Amerivantage Classic (HMO)

Amerivantage Classic (HMO) H2593-029 Plan Details
3 out of 5 stars

Amerivantage Classic (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Amerigroup.
Plan ID: H2593-029.

$0.00
Monthly Premium

Amerivantage Classic (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Amerigroup.
Plan ID: H2593-029.

Amerivantage Classic (HMO) H2593-029 Plan Details
3 out of 5 stars

Amerivantage Classic (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Amerigroup.
Plan ID: H2593-029.

$0.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $7550
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:
$0.00 copay
Specialty Doctor Visit
In-Network:
$30.00 copay
Inpatient Hospital Care
In-Network:
Days 1-5: $335.00 per day, per admission / Days 6-90: $0.00 per day, per admission
Additional Hospital Days: Unlimited additional days
Urgent Care
Urgent Care: $35.00 copay
Emergency Room Visit
Emergency Care: $90.00 copay
Copay waived if admitted to hospital within 24 Hours
Worldwide Coverage: This plan covers urgent care and emergency services when traveling outside of the United States for less than six months. This benefit is limited to $100,000.00 per year.
Ambulance Transportation
Ground Ambulance: $260.00 copay Per Trip
Air Ambulance: $260.00 copay

Health Care Services and Medical Supplies

Amerivantage Classic (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Medicare Covered Chiropractic Services: $20.00 copay
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Diabetic Supplies: $0.00 copay
Durable Medical Eqipment (DME)
In-Network:
20% coinsurance
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:
Lab Services: $0.00 - $10.00 copay
X-Rays: $20.00 copay
Therapeutic Radiological Services: 20% coinsurance
Outpatient Diagnostic Procedures/Tests: $0.00 - $100.00 copay
Diagnostic Radiological Services: $40.00 - $100.00 copay
Home Health Care
In-Network:
$0.00 copay
Mental Health Inpatient Care
In-Network:
Days 1-5: $335.00 per day, per admission / Days 6-90: $0.00 per day, per admission
Additional Hospital Days: Unlimited additional days
Mental Health Outpatient Care
In-Network:
Individual and Group Sessions: $35.00 copay
Outpatient Services / Surgery
In-Network:
Outpatient Hospital - Surgery: $335.00 copay
Observation Services: $335.00 copay
Ambulatory Surgical Center: $275.00 copay
Outpatient Substance Abuse Care
In-Network:
Individual and Group Sessions: $35.00 copay
Podiatry Services
In-Network:
Medicare Covered Podiatry Services: $30.00 copay
Skilled Nursing Facility Care
In-Network:
SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $188.00 per day

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:
Preventive Dental Services: $0.00 copay
This plan covers: 1 oral exam(s), 1 cleaning(s) every year.

Medicare Covered Dental: $30.00 copay

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:
Medicare Covered Eye Exam: $0.00 - $30.00 copay
Routine Eye Exam: $0.00 copay
This plan covers 1 routine eye exam(s) every year.
Medicare Covered Eye Wear: 20% coinsurance

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:
Medicare Covered Hearing Exam: $30.00 copay

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services