MedMutual Advantage Access (PPO)

MedMutual Advantage Access (PPO) H4497-005 Plan Details
4.5 out of 5 stars

MedMutual Advantage Access (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by MEDICAL MUTUAL OF OHIO.
Plan ID: H4497-005.

$0.00
Monthly Premium

MedMutual Advantage Access (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by MEDICAL MUTUAL OF OHIO.
Plan ID: H4497-005.

MedMutual Advantage Access (PPO) H4497-005 Plan Details
4.5 out of 5 stars

MedMutual Advantage Access (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by MEDICAL MUTUAL OF OHIO.
Plan ID: H4497-005.

$0.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $5400
Out-of-Network: 11300
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $5.00
Out-of-Network:

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $20.00
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $40.00
Prior Authorization Required for Doctor Specialty Visit
Prior authorization required
Out-of-Network:

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $55.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$375.00 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
Out-of-Network:
Coinsurance for Acute Hospital Services per Stay 40%
Urgent Care
Copayment for Urgent Care $40.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $40.00
Maximum Plan Benefit of $50,000
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
Maximum Plan Benefit of $50,000
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $200.00

Air Ambulance:
Coinsurance for Air Ambulance Services 50%

Non-emergency air ambulance may require authorization. Please contact Plan for details.
Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $200.00
Coinsurance for Medicare Covered Ambulance Services - Air 50%

Health Care Services and Medical Supplies

MedMutual Advantage Access (PPO) 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 $10.00
Out-of-Network:
Copayment for Medicare Covered Chiropractic Services $15.00
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%
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 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Durable Medical Equipment 40%
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 $10.00
Copayment for Medicare-covered Lab Services $0.00 to $10.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $100.00 to $175.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $50.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40%
Coinsurance for Medicare Covered Lab Services 40%
Coinsurance for Medicare Covered Diagnostic Radiological Services 40%
Coinsurance for Medicare Covered Therapeutic Radiological Services 40%
Coinsurance for Medicare Covered Outpatient X-Ray Services 40%
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required
Out-of-Network:
Coinsurance for Medicare Covered Home Health 40%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$370.00 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
Out-of-Network:
Coinsurance for Psychiatric Hospital Services per Stay 40%
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Out-of-Network:
Copayment for Medicare Covered Individual Sessions $45.00
Copayment for Medicare Covered Group Sessions $45.00
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $420.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Coinsurance for Medicare Covered Observation Services 20%

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $350.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 40%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40%
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Out-of-Network:
Copayment for Medicare Covered Individual or Group Sessions $45.00
Over-the-counter (OTC) Items
Not Covered
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $40.00
Prior Authorization Required for Podiatry Services
Prior authorization required
Out-of-Network:
Copayment for Medicare Covered Podiatry Services $55.00
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$188.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:
Coinsurance for Skilled Nursing Facility Services per Stay 40%

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 2 visits every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 2 visits every year
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit every year

Comprehensive Dental:
Copayment for Medicare-covered Benefits $40.00
Coinsurance for Non-routine Services 30%
Coinsurance for Diagnostic Services 30%
Coinsurance for Restorative Services 30%
Coinsurance for Endodontics 50%
Coinsurance for Periodontics 50%
Coinsurance for Extractions 30%
Maximum Plan Benefit of $500.00 every year for in and out of network services combined for Non-Medicare Covered Comprehensive
Out-of-Network:

Medicare Covered Dental Services:
Copayment for Medicare Covered Comprehensive Dental $55.00
Non-Medicare Covered Dental Services:
Coinsurance for Non-Medicare Covered Preventive Dental 50%
Coinsurance for Non-Medicare Covered Comprehensive Dental 55% to 70%

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:
Coinsurance for Medicare-Covered Benefits 20%
Copayment for Contact Lenses $0.00
  • Maximum 1 Pair
Copayment for Eyeglasses (lenses and frames) $0.00
  • Maximum 1 Pair
Maximum Plan Benefit of $100.00 every year for all Non-Medicare covered eyewear for in and out of network services combined
Out-of-Network:

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 40%
Coinsurance for Medicare Covered Eyewear 40%
Non-Medicare Covered Vision Services:
Copayment for Non-Medicare Covered Eye Exams $50.00
Copayment for Non-Medicare Covered Eyewear $0.00

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 $0.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year

Hearing Aids:
Copayment for Hearing Aids $699.00 to $999.00
  • Maximum 2 Hearing Aids every year
We offer two tiers of hearing aids. A $699 copay applies to a standard hearing aid. A $999 copay applies to a premium hearing aid. Hearing aids are limited to one per ear per benefit period. You must see a contracted provider to use this benefit.
Out-of-Network:

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 40%
Non-Medicare Covered Hearing Services:
Copayment for Non-Medicare Covered Hearing Exams $0.00
Copayment for Non-Medicare Covered 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:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit
    Out-of-Network:

    Medicare-covered Zero Dollar Preventive Services:
    Coinsurance for Medicare Covered Medicare-covered Preventive Services 40%