Amerivantage Classic Plus (HMO-POS)
Amerivantage Classic Plus (HMO-POS) H5828-005 Plan Details
Amerivantage Classic Plus (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Amerigroup.
Plan ID: H5828-005.
$0.00
Monthly Premium
Amerivantage Classic Plus (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Amerigroup.
Plan ID: H5828-005.
Tennessee Counties Served
Anderson
Bedford
Benton
Bledsoe
Cannon
Blount
Bradley
Campbell
Carroll
Carter
Cheatham
Chester
Claiborne
Clay
Cocke
Coffee
Crockett
Cumberland
Davidson
Decatur
Dekalb
Dickson
Dyer
Fayette
Fentress
Franklin
Gibson
Giles
Grainger
Greene
Grundy
Hamblen
Hamilton
Hancock
Hardeman
Hardin
Hawkins
Haywood
Henderson
Henry
Hickman
Houston
Humphreys
Jackson
Jefferson
Johnson
Knox
Lake
Lauderdale
Lawrence
Lewis
Lincoln
Loudon
Macon
Madison
Marion
Marshall
Maury
Mcminn
Mcnairy
Meigs
Monroe
Montgomery
Moore
Morgan
Obion
Overton
Perry
Pickett
Polk
Putnam
Rhea
Roane
Robertson
Rutherford
Scott
Sequatchie
Sevier
Shelby
Smith
Stewart
Sullivan
Sumner
Tipton
Trousdale
Unicoi
Union
Van Buren
Warren
Washington
Wayne
Weakley
White
Williamson
Wilson
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $4900 Out-of-Network: N/A |
| Initial Coverage Limit | $4660 |
| Catastrophic Coverage Limit | $7,400 |
| Primary Care Doctor Visit | In-Network: $0.00 copay Out-of-Network: $30.00 copay |
| Specialty Doctor Visit | In-Network: $30.00 copay Out-of-Network: $50.00 copay |
| Inpatient Hospital Care | In-Network: Days 1-5: $290.00 per day, per admission / Days 6-90: $0.00 per day, per admission Additional Hospital Days: Unlimited additional days Out-of-Network: 40% coinsurance per stay |
| Urgent Care | Urgent Care: $30.00 copay |
| Emergency Room Visit | Emergency Care: $90.00 copay 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: $295.00 copay Per Trip Air Ambulance: $295.00 copay |
Health Care Services and Medical Supplies
Amerivantage Classic Plus (HMO-POS) 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 Out-of-Network: Medicare Covered Chiropractic Services: 40% coinsurance |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies: $0.00 copay Out-of-Network: 40% coinsurance |
| Durable Medical Eqipment (DME) | In-Network: 20% coinsurance Out-of-Network: 40% coinsurance |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Lab Services: $0.00 - $10.00 copay X-Rays: $50.00 - $110.00 copay Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: $0.00 - $150.00 copay Diagnostic Radiological Services: $130.00 - $220.00 copay Out-of-Network: Lab Services: 40% coinsurance X-Rays: 40% coinsurance Therapeutic Radiological Services: 40% coinsurance Outpatient Diagnostic Procedures/Tests: 40% coinsurance Diagnostic Radiological Services: 40% coinsurance |
| Home Health Care | In-Network: $0.00 copay Out-of-Network: 40% coinsurance |
| Mental Health Inpatient Care | In-Network: Days 1-5: $250.00 per day, per admission / Days 6-90: $0.00 per day, per admission Additional Hospital Days: Unlimited additional days Out-of-Network: 40% coinsurance per stay |
| Mental Health Outpatient Care | In-Network: Individual and Group Sessions: $40.00 copay Out-of-Network: 40% coinsurance |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital - Surgery: $280.00 copay Observation Services: $280.00 copay Ambulatory Surgical Center: $225.00 copay Out-of-Network: Outpatient Hospital - Surgery: 40% coinsurance Observation Services: 40% coinsurance Ambulatory Surgical Center: 40% coinsurance |
| Outpatient Substance Abuse Care | In-Network: Individual and Group Sessions: $40.00 copay Out-of-Network: 40% coinsurance |
| Over-the-counter (OTC) Items | This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $168 every quarter. Unused OTC amounts do roll over to the next quarter. Unused OTC amounts do not roll over to the next calendar year. |
| Podiatry Services | In-Network: Medicare Covered Podiatry Services: $0.00 - $30.00 copay Routine Foot Care: $0.00 copay Unlimited routine foot care visits each year. Out-of-Network: Medicare Covered Podiatry Services: $50.00 copay |
| Skilled Nursing Facility Care | In-Network: SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $196.00 per day Out-of-Network: 50% coinsurance per stay |
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: 2 oral exam(s), 2 cleaning(s), 1 dental X-ray(s), 1 fluoride treatment(s) every year. Medicare Covered Dental: $0.00 copay Comprehensive Dental Services: $0.00 copay This plan covers up to a $2,000.00 allowance for covered comprehensive dental services every year. Out-of-Network: Medicare Covered Dental Services: $50.00 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: $0.00 copay Routine Eye Wear: $0.00 copay This plan covers up to $250.00 for eyeglasses or contact lenses every year. Out-of-Network: Medicare Covered Eye Exam: $50.00 copay Medicare Covered Eye Wear: $50.00 copay |
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 Routine Hearing Exam: $0.00 copay for routine hearing exam(s). $0.00 copay for hearing aids up to the maximum plan benefit amount. This plan covers 1 routine hearing exam(s) and hearing aid fitting/evaluation(s) every year. $3,000.00 maximum plan benefit coverage amount applies to prescribed hearing aids covered by the plan every year. Out-of-Network: Medicare Covered Hearing Exam: $50.00 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 Out-of-Network: 40% coinsurance |
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