HAP Primary Choice Medicare (HMO)

HAP Primary Choice Medicare (HMO) H2354-024 Plan Details
4.5 out of 5 stars

HAP Primary Choice Medicare (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Health Alliance Plan.
Plan ID: H2354-024.

$0.00
Monthly Premium

HAP Primary Choice Medicare (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Health Alliance Plan.
Plan ID: H2354-024.

HAP Primary Choice Medicare (HMO) H2354-024 Plan Details
4.5 out of 5 stars

HAP Primary Choice Medicare (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Health Alliance Plan.
Plan ID: H2354-024.

$0.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $4300
Out-of-Network: 0
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 $40.00
Referral Required for Doctor Specialty Visit
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$245.00 per day for days 1 to 7
$0.00 per day for days 8 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Urgent Care
Copayment for Urgent Care $0.00 to $55.00

Copayment depends upon place of service: $0 copayment if service rendered at PCP office, $40 if rendered at specialist office, $55 at urgent care facility.

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $55.00
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $90.00
Copayment for Worldwide Emergency Transportation $275.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $275.00

Air Ambulance:
Copayment for Air Ambulance Services $275.00

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

Health Care Services and Medical Supplies

HAP Primary Choice Medicare (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
Referral Required for Chiropractic Services
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Coinsurance for Medicare-covered Diabetic Supplies 0% to 20%
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00
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 $150.00
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 $0.00 to $175.00
Copayment for Medicare-covered Therapeutic Radiological Services $60.00
Copayment for Medicare-covered X-Ray Services $35.00
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
Referral Required for Home Health Services
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$245.00 per day for days 1 to 7
$0.00 per day for days 8 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
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 $225.00
Prior Authorization Required for Outpatient Hospital Services
Referral Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $225.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $120.00
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 $40.00
Copayment for Medicare-covered Group Sessions $40.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Over-the-counter (OTC) Items
Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $100.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $0.00 to $40.00
Referral Required for Podiatry Services
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$188.00 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
Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 2 visits every year
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 to $40.00
Copayment for Non-routine Services $0.00
Copayment for Diagnostic Services $0.00
Coinsurance for Restorative Services 50%
Coinsurance for Endodontics 50%
Copayment for Periodontics $0.00
  • Maximum 2 visits every year
Maximum Plan Benefit of $1,000.00 every year for Non-Medicare Covered Comprehensive Dental Services

Vision Benefits

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

Coverage Cost
Vision Benefits
Eye Exams:
Copayment for Medicare Covered Benefits $0.00 to $40.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year
Referral Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Maximum Plan Allowance of $125.00 every year for all Non-Medicare covered eyewear at an EyeMed Provider

Hearing Benefits

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

Coverage Cost
Hearing Benefits
Hearing Exams:
Copayment for Medicare Covered Benefits $0.00 to $40.00
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

Hearing Aids:
Copayment for Hearing Aids $689.00 to $2039.00
  • Maximum 2 Hearing Aids every year
Member must obtain hearing aids from a NationsHearing provider. Hearing aid purchases include one hearing aid per ear per calendar year, three follow-up visits within first year of initial fitting date, 60-day trial period from date of fitting, 60 batteries per year per aid (3-year supply), 3-year manufacturer repair warranty, 1-time replacement coverage for lost, stolen or damaged hearing aid (replacement cost may apply per aid). Copayment will depend upon the technology level. $689 copay per aid for basic technology level, $989 copay per aid for prime technology level, $1,539 copay per aid for advanced technology level, $2,039 copay per aid for premium technology level.

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