Health Alliance Medicare POS 10 Rx (HMO-POS)
Health Alliance Medicare POS 10 Rx (HMO-POS) H1463-019 Plan Details
Health Alliance Medicare POS 10 Rx (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by The Carle Foundation.
Plan ID: H1463-019.
$165.00
Monthly Premium
Health Alliance Medicare POS 10 Rx (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by The Carle Foundation.
Plan ID: H1463-019.
Illinois Counties Served
Boone
Henry
Brown
Bureau
Carroll
Cass
Champaign
Christian
Clark
Clay
Coles
Crawford
Cumberland
Dekalb
Dewitt
Douglas
Edgar
Edwards
Effingham
Fayette
Ford
Franklin
Fulton
Hancock
Henderson
Iroquois
Jackson
Jasper
Jefferson
Jo Daviess
Johnson
Kankakee
Knox
La Salle
Lawrence
Lee
Livingston
Logan
Macon
Macoupin
Marion
Marshall
Mason
Mcdonough
Mclean
Menard
Mercer
Montgomery
Morgan
Moultrie
Ogle
Peoria
Perry
Piatt
Pike
Putnam
Richland
Rock Island
Saline
Sangamon
Schuyler
Scott
Shelby
Stark
Stephenson
Tazewell
Vermilion
Wabash
Warren
Wayne
Whiteside
Williamson
Winnebago
Woodford
Iowa Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $4500 Out-of-Network: N/A |
| Initial Coverage Limit | $4660 |
| Catastrophic Coverage Limit | $7,400 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $20.00 POS (Out-of-Network): Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $40.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $30.00 POS (Out-of-Network): Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $40.00 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $250.00 per day for days 1 to 8 $0.00 per day for days 9 to 90 Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: Coinsurance for Acute Hospital Services per Stay 25% |
| Urgent Care | Copayment for Urgent Care $30.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $30.00 |
| Emergency Room Visit | Copayment for Emergency Care $110.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital Worldwide Coverage: Copayment for Worldwide Emergency Coverage $110.00 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
Health Alliance Medicare POS 10 Rx (HMO-POS) 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 Prior Authorization Required for Chiropractic Services Prior authorization required POS (Out-of-Network): Copayment for Medicare Covered Chiropractic Services $45.00 |
| 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) POS (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 0% to 20% Prior Authorization Required for Durable Medical Equipment This Plan has preferred Vendors/Manufacturers - Please see Evidence of Coverage Prior authorization required POS (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 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 Copayment for Medicare-covered Therapeutic Radiological Services $0.00 Copayment for Medicare-covered X-Ray Services $0.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required POS (Out-of-Network): Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $30.00 Copayment for Medicare Covered Lab Services $30.00 Copayment for Medicare Covered Diagnostic Radiological Services $30.00 Copayment for Medicare Covered Therapeutic Radiological Services $30.00 Copayment for Medicare Covered Outpatient X-Ray Services $30.00 |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 POS (Out-of-Network): Copayment for Medicare Covered Home Health $30.00 |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $175.00 per day for days 1 to 9 $0.00 per day for days 10 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Coinsurance for Psychiatric Hospital Services per Stay 25% |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $30.00 Copayment for Medicare-covered Group Sessions $30.00 POS (Out-of-Network): Copayment for Medicare Covered Individual Sessions $40.00 Copayment for Medicare Covered Group Sessions $40.00 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $275.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $30.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $275.00 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required POS (Out-of-Network): Outpatient Hospital and ASC Services: Copayment for Medicare Covered Outpatient Hospital Services $325.00 Copayment for Medicare Covered Ambulatory Surgical Center Services $325.00 |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $30.00 Copayment for Medicare-covered Group Sessions $30.00 POS (Out-of-Network): Copayment for Medicare Covered Individual or Group Sessions $40.00 |
| 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 $96.00 every month |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $30.00 POS (Out-of-Network): Copayment for Medicare Covered Podiatry Services $40.00 |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $196.00 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 Out-of-Network: $85.00 per day for days 1 to 20 $225.00 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: Maximum Plan Allowance of $2000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined Comprehensive Dental: Copayment for Medicare-covered Benefits $20.00 Coinsurance for Non-routine Services 20% Copayment for Diagnostic Services $0.00 Coinsurance for Restorative Services 20% Coinsurance for Endodontics 20% Coinsurance for Periodontics 20% Coinsurance for Extractions 20% Coinsurance for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services 20% to 40% Maximum Plan Benefit of $2000.00 every year for Preventive and Non-Medicare Covered Comprehensive combined POS (Out-of-Network): Medicare Covered Dental Services: Copayment for Medicare Covered Comprehensive Dental $20.00 Non-Medicare Covered Dental Services: Coinsurance for Non-Medicare Covered Preventive Dental 0% to 40% Coinsurance for Non-Medicare Covered Comprehensive Dental 0% to 40% Maximum Plan Benefit of $2000.00 every year |
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 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $25.00 Maximum Plan Allowance of $150.00 every year for all Non-Medicare covered eyewear POS (Out-of-Network): Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $40.00 Copayment for Medicare Covered Eyewear $40.00 Non-Medicare Covered Vision Services: Copayment for Non-Medicare Covered Eyewear $0.00 Maximum Plan Benefit of $150.00 every year |
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 $25.00 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for Hearing Aids $699.00 to $999.00
POS (Out-of-Network): Medicare Covered Hearing Services: Copayment for Medicare Covered Hearing Exams $40.00 |
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:
Yearly "Wellness" visit POS (Out-of-Network): Medicare-covered Zero Dollar Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $30.00 |
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