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
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
$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
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Illinois Counties Served
Grundy
Kankakee
Henry
Rock Island
Mercer
Dekalb
La Salle
Iroquois
Ford
Livingston
Hancock
Scott
Carroll
Bureau
Sangamon
Knox
Ogle
Macoupin
Henderson
Mcdonough
Schuyler
Williamson
Christian
Mason
Marshall
Putnam
Winnebago
Peoria
Morgan
Boone
Montgomery
Moultrie
Woodford
Mclean
Logan
Lee
Cass
Macon
Warren
Shelby
Pike
Brown
Perry
Fulton
Stephenson
Piatt
Dewitt
Tazewell
Menard
Stark
Whiteside
Edgar
Jasper
Richland
Clark
Vermilion
Effingham
Coles
Wabash
Marion
Johnson
Franklin
Douglas
Jo Daviess
Saline
Crawford
Fayette
Jackson
Jefferson
Edwards
Clay
Lawrence
Champaign
Cumberland
Wayne
Iowa Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $4000 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| 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 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 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 $120.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital Worldwide Coverage: Copayment for Worldwide Emergency Coverage $120.00 Copayment for Worldwide Emergency Transportation $275.00 to $400.00 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $275.00 Air Ambulance: Copayment for Air Ambulance Services $400.00 Please see Evidence of Coverage for Prior Authorization rules Prior authorization required POS (Out-of-Network): Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $275.00 Copayment for Medicare Covered Ambulance Services - Air $400.00 |
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 |
| 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 $300.00 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 $300.00 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 $350.00 Copayment for Medicare Covered Ambulatory Surgical Center Services $350.00 |
| 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 $35.00 every three months |
| 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 $203.00 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: 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 $200.00 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 $200.00 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 |
Find Medicare Advantage Plans
Visit MedicareAdvantage.com to compare multiple Medicare Advantage plans, side by side.
