HAP Senior Plus Option 4 (PPO)

HAP Senior Plus Option 4 (PPO) H2322-004 Plan Details
4 out of 5 stars

HAP Senior Plus Option 4 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Health Alliance Plan.
Plan ID: H2322-004.

$200.00
Monthly Premium

HAP Senior Plus Option 4 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Health Alliance Plan.
Plan ID: H2322-004.

HAP Senior Plus Option 4 (PPO) H2322-004 Plan Details
4 out of 5 stars

HAP Senior Plus Option 4 (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Health Alliance Plan.
Plan ID: H2322-004.

$200.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $4000
Out-of-Network: 6100
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $5.00
Out-of-Network:

Doctor Office Visit:
Coinsurance for Medicare Covered Primary Care Office Visit 20%
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $30.00
Out-of-Network:

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 20%
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$145.00 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
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 20%
Urgent Care
Copayment for Urgent Care $5.00 to $55.00

Copayment depends upon place of service: $5 copay if service rendered at PCP office, $30 copay if rendered at specialist office, $55 copay 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 $175.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $175.00

Air Ambulance:
Copayment for Air Ambulance Services $175.00

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required
Out-of-Network:

Ambulance Services:
Coinsurance for Medicare Covered Ambulance Services - Ground 20%
Coinsurance for Medicare Covered Ambulance Services - Air 20%

Health Care Services and Medical Supplies

HAP Senior Plus Option 4 (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
Out-of-Network:
Coinsurance for Medicare Covered Chiropractic Services 20%
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

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 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 $100.00
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% to $150.00
Copayment for Medicare-covered Therapeutic Radiological Services $30.00
Copayment for Medicare-covered X-Ray Services $0.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services

Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests
0% to 20%
Coinsurance for Medicare Covered Lab Services
20%
Coinsurance for Medicare Covered Diagnostic Radiological Services 20%
Coinsurance for Medicare Covered Therapeutic Radiological Services 20%
Coinsurance for Medicare Covered Outpatient X-Ray Services 20%
Prior authorization required
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Out-of-Network:
Coinsurance for Medicare Covered Home Health 20%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$145.00 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
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 20%
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $5.00
Copayment for Medicare-covered Group Sessions $5.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Individual Sessions 20%
Coinsurance for Medicare Covered Group Sessions 20%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $175.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $175.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $95.00
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 20%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 20%
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $5.00
Copayment for Medicare-covered Group Sessions $5.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Individual or Group Sessions 20%
Over-the-counter (OTC) Items
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 $0.00 to $30.00
Out-of-Network:
Coinsurance for Medicare Covered Podiatry Services 20%
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
Prior authorization required
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 20%

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 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 $5.00 to $30.00
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 $1000.00 every year for Non-Medicare Covered Comprehensive Dental Services

Out-of-Network:

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 20%

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 $5.00 to $30.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

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

Out-of-Network:

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 20%
Coinsurance for Medicare Covered Eyewear 20%

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 $5.00 to $30.00
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.

Out-of-Network:

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 20%

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:
Coinsurance for Medicare Covered Medicare-covered Preventive Services 20%