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Amerivantage Dual Coordination Plus (HMO D-SNP)

Amerivantage Dual Coordination Plus (HMO D-SNP) H8849-010 Plan Details
3 out of 5 stars

Amerivantage Dual Coordination Plus (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Amerigroup.
Plan ID: H8849-010.

$0.00
Monthly Premium

Amerivantage Dual Coordination Plus (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Amerigroup.
Plan ID: H8849-010.

Amerivantage Dual Coordination Plus (HMO D-SNP) H8849-010 Plan Details
3 out of 5 stars

Amerivantage Dual Coordination Plus (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Amerigroup.
Plan ID: H8849-010.

$0.00
Monthly Premium

Texas Counties Served

Anderson Angelina Bandera Camp Dona Ana El Paso Archer Austin Bailey Bastrop Bexar Blanco Brazoria Briscoe Burnet Caldwell Castro Chambers Cherokee Clay Cochran Collin Colorado Comal Cooke Crosby Dallas Delta Denton Dickens Ellis Floyd Fort Bend Franklin Galveston Garza Gonzales Grayson Gregg Grimes Guadalupe Hale Hamilton Hardin Harris Hays Henderson Hockley Hood Hopkins Hudspeth Hunt Jack Jasper Jefferson Johnson Kaufman Kendall La Salle Lamb Lampasas Lee Liberty Lubbock Lynn Mason Matagorda Medina Mills Montague Montgomery Motley Nacogdoches Navarro Orange Palo Pinto Parker Polk Rains Real Rockwall Rusk San Jacinto San Saba Smith Swisher Tarrant Terry Throckmorton Titus Travis Upshur Van Zandt Walker Waller Wharton Williamson Wilson Wise Wood 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 $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 per stay
Urgent Care
Urgent Care: $0.00 copay
Emergency Room Visit
Emergency Care: $0.00 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 Per Trip
Air Ambulance: $0.00 copay

Health Care Services and Medical Supplies

Amerivantage Dual Coordination Plus (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
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Diabetic Supplies: $0.00 copay
Durable Medical Eqipment (DME)
In-Network:
$0.00 copay
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:
Lab Services: $0.00 copay
X-Rays: $0.00 copay
Therapeutic Radiological Services: $0.00 copay
Outpatient Diagnostic Procedures/Tests: $0.00 copay
Diagnostic Radiological Services: $0.00 copay
Home Health Care
In-Network:
$0.00 copay
Mental Health Inpatient Care
In-Network:
$0.00 copay per stay
Mental Health Outpatient Care
In-Network:
Individual and Group Sessions: $0.00 copay
Outpatient Services / Surgery
In-Network:
Outpatient Hospital - Surgery: $0.00 copay
Observation Services: $0.00 copay
Ambulatory Surgical Center: $0.00 copay
Outpatient Substance Abuse Care
In-Network:
Individual and Group Sessions: $0.00 copay
Over-the-counter (OTC) Items
This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $290 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
Routine Foot Care: $0.00 copay
Unlimited routine foot care visits each year.
Skilled Nursing Facility Care
In-Network:
$0.00 copay 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 $4,500.00 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
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 $350.00 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
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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