CarePartners Access (PPO)

CarePartners Access (PPO) H0342-001 Plan Details
Plan too new to be measured

CarePartners Access (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by CAREPARTNERS OF CONNECTICUT, INC..
Plan ID: H0342-001.

$0.00
Monthly Premium

CarePartners Access (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by CAREPARTNERS OF CONNECTICUT, INC..
Plan ID: H0342-001.

CarePartners Access (PPO) H0342-001 Plan Details
Plan too new to be measured

CarePartners Access (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by CAREPARTNERS OF CONNECTICUT, INC..
Plan ID: H0342-001.

$0.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $4900
Out-of-Network: 10000
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

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

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $50.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $45.00
Out-of-Network:

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $50.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $795.00
Your plan covers an unlimited number of days for an inpatient stay.
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 30%
Urgent Care
Copayment for Urgent Care $45.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $45.00
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 for the same condition

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Copayment for Worldwide Emergency Transportation $325.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $325.00 per one-way trip

Air Ambulance:
Copayment for Air Ambulance Services $325.00 per one-way trip

Please see Evidence of Coverage for Prior Authorization rules

Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $325.00 per one-way trip
Copayment for Medicare Covered Ambulance Services - Air $325.00 per one-way trip
Prior authorization required

Health Care Services and Medical Supplies

CarePartners Access (PPO) 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
Copayment for Initial chiropractic evaluation $20.00
  • Initial Evaluation covered once per calendar year
Out-of-Network:
Copayment for Medicare Covered Chiropractic Services $50.00 Copayment for Non-Medicare Covered Chiropractic Services $50.00
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Coinsurance for Medicare-covered Diabetic Supplies 0% to 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Prior Authorization Required for Therapeutic Continuous Glucose Monitors
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)

Out-of-Network:
Coinsurance for Medicare Covered Diabetic Supplies and Services 0% to 30%
Prior authorization required
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Durable Medical Equipment 30%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $45.00
Copayment for Medicare-covered Lab Services $0.00 to $45.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $60.00 to $250.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0.00 to $45.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 30%
Coinsurance for Medicare Covered Lab Services 30%
Coinsurance for Medicare Covered Diagnostic Radiological Services 30%
Coinsurance for Medicare Covered Therapeutic Radiological Services 30%
Coinsurance for Medicare Covered Outpatient X-Ray Services 30%
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Out-of-Network:
Coinsurance for Medicare Covered Home Health 30%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $1763.00
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 30%
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00 to $40.00
Copayment for Medicare-covered Group Sessions $0.00 to $40.00
Out-of-Network:
Coinsurance for Medicare Covered Individual Sessions 30%
Coinsurance for Medicare Covered Group Sessions 30%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $250.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services $0.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00 to $250.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 30%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 30%
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Out-of-Network:
Coinsurance for Medicare Covered Individual or Group Sessions 30%
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 three months
Out-of-Network:

Over-The-Counter (OTC) Items:
Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $50.00
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $45.00
Out-of-Network:
Copayment for Medicare Covered Podiatry Services $50.00
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$178.00 per day for days 21 to 100
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 30%

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 Dental X-Rays $0.00
  • Maximum 2 visits every year
Maximum Plan Benefit of $1000.00 every year for in and out of network services combined

Comprehensive Dental:
Copayment for Medicare-covered Benefits $40.00
Coinsurance for Non-routine Services 50%
Coinsurance for Diagnostic Services 0% to 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Restorative Services 50%
  • Maximum 1 visit every two years
Coinsurance for Endodontics 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Periodontics 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Extractions 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Out-of-Network:

Medicare Covered Dental Services:
Copayment for Medicare Covered Comprehensive Dental $50.00
Non-Medicare Covered Dental Services:
Coinsurance for Non-Medicare Covered Preventive Dental 0% to 50%
Coinsurance for Non-Medicare Covered Comprehensive Dental 0% to 50%

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 $45.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Maximum Plan Allowance of $150.00 every year for all Non-Medicare covered eyewear for in and out of network services combined
Out-of-Network:

Medicare Covered Vision Services:
Copayment for Medicare Covered Eye Exams $50.00
Copayment for Medicare Covered Eyewear $50.00
Non-Medicare Covered Vision Services:
Copayment for Non-Medicare Covered Eye Exams $50.00
Copayment for Non-Medicare Covered Eyewear $50.00

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 $45.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 1 visit every year

Hearing Aids:
Copayment for Hearing Aids $250.00 to $1150.00
  • Maximum 2 Hearing Aids every year
$250 copayment for standard level hearing aid up to 1 per ear, per year $475 copayment for superior level hearing aid up to 1 per ear, per year $650 copayment for advanced level hearing aid up to 1 per ear, per year $850 copayment for advanced plus level hearing aid up to 1 per ear, per year $1150 copayment for premier level hearing aid up to 1 per ear, per year To access the hearing aid benefit, the member must use a Hearing Care Solutions provider
Out-of-Network:

Medicare Covered Hearing Services:
Copayment for Medicare Covered Hearing Exams $50.00
Non-Medicare Covered Hearing Services:
Copayment for Non-Medicare Covered Hearing Exams $50.00
Copayment for Non-Medicare Covered Hearing Aids $250.00 to $1150.00

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
    Out-of-Network:

    Medicare-covered Zero Dollar Preventive Services:
    Coinsurance for Medicare Covered Medicare-covered Preventive Services 0% to 30%