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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

Texas Counties Served

Archer Atascosa Austin Bailey Bandera Bastrop Bexar Blanco Briscoe Burnet Caldwell Castro Chambers Clay Cochran Collin Colorado Comal Cooke Crosby Dallas Delta Denton Dickens El Paso Floyd Fort Bend Galveston Garza Gonzales Grayson Grimes Guadalupe Hale Hamilton Hardin Harris Hays Henderson Hockley Hudspeth Hunt Jack Jasper Jefferson Johnson Kendall La Salle Lamb Lampasas Lee Liberty Lubbock Lynn Mason Matagorda Medina Mills Montague Montgomery Motley Navarro Orange Palo Pinto Parker Rains Real Rockwall San Jacinto San Saba Swisher Tarrant Terry Throckmorton Travis Van Zandt Walker Waller Wharton Williamson Wilson Wise Zavala

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
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