Health Alliance Medicare POS Basic Rx (HMO-POS)
Health Alliance Medicare POS Basic Rx (HMO-POS) H1463-015 Plan Details
Health Alliance Medicare POS Basic Rx (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by The Carle Foundation
Plan ID: H1463-015
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$53.00
Monthly Premium
Health Alliance Medicare POS Basic Rx (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by The Carle Foundation
Plan ID: H1463-015
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Illinois Counties Served
Jo Daviess
Hancock
Scott
Carroll
Saline
Edwards
Champaign
La Salle
Bureau
Crawford
Sangamon
Knox
Ogle
Macoupin
Henderson
Mcdonough
Schuyler
Cumberland
Perry
Fulton
Ford
Dekalb
Stephenson
Piatt
Dewitt
Tazewell
Menard
Stark
Whiteside
Jefferson
Clay
Livingston
Williamson
Grundy
Christian
Mason
Mercer
Marshall
Putnam
Winnebago
Edgar
Fayette
Peoria
Jasper
Jackson
Morgan
Boone
Lawrence
Richland
Henry
Kankakee
Montgomery
Moultrie
Clark
Woodford
Mclean
Wayne
Logan
Lee
Cass
Effingham
Coles
Wabash
Macon
Warren
Shelby
Pike
Iroquois
Marion
Johnson
Franklin
Douglas
Brown
Rock Island
Vermilion
Indiana Counties Served
Iowa Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $5400 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 $15.00 POS (Out-of-Network): Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $50.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $50.00 POS (Out-of-Network): Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $65.00 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $450.00 per day for days 1 to 4 $0.00 per day for days 5 to 90 Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: $600.00 per day for days 1 to 6 $0.00 per day for days 7 to 90 |
| Urgent Care | Copayment for Urgent Care $55.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $55.00 |
| Emergency Room Visit | Copayment for Emergency Care $100.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital Worldwide Coverage: Copayment for Worldwide Emergency Coverage $100.00 Copayment for Worldwide Emergency Transportation $350.00 to $425.00 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $350.00 Air Ambulance: Copayment for Air Ambulance Services $425.00 Please see Evidence of Coverage for Prior Authorization rules Prior authorization required |
Health Care Services and Medical Supplies
Health Alliance Medicare POS Basic 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 $15.00 Prior Authorization Required for Chiropractic Services Prior authorization required POS (Out-of-Network): Copayment for Medicare Covered Chiropractic Services $50.00 |
| 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) |
| 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 |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $20.00 Copayment for Medicare-covered Lab Services $0.00 to $20.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $50.00 Copayment for Medicare-covered Therapeutic Radiological Services $50.00 Copayment for Medicare-covered X-Ray Services $25.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Please see Evidence of Coverage for Additional Home Health Benefits POS (Out-of-Network): Copayment for Medicare Covered Home Health $50.00 |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $395.00 per day for days 1 to 4 $0.00 per day for days 5 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 POS (Out-of-Network): Copayment for Medicare Covered Individual Sessions $50.00 Copayment for Medicare Covered Group Sessions $50.00 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services 25% Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $55 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services 25% Prior Authorization Required for Ambulatory Surgical Center Services POS (Out-of-Network): Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 25% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 25% Prior authorization required |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $50.00 Copayment for Medicare-covered Group Sessions $50.00 |
| 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 $50.00 POS (Out-of-Network): Copayment for Medicare Covered Podiatry Services $50.00 |
| 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 Out-of-Network: $100.00 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): 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 |
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
|
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 |
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