Amerivantage Dual Coordination (HMO D-SNP)
Amerivantage Dual Coordination (HMO D-SNP) H1894-002 Plan Details
Amerivantage Dual Coordination (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Amerigroup.
Plan ID: H1894-002.
$19.40
Monthly Premium
Amerivantage Dual Coordination (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Amerigroup.
Plan ID: H1894-002.
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $7550 Out-of-Network: N/A |
| Initial Coverage Limit | $4660 |
| Catastrophic Coverage Limit | $7,400 |
| Primary Care Doctor Visit | In-Network: $0.00 copay |
| Specialty Doctor Visit | In-Network: $0.00 copay |
| Inpatient Hospital Care | In-Network: $0.00 copay - Medicare-defined cost share |
| Urgent Care | Urgent Care: $0.00 copay - $60.00 copay |
| Emergency Room Visit | Emergency Care: $0.00 copay - $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: $0.00 copay - 20% coinsurance Per Trip Air Ambulance: $0.00 copay - 20% coinsurance |
Health Care Services and Medical Supplies
Amerivantage Dual Coordination (HMO D-SNP) 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: $0.00 copay - 20% coinsurance Routine Chiropractic Services: $0.00 copay 24 visits each year |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies: $0.00 copay |
| Durable Medical Eqipment (DME) | In-Network: $0.00 copay - 20% coinsurance |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Lab Services: $0.00 copay - 20% coinsurance X-Rays: $0.00 copay - 20% coinsurance Therapeutic Radiological Services: $0.00 copay - 20% coinsurance Outpatient Diagnostic Procedures/Tests: $0.00 copay - 20% coinsurance Diagnostic Radiological Services: $0.00 copay - 20% coinsurance |
| Home Health Care | In-Network: $0.00 copay |
| Mental Health Inpatient Care | In-Network: $0.00 copay - Medicare-defined cost share |
| Mental Health Outpatient Care | In-Network: Individual and Group Sessions: $0.00 copay - 20% coinsurance |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital - Surgery: $0.00 copay - 20% coinsurance Observation Services: $0.00 copay - 20% coinsurance Ambulatory Surgical Center: $0.00 copay - 20% coinsurance |
| Outpatient Substance Abuse Care | In-Network: Individual and Group Sessions: $0.00 copay - 20% coinsurance |
| Over-the-counter (OTC) Items | This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $300 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 copay - 20% coinsurance Routine Foot Care: $0.00 copay Unlimited routine foot care visits each year. |
| Skilled Nursing Facility Care | In-Network: $0.00 copay - Medicare-defined Cost Share |
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 - 20% coinsurance Comprehensive Dental Services: $0.00 copay This plan covers up to a $3,000.00 allowance for covered comprehensive dental services every year. |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Medicare Covered Eye Exam: $0.00 copay - 20% coinsurance Routine Eye Exam: $0.00 copay This plan covers 1 routine eye exam(s) every year. Medicare Covered Eye Wear: $0.00 copay - 20% coinsurance Routine Eye Wear: $0.00 copay This plan covers up to $200.00 for eyeglasses or contact lenses every year. |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Medicare Covered Hearing Exam: $0.00 copay - 20% coinsurance 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. |
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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