PARTC

Plan Summary

Insurance Type
Medicare Advantage Plan (Part C)
Insurance Provider
Rocky Mountain Health Plan
CMS Rating
Plan Type
Cost
Annual Deductible
$0.00

What To Know About This Plan

  • This is a health coverage only plan

Plan Details

Costs and Other Important Information

Plan Year:
2014
Optional Supplemental Benefits?
Yes
Choice of Doctors?
Plan Doctors Only
Prescription Drugs Covered?
No
Out-Of-Pocket Spending Limit
$6,700 In-Network
Other Deductibles?
In Network: Yes. Out of Network: No
Health Plan Deductible
$500 In-Network
Monthly Drug Plan Premium
Not Applicable
Monthly Health Plan Premium
$10.00

Benefits

Service
In Network
Out of Network
Inpatient Hospital Care
Days 1-7: $300 copay per day. Days 8-90: $0 copay per day
Not Applicable
Inpatient Mental Health Care
Days 1-7: $300 copay per day. Days 8-90: $0 copay per day
Not Applicable
Skilled Nursing Facility (SNF)
Days 1-20: $0 copay per day. Days 21-100: $100 copay per day
Not Applicable
Home Health Care
$0
Not Applicable
Doctor Office Visits
$20 maximum per visit
Not Applicable
Outpatient Services
$400 maximum per visit
Not Applicable
Ambulance Services
$200 maximum
Not Applicable
Emergency Care
$65 maximum per visit
Not Applicable
Durable Medical Equipment
20% maximum per item
Not Applicable
Kidney Disease and Conditions
20% maximum per visit
Not Applicable
Specialist Office Visit
$50 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.


Other Services

Inpatient Care

Doctor and Hospital Choice



In-Network

No referral required for network doctors, specialists, and hospitals.

In and Out-of-Network

You can use any network doctor. If you go to out-of-network doctors the plan may not cover the services but Medicare will pay its share for Medicare-covered services. When Medicare pays its share, you pay the Medicare Part B deductible and coinsurance.


Inpatient Hospital Care



In-Network

Plan covers 90 days each benefit period.

For Medicare-covered hospital stays:

  • Days 1 - 7: $300 copay per day


  • Days 8 - 90: $0 copay per day


Plan covers 60 lifetime reserve days. Cost per lifetime reserve day:

  • Days 1 - 7: $300 copay per day


  • Days 8 - 60: $0 copay per day



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.

For Medicare-covered hospital stays:

  • Days 1 - 7: $300 copay per day


  • Days 8 - 90: $0 copay per day


Plan covers 60 lifetime reserve days. Cost per lifetime reserve day:

  • Days 1 - 7: $300 copay per day


  • Days 8 - 60: $0 copay per day



Skilled Nursing Facility (SNF)



In-Network

Plan covers up to 100 days each benefit period

For Medicare-covered SNF stays:

  • Days 1 - 20: $0 copay per day


  • Days 21 - 100: $100 copay per day



Home Health Care



In-Network

$0 copay for Medicare-covered home health visits


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

$20 copay for each Medicare-covered primary care doctor visit.

$50 copay for each Medicare-covered specialist visit.


Outpatient Medical Services and Supplies

Chiropractic Services



In-Network

20% of the cost 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



In-Network

$50 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

$50 copay for each Medicare-covered individual therapy visit

$50 copay for each Medicare-covered group therapy visit

$50 copay for each Medicare-covered individual therapy visit with a psychiatrist

$50 copay for each Medicare-covered group therapy visit with a psychiatrist

$50 copay for Medicare-covered partial hospitalization program services


Outpatient Substance Abuse Care



General

Authorization rules may apply.

In-Network

$50 copay for Medicare-covered individual substance abuse outpatient treatment visits

$50 copay for Medicare-covered group substance abuse outpatient treatment visits


Outpatient Services



General

Authorization rules may apply.

In-Network

$400 copay for each Medicare-covered ambulatory surgical center visit

$400 copay for each Medicare-covered outpatient hospital facility visit


Ambulance Services



General

Authorization rules may apply.

In-Network

$200 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 24-hour(s) for the same condition, you pay $0 for the emergency room visit.


Urgently Needed Care



General

$50 copay for Medicare-covered urgently-needed-care visits


Outpatient Rehabilitation Services



General

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

In-Network

$15 copay for Medicare-covered Occupational Therapy visits

$15 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



In-Network

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

20% 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:

  • lab services


$0 to $400 copay for Medicare-covered diagnostic procedures and tests

20% of the cost for Medicare-covered X-rays

20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)

20% of the cost for Medicare-covered therapeutic radiology services

If the doctor provides you services in addition to Outpatient Diagnostic Procedures, Tests and Lab Services, separate cost sharing of $20 to $50 may apply

If the doctor provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services, separate cost sharing of $20 to $50 may apply


Cardiac and Pulmonary Rehabilitation Services



In-Network

$0 copay for:

  • Medicare-covered Cardiac Rehabilitation Services


  • Medicare-covered Intensive Cardiac Rehabilitation Services


  • 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.

In-Network

$0 copay for a supplemental annual physical exam


Kidney Disease and Conditions



General

Cost plan members pay Original Medicare cost sharing for out-of-area dialysis.

In-Network

20% of the cost for Medicare-covered renal dialysis

$0 copay for Medicare-covered kidney disease education services


Dental Services



In-Network

This plan covers some preventive dental benefits for an extra cost (see "Optional Supplemental Benefits.")

$0 to $2,100 copay [or 0% to 20% of the cost] for Medicare-covered dental benefits


Hearing Services



In-Network

Hearing aids not covered.

$20 to $50 copay for Medicare-covered diagnostic hearing exams

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


Vision Services



In-Network

$0 to $50 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye, including an annual glaucoma screening for people at risk

$15 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



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
Not Rated

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

Physician Finder

Physicians that accept Rocky Mountain Green (Cost) for Colorado

/
SEEFELDT, BRIEANNA
8015 W ALAMEDA AVE
LAKEWOOD, CO 80226
MANCUSO, TINA
11150 HURON ST
NORTHGLENN, CO 80234
NGUYEN, LISA
8015 W ALAMEDA
LAKEWOOD, CO 80226
VANDERHEIDEN, TODD
777 BANNOCK ST
DENVER, CO 80204
HELLER, JULIE
777 BANNOCK ST
DENVER, CO 80204
ROSSMAN, MITCHEL
1601 LOWELL BLVD
DENVER, CO 80204
CASAULT, TRACY
119 UCB
BOULDER, CO 80309
LIVERMORE, MERYL
777 BANNOCK ST # MC0188
DENVER, CO 80204
ALSTON, MEREDITH
777 BANNOCK ST
DENVER, CO 80204
EUTERMOSER, MORGAN
12605 E 16TH AVE
AURORA, CO 80045
KAPLAN, BONNIE
777 BANNOCK ST
DENVER, CO 80204
LALLY, THOMAS
4101 W CONEJOS PL
DENVER, CO 80204
LAGRENADE, KEITH
3520 W OXFORD AVE
DENVER, CO 80236
LEON, DAVID
2020 WADSWORTH BLVD
LAKEWOOD, CO 80214
BURNS, EDITH
2405 WADSWORTH BLVD
LAKEWOOD, CO 80214
COAKLEY, SARAH
3620 MASTERS DRIVE
COLORADO SPRINGS, CO 80907
SHEPHERD, JANET
700 E 9TH AVE
DENVER, CO 80203
DEFFENBACHER, BRANDY
3055 ROSLYN ST
DENVER, CO 80238
BURKE, DANIEL
12605 E 16TH AVE
AURORA, CO 80045
GASPAR, DAVID
3055 ROSLYN ST
DENVER, CO 80238
FULLER, BRIAN
2373 CENTRAL PARK BLVD
DENVER, CO 80238
DAR, HUNAIF
535 16TH ST
DENVER, CO 80202
DRUCKER, DAVID
1255 19TH ST
DENVER, CO 80202
DOYLE, ROBERT
7550 W YALE AVE
DENVER, CO 80227
BLITZ, SCOTT
7550 W YALE AVE
DENVER, CO 80227
Details
BRIEANNA SEEFELDT, D.O.
Phone Number
(303) 268-1577
Office Locations
8015 W ALAMEDA AVE
LAKEWOOD, CO 80226
8015 W ALAMEDA AVE LAKEWOOD CO, 80226

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