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MercyOne Health Plan Cash Back (HMO)
The Centers for Medicare & Medicaid Services (CMS) publishes annual Star Ratings that reflect how each Medicare Advantage plan performs across a range of metrics, using a system of one to five stars.
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Monthly Premium
MercyOne Health Plan Cash Back (HMO) is a HMO plan offered by Trinity Health
Plan ID: H3668-031
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Medicare beneficiaries may find it helpful to review available Medicare Advantage plans in their area. Medicare Advantage plans are designed to combine the coverage offered from Original Medicare (Medicare Part A and Part B) while also offering additional benefits.
Many Medicare Advantage plans may cover prescription drug coverage as well as additional benefits such as Dental, Vision and Hearing.
Learn more about Medicare Advantage plans such as MercyOne Health Plan Cash Back (HMO) - H3668-031 by Trinity Health as well as other Medicare Advantage plans available in your area.
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Monthly Premium
Iowa Counties Served
AdairAdamsAppanooseBentonBlack HawkBooneBremerBuchananButlerCedarCerro GordoCherokeeChickasawClarkeClaytonClintonDallasDelawareFayetteFloydFranklinGreeneGrundyGuthrieHamiltonHancockHardinHenryHumboldtIdaJacksonJasperJonesKeokukKossuthLouisaLucasMadisonMahaskaMarionMitchellMononaMonroeMuscatinePlymouthPolkPoweshiekRinggoldScottSiouxTamaUnionWarrenWayneWinnebagoWoodburyWorthWright
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $275 |
| Out of Pocket Max |
In-Network: $6900 Out-of-Network: N/A |
| Initial Coverage Limit | $0 |
| Catastrophic Coverage Limit | $2000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $40 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $395 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Acute Hospital Services |
| Urgent Care | Urgent Care: Copayment for Urgent Care $45 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $110 |
| Emergency Room Visit | Emergency Care: Copayment for Emergency Care $110 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 48 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $110 Copayment for Worldwide Emergency Transportation $275 to $325 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $275 Prior Authorization is required if outside Medicare benefit parameters. Air Ambulance: Copayment for Air Ambulance Services $325 Prior Authorization Required for Air Ambulance Prior Authorization is required for Non Emergency Fixed Wing, Rotary Wing ambulance services. |
Health Care Services and Medical Supplies
MercyOne Health Plan Cash Back (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: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Prior Authorization Required for Chiropractic Services Prior Authorization is required if exceeds Medicare benefit limits. |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% |
| Durable Medical Equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment Prior Authorization is required for Power Mobility Devices. |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $50 Copayment for Medicare-covered Lab Services $10 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Prior Authorization is required for Oncology Services and Genetic testing. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $295 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $20 |
| Home Health Care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $395 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services |
| Mental Health Outpatient Care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $10 to $400 The minimum cost share applies to services received in Coumadin Clinics. The Specialist Services cost share applies to services received in Respiratory Therapy Departments or other Outpatient Hospital Service Departments not otherwise noted in an alternative PBP benefit category. The maximum cost share applies to Outpatient Hospital Surgery Department services.If multiple outpatient services are received from the same provider on the same date, the service with the highest copayment will apply for that day.There is no copayment for outpatient observation stays, however, a copayment does apply for outpatient services rendered during the observation stay. The outpatient service with the highest copayment will apply each day. Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $400 |
| Outpatient Substance Abuse Care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0
|
| Podiatry Services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $40 |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 55 $0 per day for days 56 to 100 Notification will be required within two days of admission. |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Copayment for Medicare-Covered Services $40 Preventive Dental: Copayment for Preventive Dental $0; includes the following services:
Comprehensive Dental: Coinsurance for Restorative Services 50% Coinsurance for Oral and Maxillofacial Surgery (Extractions) 50% Copayment for Adjunctive General Services $0 Maximum Plan Benefit of $1,000 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 to $40 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Maximum Plan Allowance of $150 every year |
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 Copayment for Routine Hearing Exams $0
Hearing Aids: Copayment for Hearing Aids $599 per ear for TruHearing Advanced, $899 per ear for TruHearing Premium
|
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 |
Prescription Drug Costs and Coverage
The MercyOne Health Plan Cash Back (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $275 (excludes Tiers 1 and 2) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $275 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $275 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|
| Annual Drug Deductible | $275 (excludes Tiers 1 and 2) |
| Preferred Generic |
|
| Generic |
|