Clover Health LiveHealthy (PPO)

Clover Health LiveHealthy (PPO) H5141-026 Plan Details
3 out of 5 stars

Clover Health LiveHealthy (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H5141-026.

$0.00
Monthly Premium

Clover Health LiveHealthy (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H5141-026.

Clover Health LiveHealthy (PPO) H5141-026 Plan Details
3 out of 5 stars

Clover Health LiveHealthy (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H5141-026.

$0.00
Monthly Premium

Georgia Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $7550
Out-of-Network: 7550
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 $0.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $15.00
Out-of-Network:

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $15.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$290.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Out-of-Network:
$290.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Urgent Care
Copayment for Urgent Care $25.00
Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $25.00
Maximum Plan Benefit of $25,000
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 $270.00
Maximum Plan Benefit of $25,000
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 $270.00
Copayment for Medicare Covered Ambulance Services - Air $270.00

Health Care Services and Medical Supplies

Clover Health LiveHealthy (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 $15.00
Prior Authorization Required for Chiropractic Services
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Chiropractic Services $15.00
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
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Out-of-Network:
Copayment for Medicare Covered Diabetic Supplies and Services $0.00
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 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 to $175.00
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 to $175.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $10.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare Covered Diagnostic Procedures/Tests $0.00 to $175.00
Copayment for Medicare Covered Lab Services $0.00
Copayment for Medicare Covered Diagnostic Radiological Services $0.00 to $175.00
Coinsurance for Medicare Covered Therapeutic Radiological Services 20%
Copayment for Medicare Covered Outpatient X-Ray Services $10.00
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:
Copayment for Medicare Covered Home Health $0.00
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$290.00 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:
$290.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $15.00
Copayment for Medicare-covered Group Sessions $15.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Individual Sessions $15.00
Copayment for Medicare Covered Group Sessions $15.00
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $290.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $90.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $275.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Out-of-Network:

Outpatient Hospital and ASC Services:
Copayment for Medicare Covered Outpatient Hospital Services $290.00
Copayment for Medicare Covered Ambulatory Surgical Center Services $275.00
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $15.00
Copayment for Medicare-covered Group Sessions $15.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Individual or Group Sessions $15.00
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 $100.00 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 $100.00
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $15.00
Out-of-Network:
Copayment for Medicare Covered Podiatry Services $15.00
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
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:
$0.00 per day for days 1 to 20
$178.00 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
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 2 visits every year
Copayment for Fluoride Treatment $0.00
  • Maximum 2 visits every year
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Comprehensive Dental:
Copayment for Medicare-covered Benefits $0.00
Copayment for Restorative Services $20.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Endodontics $20.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Periodontics $20.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Extractions $20.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $20.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $1000.00 every year for in and out of network services combined for Non-Medicare Covered Comprehensive
Out-of-Network:

Medicare Covered Dental Services:
Copayment for Medicare Covered Comprehensive Dental $20.00
Non-Medicare Covered Dental Services:
Copayment for Non-Medicare Covered Preventive Dental $0.00
Copayment for Non-Medicare Covered Comprehensive Dental $20.00

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 $15.00
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
  • Maximum 1 Pair every year
Copayment for Eyeglasses (lenses and frames) $0.00
  • Maximum 1 Pair every year
Maximum Plan Benefit of $100.00 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 $15.00
Copayment for Medicare Covered Eyewear $0.00
Non-Medicare Covered Vision Services:
Copayment for Non-Medicare Covered Eye Exams $0.00
Copayment for Non-Medicare Covered Eyewear $0.00

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 $15.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year

Hearing Aids:
Copayment for Hearing Aids $699.00 to $999.00
  • Maximum 2 Hearing Aids every year
Up to two TruHearing-branded hearing aids every year (one per ear per year). Benefit is limited to TruHearing's Advanced and Premium hearing aids. Premium hearing aids are available in rechargeable style options for an additional $75 per aid. $699 copay for each Advanced aid or $999 copay for each Premium aid. TruHearing hearing aid purchase includes: * 3 provider visits within first year of hearing aid purchase. * 45-day trial period. * 3-year extended warranty. * 48 batteries per aid for non-rechargeable models. Benefit does not include or cover any of the following: * Additional cost for optional hearing aid rechargeability. * Ear molds. * Hearing aid accessories. * Additional provider visits. * Additional batteries, batteries when a rechargeable hearing aid is purchased. * Hearing aid return fees. * Costs associated with loss & damage warranty claims. Costs associated with excluded items are the responsibility of the member and not covered by the plan.
Out-of-Network:

Medicare Covered Hearing Services:
Copayment for Medicare Covered Hearing Exams $15.00
Non-Medicare Covered Hearing Services:
Copayment for Non-Medicare Covered Hearing Exams $0.00
Copayment for Non-Medicare Covered Hearing Aids $999.00

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