Health Alliance NW SignalAdvantage POS Basic Rx (HMO-POS)

Health Alliance NW SignalAdvantage POS Basic Rx (HMO-POS) H3471-019 Plan Details
3 out of 5 stars

Health Alliance NW SignalAdvantage POS Basic Rx (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by The Carle Foundation
Plan ID: H3471-019

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

$0.00
Monthly Premium

Health Alliance NW SignalAdvantage POS Basic Rx (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by The Carle Foundation
Plan ID: H3471-019

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Health Alliance NW SignalAdvantage POS Basic Rx (HMO-POS) H3471-019 Plan Details
3 out of 5 stars

Health Alliance NW SignalAdvantage POS Basic Rx (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by The Carle Foundation
Plan ID: H3471-019

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

$0.00
Monthly Premium

Washington Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $3800
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 $0.00
POS (Out-of-Network):

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $25.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $45.00
POS (Out-of-Network):

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $10.00 to $65.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$370.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Out-of-Network:
$500.00 per day for days 1 to 20
$0.00 per day for days 21 to 90
Urgent Care
Copayment for Urgent Care $40.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $40.00
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 $500.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $500.00

Air Ambulance:
Copayment for Air Ambulance Services $500.00

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

Health Care Services and Medical Supplies

Health Alliance NW SignalAdvantage 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 $10.00 to $65.00
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 $30.00
Copayment for Medicare-covered Lab Services $0.00 to $30.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $375.00
Copayment for Medicare-covered Therapeutic Radiological Services $60.00
Copayment for Medicare-covered X-Ray Services $15.00
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

Out-of-Network:
Coinsurance for Medicare-covered Home Health Services 50%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$500.00 per day for days 1 to 3
$0.00 per day for days 4 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $10.00
Copayment for Medicare-covered Group Sessions $10.00
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 $350.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services $55.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $350.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $10.00
Copayment for Medicare-covered Group Sessions $10.00
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $45.00
POS (Out-of-Network):
Copayment for Medicare Covered Podiatry Services $10.00 to $65.00
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

POS (Out-of-Network):

Skilled Nursing Facility Services:
$225.00 per day for days 1 to 45
$0 per day for days 46 to 100
Prior Authorization 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 $750.00 every year for Preventive and Non-Medicare Covered Comprehensive combined
Referral Required for Preventive Dental

Comprehensive Dental:
Maximum Plan Allowance of $750.00 every year for Preventive and Non-Medicare Covered Comprehensive combined
POS (Out-of-Network):

Non-Medicare Covered Dental Services:
Copayment for Non-Medicare Covered Preventive Dental $0.00
Copayment for Non-Medicare Covered Comprehensive Dental $0.00
Maximum Plan Benefit of $750.00 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
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
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 $40.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00

Hearing Aids:
Copayment for Hearing Aids $699.00 to $999.00
  • Maximum 2 Hearing Aids every year

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:
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
Tobacco use cessation
Yearly "Wellness" visit