Medica Advantage Solution with CHI Health (HMO)

Medica Advantage Solution with CHI Health (HMO) H0798-001 Plan Details
Plan too new to be measured

Medica Advantage Solution with CHI Health (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Medica Holding Company.
Plan ID: H0798-001.

$0.00
Monthly Premium

Medica Advantage Solution with CHI Health (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Medica Holding Company.
Plan ID: H0798-001.

Medica Advantage Solution with CHI Health (HMO) H0798-001 Plan Details
Plan too new to be measured

Medica Advantage Solution with CHI Health (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Medica Holding Company.
Plan ID: H0798-001.

$0.00
Monthly Premium

Iowa Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $245
Out of Pocket Max In-Network: $4000
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $45.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$350.00 per day for days 1 to 5
$0.00 per day for days 6 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Urgent Care
Copayment for Urgent Care $0.00 to $45.00

The Minimum copayment amount applies to care received at select retail Convenience Care clinics. The Maximum copayment amount applies to care received at traditional Urgent Care Centers and all other retail Convenience Care clinics.
Emergency Room Visit
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 1 days

Worldwide Coverage:
Coinsurance for Worldwide Emergency Coverage 20%
Coinsurance for Worldwide Emergency Transportation 20%
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $250.00

Air Ambulance:
Coinsurance for Air Ambulance Services 20%

Health Care Services and Medical Supplies

Medica Advantage Solution with CHI Health (HMO) 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
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Coinsurance for Medicare-covered Diabetic Supplies 0% to 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 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
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20%
Copayment for Medicare-covered Lab Services $0.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Coinsurance for Medicare-covered Diagnostic Radiological Services 20%
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Coinsurance for Medicare-covered X-Ray Services 20%
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
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$350.00 per day for days 1 to 5
$0.00 per day for days 6 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
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $395.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per day $350.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $295.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $20.00
Copayment for Medicare-covered Group Sessions $20.00
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 $50.00 every three months
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $45.00
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$184.00 per day for days 21 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 $600.00 every year for Preventive and Non-Medicare Covered Comprehensive combined

Comprehensive Dental:
Coinsurance for Medicare-covered Benefits 20%
Maximum Plan Allowance of $600.00 every year for Preventive and Non-Medicare Covered Comprehensive combined

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 to $45.00
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 $100.00 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
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00 to $50.00
  • Maximum 3 visits every year

Hearing Aids:
Copayment for Hearing Aids $549.00 to $799.00
The Minimum copayment amount applies to private label Basic level hearing aid. The Maximum copayment amount applies to private label Reserve level hearing aid.

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

    Prescription Drug Costs and Coverage

    The Medica Advantage Solution with CHI Health (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $245 (excludes Tiers 1, 2 and 3) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $245 (excludes Tiers 1, 2 and 3)
    Preferred Generic
    • Preferred retail $0.00
    • Standard retail $10.00
    • Preferred mail order $0.00
    • Standard mail order $10.00
    Generic
    • Preferred retail $14.00
    • Standard retail $20.00
    • Preferred mail order $14.00
    • Standard mail order $20.00
    Preferred Brand
    • Preferred retail $47.00
    • Standard retail $47.00
    • Preferred mail order $47.00
    • Standard mail order $47.00
    Annual Drug Deductible $245 (excludes Tiers 1, 2 and 3)
    Preferred Generic
    • Preferred retail $0.00
    • Standard retail $20.00
    • Preferred mail order $0.00
    • Standard mail order $20.00
    Generic
    • Preferred retail $28.00
    • Standard retail $40.00
    • Preferred mail order $28.00
    • Standard mail order $40.00
    Preferred Brand
    • Preferred retail $94.00
    • Standard retail $94.00
    • Preferred mail order $94.00
    • Standard mail order $94.00
    Annual Drug Deductible $245 (excludes Tiers 1, 2 and 3)
    Preferred Generic
    • Preferred retail $0.00
    • Standard retail $30.00
    • Preferred mail order $0.00
    • Standard mail order $30.00
    Generic
    • Preferred retail $42.00
    • Standard retail $60.00
    • Preferred mail order $0.00
    • Standard mail order $60.00
    Preferred Brand
    • Preferred retail $141.00
    • Standard retail $141.00
    • Preferred mail order $131.00
    • Standard mail order $141.00