FHCP Medicare Flagler Advantage (HMO)

FHCP Medicare Flagler Advantage (HMO) H1035-016 Plan Details
4.5 out of 5 stars

FHCP Medicare Flagler Advantage (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Guidewell Mutual Holding Corporation.
Plan ID: H1035-016.

$0.00
Monthly Premium

FHCP Medicare Flagler Advantage (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Guidewell Mutual Holding Corporation.
Plan ID: H1035-016.

FHCP Medicare Flagler Advantage (HMO) H1035-016 Plan Details
4.5 out of 5 stars

FHCP Medicare Flagler Advantage (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Guidewell Mutual Holding Corporation.
Plan ID: H1035-016.

$0.00
Monthly Premium

Florida Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
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 $0.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $15.00
Prior Authorization Required for Doctor Specialty Visit
Referral Required for Doctor Specialty Visit
Prior authorization required
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$215.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Acute Hospital Services
Referral Required for Acute Hospital Services
Prior authorization required
Urgent Care
Copayment for Urgent Care $0.00 to $10.00

$0 copay for urgently needed services in an FHCP Extended Hours Care Center $10 copay for urgently needed services in an Urgent Care Center.

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $10.00
Maximum Plan Benefit of $25,000
Emergency Room Visit
Copayment for Emergency Care $120.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours for the same condition

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $120.00
Copayment for Worldwide Emergency Transportation $265.00
Maximum Plan Benefit of $25,000
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $265.00

Air Ambulance:
Copayment for Air Ambulance Services $265.00

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

Health Care Services and Medical Supplies

FHCP Medicare Flagler Advantage (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:
Copayment for Medicare-covered Diabetic Supplies $0.00 to $10.00
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 20%
Prior Authorization Required for Durable Medical Equipment
This Plan has preferred Vendors/Manufacturers - Please see Evidence of Coverage
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 $0.00 to $200.00
Copayment for Medicare-covered Lab Services $0.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
Referral Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $175.00
Copayment for Medicare-covered Therapeutic Radiological Services $10.00 to $50.00
Copayment for Medicare-covered X-Ray Services $10.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Referral 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
Referral Required for Home Health Services
Prior authorization required
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$215.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
Referral Required for Psychiatric Hospital Services
Prior authorization required
Mental Health Outpatient Care
In-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 $150.00
Prior Authorization Required for Outpatient Hospital Services
Referral Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $150.00
Prior Authorization Required for Outpatient Observation Services
Referral Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $75.00
Prior Authorization Required for Ambulatory Surgical Center Services
Referral Required for Ambulatory Surgical Center Services
Prior authorization required
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
Referral Required for Outpatient Substance Abuse Services
Prior authorization required
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 $75.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $15.00
Copayment for Routine Foot Care $10.00
  • Maximum 6 visits every year
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$150.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Referral 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:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 2 visits per 12 consecutive months
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 2 visits per 12 consecutive months
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Comprehensive Dental:
Copayment for Medicare-covered Benefits $20.00
Copayment for Extractions $0.00
  • Maximum 2 visits every year
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00
  • Maximum 2 visits (Please see Evidence of Coverage for details)
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 $0.00 to $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 Eyeglasses (lenses and frames) $0.00
  • Maximum 1 Pair every two years
  • Maximum plan benefit of $180.00 every two years for Eyeglasses (lenses and frames)

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
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 1 visit every year
Referral Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $0.00
  • Maximum 2 Hearing Aids every year
Maximum Plan Benefit of $300.00 every year per ear
Up to 2 hearing aids every year.
Additional hearing services must be obtained through our participating provider to receive in-network benefits.
Member is responsible for any amount after the benefit allowance has been applied.

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
Diabetic prevention program
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Health and wellness education programs
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