Cigna TotalCare Plus (HMO D-SNP)
Cigna TotalCare Plus (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Cigna
Plan ID: H4513-034
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Talk to a licensed agent today to find a plan that fits your needs.
Cigna TotalCare Plus (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Cigna
Plan ID: H4513-034
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Tennessee Counties Served
Basic Costs and Coverage
Coverage | Cost |
---|---|
Monthly Deductible | $0 |
Out of Pocket Max |
In-Network: $8300 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 | $100 Copay is waived if hospital admission occurs within: 24 hours Worldwide Emergency Coverage: $100 |
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 | If you’re managing diabetes, Cigna Healthcare makes it easier and more affordable to get monitoring and testing supplies. Your plan covers preferred brand diabetic supplies plus home delivery options. So you have less to worry about. Diabetic Supplies: $0 Diabetic Therapeutic Shoes or Inserts: 20% |
Durable Medical Eqipment (DME) | 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 $0.00 Coinsurance 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 | 20% |
Over-the-counter (OTC) Items | $225 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 | In-Network: Preventive Dental: Maximum Plan Allowance of $3500.00 every year for Preventive and Non-Medicare Covered Comprehensive combined Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00 Maximum Plan Allowance of $3500.00 every year for Preventive and Non-Medicare Covered Comprehensive combined |
Vision Benefits
The following vision services are covered from in-network providers.
Coverage | Cost |
---|---|
Vision Benefits | In-Network: Eye Exams: Coinsurance for Medicare Covered Benefits $0.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Copayment for Contact Lenses $0.00 Copayment for Eyeglasses (lenses and frames) $0.00
Maximum Plan Benefit of $400.00 every year for all Non-Medicare covered eyewear |
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 |