


,

Skilled Nursing Facility (SNF)



General

Authorization rules may apply.

In-Network

Plan covers up to 100 days each benefit period

No prior hospital stay is required.

For SNF stays:

  • Days 1 - 20: $0 copay per day


  • Days 21 - 100: $125 copay per day



,

Home Health Care



General

Authorization rules may apply.

In-Network

$10 copay for each Medicare-covered home health visit


,

Hospice



General

You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice.


,

Doctor Office Visits



General

Authorization rules may apply.

In-Network

$5 copay for each Medicare-covered primary care doctor visit.

$20 copay for each Medicare-covered specialist visit.


Outpatient Medical Services and Supplies

Chiropractic Services



General

Authorization rules may apply.

In-Network

$20 copay for each Medicare-covered chiropractic visit

Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part).


,

Podiatry Services



General

Authorization rules may apply.

In-Network

$20 copay for each Medicare-covered podiatry visit

Medicare-covered podiatry visits are for medically necessary foot care.


,

Outpatient Mental Health Care



General

Authorization rules may apply.

In-Network

$35 copay for each Medicare-covered individual therapy visit

$20 copay for each Medicare-covered group therapy visit

$35 copay for each Medicare-covered individual therapy visit with a psychiatrist

$20 copay for each Medicare-covered group therapy visit with a psychiatrist

$35 copay for Medicare-covered partial hospitalization program services


,

Outpatient Substance Abuse Care



General

Authorization rules may apply.

In-Network

$35 copay for Medicare-covered individual substance abuse outpatient treatment visits

$20 copay for Medicare-covered group substance abuse outpatient treatment visits


,

Outpatient Services



General

Authorization rules may apply.

In-Network

$225 copay for each Medicare-covered ambulatory surgical center visit

$250 copay for each Medicare-covered outpatient hospital facility visit


,

Ambulance Services



General

Authorization rules may apply.

In-Network

$100 copay for Medicare-covered ambulance benefits.


,

Emergency Care



General

$65 copay for Medicare-covered emergency room visits

Worldwide coverage.

If you are admitted to the hospital within 3-day(s) for the same condition, you pay $0 for the emergency room visit.


,

Urgently Needed Care



General

$65 copay for Medicare-covered urgently-needed-care visits


,

Outpatient Rehabilitation Services



General

Authorization rules may apply.

Medically necessary physical therapy, occupational therapy, and speech and language pathology services are covered.

In-Network

$20 copay for Medicare-covered Occupational Therapy visits

$20 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits


,

Durable Medical Equipment



General

Authorization rules may apply.

In-Network

20% of the cost for Medicare-covered durable medical equipment


Preventive Services

Prosthetic Devices



General

Authorization rules may apply.

In-Network

20% of the cost for Medicare-covered prosthetic devices

20% of the cost for Medicare-covered medical supplies related to prosthetics, splints, and other devices


,

Diabetes Programs and Supplies



General

Authorization rules may apply.

In-Network

$0 copay for Medicare-covered Diabetes self-management training

0% to 10% of the cost for Medicare-covered Diabetes monitoring supplies

20% of the cost for Medicare-covered Therapeutic shoes or inserts


,

Diagnostic Tests, X-Rays, Lab Services, and Radiology Services



General

Authorization rules may apply.

In-Network

$0 copay for Medicare-covered:

  • X-rays


$0 copay for Medicare-covered lab services

$0 to $25 copay for Medicare-covered diagnostic procedures and tests

$0 to $150 copay for Medicare-covered diagnostic radiology services (not including X-rays)

$50 copay for Medicare-covered therapeutic radiology services


,

Cardiac and Pulmonary Rehabilitation Services



General

Authorization rules may apply.

In-Network

$20 copay for Medicare-covered Cardiac Rehabilitation Services

$20 copay for Medicare-covered Intensive Cardiac Rehabilitation Services

$20 copay for Medicare-covered Pulmonary Rehabilitation Services


Additional Benefits

Preventive Services



General

$0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare.


,

Kidney Disease and Conditions



General

Authorization rules may apply.

In-Network

$25 copay for Medicare-covered renal dialysis

$0 copay for Medicare-covered kidney disease education services


,

Dental Services



In-Network

In general, preventive dental benefits (such as cleaning) not covered.

$20 copay for Medicare-covered dental benefits


,

Hearing Services



General

Authorization rules may apply.

In-Network

$0 copay for up to 2 supplemental hearing aid(s) every year

$20 copay for Medicare-covered diagnostic hearing exams

$20 copay for up to 1 supplemental routine hearing exam(s) every year

$20 copay for up to 1 supplemental hearing aid fitting-evaluation(s) every year

$500 plan coverage limit for supplemental hearing aids every year.


,

Vision Services



In-Network

$20 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye, including an annual glaucoma screening for people at risk

$0 copay for up to 1 supplemental routine eye exam(s) every year

$0 copay for
  • one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery


  • up to 1 pair(s) of eyeglasses (lenses and frames) every year


  • up to 1 pair(s) of contact lenses every year


$75 plan coverage limit for supplemental eyewear every year


CMS Ratings

Staying healthy - screenings, tests and vaccines

Breast cancer screening
Not Rated
Colorectal cancer screening
Cholesterol screening for patients with heart disease
Glaucoma testing
Annual flu vaccine
Pneumonia vaccine
Improving or maintaining physical health
Improving or maintaining mental health
Monitoring physical ability
Access to primary care doctor visits
Adult BMI assessment

Managing Chronic Conditions

Care for older adults – medication review
Not Rated
Care for older adults – functional status assessment
Not Rated
Care for older adults – Pain screening
Not Rated
Osteoporosis management in women who had a fracture
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Diabetes care – cholesterol controlled
Controlling blood pressure
Rheumatoid arthritis management
Improving bladder control
Reducing the risk of falling
Plan all-cause readmissions

Ratings of Plan Responsiveness and Care

Getting needed care
Getting appointments and care quickly
Customer service
Overall rating of health care quality
Overall rating of plan

Member Complaints, Problems Getting Services, and Choosing to Leave the Plan

Complaints about the health plan
Beneficiary access and performance problems
Members choosing to leave the plan
Plan makes timely decision about appeals
Reviewing appeals decisions
Call center – foreign language interpreter and TTY/TDD availability

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