Amerivantage ESRD Care Plus (HMO C-SNP)
Amerivantage ESRD Care Plus (HMO C-SNP) H2593-043 Plan Details
Amerivantage ESRD Care Plus (HMO C-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Amerigroup.
Plan ID: H2593-043.
$0.00
Monthly Premium
Amerivantage ESRD Care Plus (HMO C-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Amerigroup.
Plan ID: H2593-043.
Texas Counties Served
Archer
Austin
Bailey
Briscoe
Castro
Chambers
Clay
Cochran
Collin
Colorado
Cooke
Crosby
Dallas
Delta
Denton
Dickens
Floyd
Fort Bend
Galveston
Garza
Grayson
Grimes
Hale
Hardin
Harris
Henderson
Hockley
Hunt
Jack
Jasper
Jefferson
Johnson
Lamb
Liberty
Lubbock
Lynn
Matagorda
Montague
Montgomery
Motley
Navarro
Orange
Palo Pinto
Parker
Rains
Rockwall
San Jacinto
Swisher
Tarrant
Terry
Throckmorton
Van Zandt
Walker
Waller
Wharton
Wise
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $2900 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 - $25.00 copay |
| Inpatient Hospital Care | In-Network: Days 1-5: $125.00 per day, per admission / Days 6-90: $0.00 per day, per admission Additional Hospital Days: Unlimited additional days |
| Urgent Care | Urgent Care: $25.00 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: $210.00 copay Per Trip Air Ambulance: $210.00 copay |
Health Care Services and Medical Supplies
Amerivantage ESRD Care Plus (HMO C-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: $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 copay X-Rays: $0.00 copay Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: $0.00 copay Diagnostic Radiological Services: $30.00 - $125.00 copay |
| Home Health Care | In-Network: $0.00 copay |
| Mental Health Inpatient Care | In-Network: Days 1-5: $125.00 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: $125.00 copay Observation Services: $125.00 copay Ambulatory Surgical Center: $100.00 copay |
| Outpatient Substance Abuse Care | In-Network: Individual and Group Sessions: $35.00 copay |
| Over-the-counter (OTC) Items | This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $90 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 - $25.00 copay Routine Foot Care: $0.00 copay Unlimited routine foot care visits each year. |
| Skilled Nursing Facility Care | In-Network: SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $140.00 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: 2 oral exam(s), 2 cleaning(s), 1 dental X-ray(s), 1 fluoride treatment(s) every year. Medicare Covered Dental: $25.00 copay Comprehensive Dental Services: $0.00 copay This plan covers up to a $750.00 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 - $25.00 copay Routine Eye Exam: $0.00 copay This plan covers 1 routine eye exam(s) every year. Medicare Covered Eye Wear: 20% coinsurance Routine Eye Wear: $0.00 copay This plan covers up to $300.00 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: $25.00 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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