Medica Prime Solution Standard (Cost)
Medica Prime Solution Standard (Cost) H2450-044 Plan Details
Medica Prime Solution Standard (Cost) is a Medicare Advantage (Medicare Part C) plan offered by Medica Holding Company.
Plan ID: H2450-044.
$0.00
Monthly Premium
Medica Prime Solution Standard (Cost) is a Medicare Advantage (Medicare Part C) plan offered by Medica Holding Company.
Plan ID: H2450-044.
Minnesota Counties Served
Nebraska Counties Served
Adams
Antelope
Boone
Boyd
Buffalo
Burt
Cedar
Cheyenne
Clay
Colfax
Cuming
Custer
Dakota
Dawes
Dixon
Fillmore
Franklin
Frontier
Furnas
Gage
Garfield
Gosper
Greeley
Hall
Hamilton
Harlan
Holt
Howard
Jefferson
Johnson
Kearney
Keya Paha
Knox
Loup
Madison
Merrick
Nance
Nemaha
Nuckolls
Otoe
Pawnee
Phelps
Pierce
Platte
Polk
Rock
Saline
Seward
Sherman
Stanton
Thayer
Thurston
Valley
Wayne
Webster
Wheeler
York
North Dakota Counties Served
Adams
Barnes
Benson
Billings
Bowman
Burleigh
Cass
Cavalier
Dickey
Dunn
Eddy
Emmons
Foster
Grand Forks
Grant
Griggs
Hettinger
Kidder
LaMoure
Logan
McHenry
McIntosh
McLean
Mercer
Morton
Nelson
Oliver
Pembina
Pierce
Ramsey
Ransom
Richland
Rolette
Sargent
Sheridan
Sioux
Slope
Stark
Steele
Stutsman
Towner
Traill
Walsh
Ward
Wells
Williams
South Dakota Counties Served
Aurora
Beadle
Bennett
Bon Homme
Brookings
Brown
Brule
Buffalo
Butte
Campbell
Charles Mix
Clark
Clay
Codington
Corson
Custer
Davison
Day
Deuel
Dewey
Douglas
Edmunds
Fall River
Faulk
Grant
Gregory
Haakon
Hamlin
Hand
Hanson
Harding
Hughes
Hutchinson
Hyde
Jackson
Jerauld
Jones
Kingsbury
Lake
Lawrence
Lincoln
Lyman
Marshall
McCook
McPherson
Meade
Mellette
Miner
Minnehaha
Moody
Oglala Lakota
Pennington
Perkins
Potter
Roberts
Sanborn
Spink
Stanley
Sully
Todd
Tripp
Turner
Union
Walworth
Yankton
Ziebach
Basic Costs and Coverage
Coverage | Cost |
---|---|
Monthly Deductible | $-1 |
Out of Pocket Max |
In-Network: $-1 Out-of-Network: 4500 |
Initial Coverage Limit | $0 |
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 $35.00 |
Inpatient Hospital Care | In-Network: Acute Hospital Services: $280.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 |
Urgent Care | Copayment for Urgent Care $0.00 to $35.00 Minimum copayment amount applies to care received at retail Convenience Care clinics. Maximum copayment amount applies to care received at traditional Urgent Care Centers. |
Emergency Room Visit | Copayment for Emergency Care $90.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $90.00 |
Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $200.00 Air Ambulance: Copayment for Air Ambulance Services $400.00 |
Health Care Services and Medical Supplies
Medica Prime Solution Standard (Cost) 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 20% Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% Maximum out of Pocket $35.00 (Please see Evidence of Coverage fo |
Durable Medical Eqipment (DME) | In-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 to $35.00 Copayment for Medicare-covered Lab Services $0.00 Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $35.00 to $150.00 Copayment for Medicare-covered Therapeutic Radiological Services $35.00 to $150.00 Copayment for Medicare-covered X-Ray Services $0.00 to $35.00 |
Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 |
Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $280.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 |
Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $30.00 Copayment for Medicare-covered Group Sessions $30.00 |
Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $200.00 Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $200.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $150.00 |
Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $30.00 Copayment for Medicare-covered Group Sessions $30.00 |
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 $25.00 every three months |
Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $35.00 |
Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $170.50 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 $500.00 every year for Preventive and Non-Medicare Covered Comprehensive combined Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00 to $35.00 Maximum Plan Allowance of $500.00 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 $35.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $45.00 Maximum Plan Allowance of $150.00 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 $35.00 Copayment for Routine Hearing Exams $0.00 to $35.00
Maximum Plan Benefit of $600.00 every yearfor Exams and Hearing Aids combined Hearing Aids: Copayment for Hearing Aids $0.00 There is no provider network for this service category. Hearing Aids may be purchased in or out-of-network. |
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 |