2019 Presbyterian MediCare PPO Plan 1 (PPO) H3206-3-0 in NM from Presbyterian | HealthPocket

Presbyterian MediCare PPO Plan 1 (PPO)

$89/mo

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Zip Code87121
Applicant4/21/1984 Male
Coverage Start4/22/2019
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Benefits & Coverage

Insurance TypeMedicare Advantage Plan (Part C)
Insurance ProviderPresbyterian
Plan IDH3206-3-0
Plan Year2019
CMS Rating
Plan TypePPO
Annual Deductible$0.00

What To Know About This Plan
  • This is a health coverage only plan with no drug coverage

Costs and Other Important Information

Plan Year2019
Monthly Health Plan Premium$89.00
Monthly Drug Plan PremiumNot Applicable
Health Plan Deductible$0
Other health plan deductibles?No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$10,000 In and Out-of-network
$6,700 In-network
Optional Supplemental BenefitsNo

Benefits

SERVICECOST
Inpatient hospital coverageIn-Network:$325 per day for days 1 through 5
$0 per day for days 6 through 90
Out-of-Network:$500 per day for days 1 through 5
$0 per day for days 6 through 90
Outpatient hospital coverageIn-Network:$325 per visit
Out-of-Network:20% per visit
Doctor visitsPrimary:
In-Network:$15 per visit
Out-of-Network:$35 per visit
Specialist:
In-Network:$50 per visit
Out-of-Network:$60 per visit
Preventive careIn-Network:$0 copay
Out-of-Network:$35
Emergency care/Urgent careEmergency:$90 per visit (always covered)
Urgent care:$15-65 per visit (always covered)
Diagnostic procedures/lab services/imagingDiagnostic tests and procedures:
In-Network:$0 copay
Out-of-Network:20%
Lab services:
In-Network:$0 copay
Out-of-Network:20%
Diagnostic radiology services (e.g., MRI):
In-Network:$300
Out-of-Network:20%
Outpatient x-rays:
In-Network:$15
Out-of-Network:20%
Mental health servicesInpatient hospital - psychiatric:
In-Network:$325 per day for days 1 through 5
$0 per day for days 6 through 90
Out-of-Network:$500 per day for days 1 through 5
$0 per day for days 6 through 90
Outpatient group therapy visit with a psychiatrist:
In-Network:$40
Out-of-Network:50%
Outpatient individual therapy visit with a psychiatrist:
In-Network:$40
Out-of-Network:50%
Outpatient group therapy visit:
In-Network:$40
Out-of-Network:50%
Outpatient individual therapy visit:
In-Network:$40
Out-of-Network:50%
Skilled Nursing FacilityIn-Network:$0 per day for days 1 through 20
$95 per day for days 21 through 100
Out-of-Network:$0 per day for days 1 through 20
$150 per day for days 21 through 100
Rehabilitation servicesOccupational therapy visit:
In-Network:$25
Out-of-Network:$35
Physical therapy and speech and language therapy visit:
In-Network:$25
Out-of-Network:$35
Ground ambulanceIn-Network:$250
Out-of-Network:$250
TransportationNot covered
Foot care (podiatry services)Foot exams and treatment:
In-Network:$0 copay
Out-of-Network:$60
Routine foot care:Not covered
Medical equipment/suppliesDurable medical equipment (e.g., wheelchairs, oxygen):
In-Network:20% per item
Out-of-Network:25% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network:20% per item
Out-of-Network:25% per item
Diabetes supplies:
In-Network:$0-10 per item
Out-of-Network:25% per item
Wellness programs (e.g., fitness, nursing hotline)Covered
Medicare Part B drugsChemotherapy:
In-Network:15%
Out-of-Network:20%
Other Part B drugs:
In-Network:$10 or 15%
Out-of-Network:20%

Benefits Services

Hearing
Hearing examIn-Network: $45
Out-of-Network: $60
Fitting/evaluationNot covered
Hearing aidsIn-Network: $699-999
Out-of-Network: 100%
There may be limits on how much the plan will provide.
Preventive Dental
Oral examNot covered
CleaningNot covered
Fluoride treatmentNot covered
Dental x-ray(s)Not covered
Comprehensive Dental
Non-routine servicesNot covered
Diagnostic servicesNot covered
Restorative servicesNot covered
EndodonticsNot covered
PeriodonticsNot covered
ExtractionsNot covered
Prosthodontics, other oral/maxillofacial surgery, other servicesNot covered
Vision
Routine eye examIn-Network: $0-50
Out-of-Network: $60
OtherNot covered
Contact lensesNot covered
Eyeglasses (frames and lenses)Not covered
Eyeglass framesNot covered
Eyeglass lensesNot covered
UpgradesNot covered

Coverage Area for Presbyterian MediCare PPO 1 (PPO)

StateNew Mexico
CountyBernalillo

Staying healthy - screenings, tests and vaccines

Breast cancer screening
Colorectal cancer screening
Annual flu vaccine
Improving or maintaining physical health
Improving or maintaining mental health
Monitoring physical ability
Adult BMI assessment

Managing Chronic Conditions

Special needs plan care managementNot Rated
Care for older adults – medication reviewNot Rated
Care for older adults – functional status assessmentNot Rated
Care for older adults – Pain screeningNot Rated
Osteoporosis management in women who had a fractureNot Rated
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Controlling blood pressure
Rheumatoid arthritis management
Reducing the risk of falling
Plan all-cause readmissions

Member Experience with Health Plan

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

Member Complaints, and Changes in Health Plan's Performance

Complaints about the health plan
Members choosing to leave the health plan
Beneficiary access and performance problems
Health plan quality improvement

Health Plan Customer Service

Plan makes timely decision about appeals
Reviewing appeals decisions
Call center – foreign language interpreter and TTY/TDD availability - Medical

Drug Plan Customer Service

Call center – foreign language interpreter and TTY/TDD availability - Drugs
Appeals auto-forward
Appeals upheld

Member Complaints, and Changes in Drug Plan's Performance

Complaints about the drug plan
Members choosing to leave the drug planNot Rated
Beneficiary access and performance problems
Drug plan quality improvement

Member Experience with Drug Plan

Rating of drug plan
Getting needed prescription drugs

Drug Pricing and Patient Safety

MPF Price Accuracy
High risk medication
Part D medication adherence for diabetes
Part D medication adherence for hypertension
Part D medication adherence for cholesterol
Medication Therapy Management program completion rate

Physicians that accept Presbyterian MediCare PPO 1 (PPO) for New Mexico

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Dozeman, Lynn
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Guerrero-pezzano, Tatyana
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Loughrey, Galen
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Tam, Adela
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Peachey, Marilyn
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Fetner, Jean
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Buxton, Benjamin
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Candelaria, Delfino
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Gallegos-macias, Angela
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Jansen, Shari
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Ponce, Liana
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Gurule, Monica
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Montoya, Andrea
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Miller, Frederick
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Barnes, Jesse
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Jacobsohn, Vanessa Cook
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Buckels, Wendy
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Kassicieh, Samir
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Hockin, Benjamin
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Shelley, Brian
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Lynn Dozeman, MD
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  • Phone Number
    (505) 831-2534
  • Office Locations
    6900 Gonzales Rd Sw
    Albuquerque, NM 87121
6900 Gonzales Rd Sw Albuquerque NM, 87121
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Medicare Plans Found

 

HealthPocket is a free information source designed to help consumers find medical coverage. Whether you are looking for Medicare, Medicaid or an individual health insurance plan, we will help you find the right healthcare option and save on your out of pocket healthcare costs. We receive our data from government, non-profit and private sources, and you should confirm key provisions of your coverage with your selected health plan. If you select a plan presented on our site, you will be directed (via a click or a call) to one of our partners who can help you with your application. Our website is not a health insurance agency and not affiliated with and does not represent or endorse any health plan. HealthPocket, Inc. is a wholly owned subsidiary of Health Plan Intermediaries Holdings LLC (NASDAQ: HIIQ)