Clear Spring Health Essential (PPO)
Clear Spring Health Essential (PPO) H2020-002 Plan Details
Clear Spring Health Essential (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Clear Spring Health.
Plan ID: H2020-002.
$0.00
Monthly Premium
Clear Spring Health Essential (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Clear Spring Health.
Plan ID: H2020-002.
Virginia Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $5000 Out-of-Network: N/A |
| 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: Coinsurance for Medicare Covered Primary Care Office Visit 45% |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $50.00 Out-of-Network: Doctor Specialty Visit: Coinsurance for Medicare Covered Physician Specialist Office Visit 45% |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $304.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: 45% per day for days 1 to 5 45% per day for days 6 to 90 |
| Urgent Care | Copayment for Urgent Care $40.00 |
| Emergency Room Visit | Copayment for Emergency Care $90.00 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $90.00 Maximum Plan Benefit of $50,000 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $270.00 Air Ambulance: Copayment for Air Ambulance Services $270.00 Please see Evidence of Coverage for Prior Authorization rules Prior authorization required Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $300.00 Copayment for Medicare Covered Ambulance Services - Air $300.00 |
Health Care Services and Medical Supplies
Clear Spring Health Essential (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 Prior Authorization Required for Chiropractic Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Chiropractic Services 45% |
| 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 Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Diabetic Supplies and Services 20% |
| 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 45% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $25.00 Copayment for Medicare-covered Lab Services $25.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $20.00 to $175.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $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 45% Coinsurance for Medicare Covered Lab Services 45% Coinsurance for Medicare Covered Diagnostic Radiological Services 45% Coinsurance for Medicare Covered Therapeutic Radiological Services 45% Coinsurance for Medicare Covered Outpatient X-Ray Services 45% |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Home Health 45% |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $330.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: 45% per day for days 1 to 6 45% per day for days 7 to 90 |
| Mental Health Outpatient 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 Sessions 45% Coinsurance for Medicare Covered Group Sessions 45% |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $45.00 to $300.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $260.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $45.00 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 45% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 45% |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Individual or Group Sessions 45% |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $45.00 Out-of-Network: Coinsurance for Medicare Covered Podiatry Services 45% |
| 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 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required Out-of-Network: 45% per day for days 1 to 20 45% per day for days 21 to 100 |
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
Comprehensive Dental: Copayment for Medicare-covered Benefits $45.00 Copayment for Diagnostic Services $0.00 Copayment for Restorative Services $0.00 Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00 Maximum Plan Benefit of $2000.00 every year for in and out of network services combined for Non-Medicare Covered Comprehensive Out-of-Network: Medicare Covered Dental Services: Coinsurance for Medicare Covered Comprehensive Dental 45% Non-Medicare Covered Dental Services: Copayment for Non-Medicare Covered Preventive Dental $0.00 Copayment for Non-Medicare Covered Comprehensive Dental $0.00 |
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
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Out-of-Network: Medicare Covered Vision Services: Coinsurance for Medicare Covered Eye Exams 45% Coinsurance for Medicare Covered Eyewear 45% Non-Medicare Covered Vision Services: Coinsurance for Non-Medicare Covered Eye Exams 45% |
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 Copayment for Fitting/Evaluation for Hearing Aid $0.00 Hearing Aids: Copayment for Hearing Aids $400.00
Out-of-Network: Medicare Covered Hearing Services: Coinsurance for Medicare Covered Hearing Exams 45% Non-Medicare Covered Hearing Services: Coinsurance for Non-Medicare Covered Hearing Exams 45% Coinsurance for Non-Medicare Covered Hearing Aids 45% |
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 Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Coinsurance for Medicare Covered Medicare-covered Preventive Services 45% |
