ConnectiCare Choice Plan 1 (HMO)

ConnectiCare Choice Plan 1 (HMO) H3528-016 Plan Details
4 out of 5 stars

ConnectiCare Choice Plan 1 (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by CONNECTICARE, INC..
Plan ID: H3528-016.

$184.00
Monthly Premium

ConnectiCare Choice Plan 1 (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by CONNECTICARE, INC..
Plan ID: H3528-016.

ConnectiCare Choice Plan 1 (HMO) H3528-016 Plan Details
4 out of 5 stars

ConnectiCare Choice Plan 1 (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by CONNECTICARE, INC..
Plan ID: H3528-016.

$184.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $300
Out of Pocket Max In-Network: $3400
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 $10.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $30.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$345.00 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
Urgent Care
Copayment for Urgent Care $30.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $90.00
Maximum Plan Benefit of $50,000
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 1 days

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Copayment for Worldwide Emergency Transportation $200.00 (Ground Transportation Only)
Maximum Plan Benefit of $50,000
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $200.00

Air Ambulance:
Coinsurance for Air Ambulance Services 20%

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required

Health Care Services and Medical Supplies

ConnectiCare Choice Plan 1 (HMO) 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
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Coinsurance for Medicare-covered Diabetic Supplies 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 10% to 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
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 $10.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $200.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $35.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $1871.00
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $30.00
Copayment for Medicare-covered Group Sessions $30.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $200.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $200.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $100.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $30.00
Copayment for Medicare-covered Group Sessions $30.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $30.00
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$184.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:
Optional Rider Available for Preventive and Comprehensive Dental Benefits
Comprehensive Dental:
Copayment for Medicare-covered Benefits $30.00
Prior Authorization Required for Comprehensive Dental
Prior authorization required

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 $30.00
Copayment for Routine Eye Exams $30.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $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 $30.00
Copayment for Routine Hearing Exams $30.00
  • Maximum 1 visit every year

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

    Prescription Drug Costs and Coverage

    The ConnectiCare Choice Plan 1 (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $300 (excludes Tiers 1 and 2) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $300 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $2.00
    • Standard retail $9.00
    • Preferred mail order $0.00
    • Standard mail order $9.00
    Generic
    • Preferred retail $10.00
    • Standard retail $20.00
    • Preferred mail order $0.00
    • Standard mail order $20.00
    Annual Drug Deductible $300 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $4.00
    • Standard retail $18.00
    • Preferred mail order $0.00
    • Standard mail order $18.00
    Generic
    • Preferred retail $20.00
    • Standard retail $40.00
    • Preferred mail order $0.00
    • Standard mail order $40.00
    Annual Drug Deductible $300 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $6.00
    • Standard retail $27.00
    • Preferred mail order $0.00
    • Standard mail order $27.00
    Generic
    • Preferred retail $30.00
    • Standard retail $60.00
    • Preferred mail order $0.00
    • Standard mail order $60.00