Care Core: M Health Fairview & North Memorial (HMO-POS)

Care Core: M Health Fairview & North Memorial (HMO-POS) H0422-001 Plan Details
Plan too new to be measured

Care Core: M Health Fairview & North Memorial (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by UCare Minnesota.
Plan ID: H0422-001.

$0.00
Monthly Premium

Care Core: M Health Fairview & North Memorial (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by UCare Minnesota.
Plan ID: H0422-001.

Care Core: M Health Fairview & North Memorial (HMO-POS) H0422-001 Plan Details
Plan too new to be measured

Care Core: M Health Fairview & North Memorial (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by UCare Minnesota.
Plan ID: H0422-001.

$0.00
Monthly Premium

Minnesota Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $395
Out of Pocket Max In-Network: $-1
Out-of-Network: 10000
Initial Coverage Limit $0
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
POS (Out-of-Network):

Doctor Office Visit:
Coinsurance for Medicare Covered Primary Care Office Visit 25%
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $40.00
POS (Out-of-Network):

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 25%
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$250.00 per day for days 1 to 5
$0.00 per day for days 6 to the end of your stay
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 25%
Urgent Care
Copayment for Urgent Care $50.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $90.00
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Copayment for Worldwide Emergency Transportation $90.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $400.00

Air Ambulance:
Copayment for Air Ambulance Services $400.00
POS (Out-of-Network):

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $400.00
Copayment for Medicare Covered Ambulance Services - Air $400.00

Health Care Services and Medical Supplies

Care Core: M Health Fairview & North Memorial (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:
Copayment for Medicare-covered Chiropractic Services $20.00
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Coinsurance for Medicare-covered Diabetic Supplies 10% to 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 10%
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
POS (Out-of-Network):
Coinsurance for Medicare Covered Diabetic Supplies and Services 25%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare-covered Diagnostic Procedures/Tests 10%
Copayment for Medicare-covered Lab Services $0.00
Maximum out of Pocket $150.00 (Please see Evidence of Coverage)

Outpatient Diag/Therapeutic Rad Services:
Coinsurance for Medicare-covered Diagnostic Radiological Services 10%
Coinsurance for Medicare-covered Therapeutic Radiological Services 10%
Coinsurance for Medicare-covered X-Ray Services 10%
Maximum out of Pocket $150.00 (Please see Evidence of Coverage)
POS (Out-of-Network):

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 25%
Copayment for Medicare Covered Lab Services $0.00
Coinsurance for Medicare Covered Diagnostic Radiological Services 25%
Coinsurance for Medicare Covered Therapeutic Radiological Services 25%
Coinsurance for Medicare Covered Outpatient X-Ray Services 25%
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
POS (Out-of-Network):
Coinsurance for Medicare Covered Home Health 25%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$250.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 25%
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
POS (Out-of-Network):
Coinsurance for Medicare Covered Individual Sessions 25%
Coinsurance for Medicare Covered Group Sessions 25%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $250.00

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $250.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $250.00
POS (Out-of-Network):

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 25%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 25%
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
POS (Out-of-Network):
Coinsurance for Medicare Covered Individual or Group Sessions 25%
Over-the-counter (OTC) Items
In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $50.00 every six months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $40.00
POS (Out-of-Network):
Coinsurance for Medicare Covered Podiatry Services 25%
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$188.00 per day for days 21 to 100
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 25%

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 2 visits every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 2 visits every year
Copayment for Fluoride Treatment $0.00
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit every year
Maximum Plan Benefit of $2000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Copayment for Medicare-covered Benefits $0.00
Coinsurance for Non-routine Services 50% to 70%
Coinsurance for Diagnostic Services 50%
Coinsurance for Restorative Services 70%
Coinsurance for Endodontics 50%
Coinsurance for Periodontics 0% to 50%
Coinsurance for Extractions 50%
Coinsurance for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services 50% to 70%
Maximum Plan Benefit of $2000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined
Deductible $100.00
POS (Out-of-Network):

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 25%
Non-Medicare Covered Dental Services:
Coinsurance for Non-Medicare Covered Preventive Dental 0% to 70%
Coinsurance for Non-Medicare Covered Comprehensive Dental 0% to 70%
Maximum Plan Benefit of $2000.00 every year

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00 to $40.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00
Copayment for Eyeglass Lenses $0.00
Copayment for Eyeglass Frames $0.00
Copayment for Upgrades $0.00
Maximum Plan Benefit of $100.00 every year for all Non-Medicare covered eyewear
POS (Out-of-Network):

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 25%
Coinsurance for Medicare Covered Eyewear 25%
Non-Medicare Covered Vision Services:
Copayment for Non-Medicare Covered Eyewear $0.00
Maximum Plan Benefit of $100.00 every year

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $40.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 3 visits every year

Hearing Aids:
Copayment for Hearing Aids $699.00 to $999.00
  • Maximum 2 Hearing Aids every year
Coverage is limited to TruHearing's Advanced and Premium hearing aids. Minimum copay applies to the Advanced hearing aid and the maximum copay applies to the Premium hearing aid
POS (Out-of-Network):

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 25%

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:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit
    POS (Out-of-Network):

    Medicare-covered Zero Dollar Preventive Services:
    Copayment for Medicare Covered Medicare-covered Preventive Services $0.00

    Prescription Drug Costs and Coverage

    The Care Core: M Health Fairview & North Memorial (HMO-POS) plan offers the following prescription drug coverage, with an annual drug deductible of $395 (excludes Tiers 1 and 2) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $395 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $3.00
    • Standard retail $12.00
    • Preferred mail order $3.00
    • Standard mail order $12.00
    Generic
    • Preferred retail $15.00
    • Standard retail $20.00
    • Preferred mail order $15.00
    • Standard mail order $20.00
    Annual Drug Deductible $395 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $6.00
    • Standard retail $24.00
    • Preferred mail order $6.00
    • Standard mail order $24.00
    Generic
    • Preferred retail $30.00
    • Standard retail $40.00
    • Preferred mail order $30.00
    • Standard mail order $40.00
    Annual Drug Deductible $395 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $9.00
    • Standard retail $36.00
    • Preferred mail order $6.00
    • Standard mail order $36.00
    Generic
    • Preferred retail $45.00
    • Standard retail $60.00
    • Preferred mail order $30.00
    • Standard mail order $60.00