Cigna TotalCare Plus (HMO D-SNP)
Cigna TotalCare Plus (HMO D-SNP) H2108-041 Plan Details
Cigna TotalCare Plus (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Cigna
Plan ID: H2108-041
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$0.00
Monthly Premium
Cigna TotalCare Plus (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Cigna
Plan ID: H2108-041
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Cigna TotalCare Plus (HMO D-SNP) H2108-041 Plan Details
Cigna TotalCare Plus (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Cigna
Plan ID: H2108-041
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
$0.00
Monthly Premium
Maryland Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $8850 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | 20% |
| Specialty Doctor Visit | 20% |
| Inpatient Hospital Care | Standard Medicare |
| Urgent Care | Copayment for Urgent Care $0.00 Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Urgent Coverage $100.00 Maximum Plan Benefit of $50,000 |
| Emergency Room Visit | Copayment for Emergency Care $0.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $100.00 Copayment for Worldwide Emergency Transportation $100.00 Maximum Plan Benefit of $50,000 |
| Ambulance Transportation | Ambulance - Ground: 20% Ambulance - Air: 20% |
Health Care Services and Medical Supplies
Cigna TotalCare 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 | 20% Routine Chiropractic (Supplemental): Not covered |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0.00 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00 Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) Prior authorization required |
| Durable Medical Eqipment (DME) | 20% |
| 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 Copayment for Medicare-covered Lab Services $0.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 Copayment for Medicare-covered Therapeutic Radiological Services $0.00 Copayment for Medicare-covered X-Ray Services $0.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required |
| Home Health Care | $0 Support for Caregivers of Enrollees: Not covered |
| Mental Health Inpatient Care | Standard Medicare |
| Mental Health Outpatient Care | Psychiatric-Individual: $0 Psychiatric-Group: $0 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required |
| Over-the-counter (OTC) Items | $150 every three months Delivered via Cigna Health Today card |
| Podiatry Services | 20% |
| Skilled Nursing Facility Care | Standard Medicare |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | Preventive and Comprehensive Base Maximum Coverage amount for Preventive Dental: $20,000 combined preventive and comprehensive every year Maximum Coverage Amount for Comprehensive Dental: $20,000 combined preventive and comprehensive every year |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | Routine Eye Exams: $0 for one routine exam every year Eye Exams (Medicare-covered): 0 - 20% Max Coverage Amount for Routine Eye Wear Coverage : $200 every year |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | 20% Fitting/Evaluation for Hearing Aids: $0 for one fitting evaluation for hearing aid every year Hearing Aids: Hearing aids (all types): two every year Cost Sharing: $399 - $1,800 per device |
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:
Yearly "Wellness" visit |
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