Molina Medicare Choice Care (HMO)
Molina Medicare Choice Care (HMO) H9082-009 Plan Details
Molina Medicare Choice Care (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Molina Healthcare, Inc.,.
Plan ID: H9082-009.
$34.30
Monthly Premium
Molina Medicare Choice Care (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Molina Healthcare, Inc.,.
Plan ID: H9082-009.
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $480 |
| Out of Pocket Max |
In-Network: $7550 Out-of-Network: N/A |
| Initial Coverage Limit | $4430 |
| Catastrophic Coverage Limit | $7,050 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Coinsurance for Primary Care Office Visit 20% |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Coinsurance for Physician Specialist Office Visit 20% |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $0.00 per day for days 1 to 60 $335.00 per day for days 61 to 90 Deductible $1340.00 Prior Authorization Required for Acute Hospital Services Prior authorization required |
| Urgent Care | Coinsurance for Urgent Care 20% Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0.00 Maximum Plan Benefit of $10,000 |
| Emergency Room Visit | Coinsurance for Emergency Care 20% Coinsurance for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0.00 Copayment for Worldwide Emergency Transportation $0.00 Maximum Plan Benefit of $10,000 |
| Ambulance Transportation | In-Network: Ground Ambulance: Coinsurance for Ground Ambulance Services 20% Air Ambulance: Coinsurance for Air Ambulance Services 20% Prior authorization required for non-emergent ambulance only. Please see Evidence of Coverage for Prior Authorization rules Prior authorization required |
Health Care Services and Medical Supplies
Molina Medicare Choice Care (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: Coinsurance for Medicare-covered Chiropractic Services 20% Copayment for Routine Care $0.00
|
| 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 Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) Prior authorization required |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 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: Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20% Coinsurance for Medicare-covered Lab Services 20% 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 Prior Authorization Required for Home Health Services Prior authorization required |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $0.00 per day for days 1 to 60 $341.00 per day for days 61 to 90 Deductible $1364.00 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required |
| Mental Health Outpatient Care | In-Network: Coinsurance for Medicare-covered Individual Sessions 20% Coinsurance for Medicare-covered Group Sessions 20% Prior Authorization Required for Outpatient Mental Health Services Prior authorization required |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 20% Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Coinsurance for Medicare Covered Observation Services 20% Ambulatory Surgical Center Services: Coinsurance for Ambulatory Surgical Center Services 20% Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required |
| Outpatient Substance Abuse Care | In-Network: Coinsurance for Medicare-covered Individual Sessions 20% Coinsurance for Medicare-covered Group Sessions 20% Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required |
| 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 $465.00 every three months Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit |
| Podiatry Services | In-Network: Coinsurance for Medicare-Covered Podiatry Services 20% Prior Authorization Required for Podiatry Services Prior authorization required |
| 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 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 $3500.00 every year for Preventive and Non-Medicare Covered Comprehensive combined Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00 Maximum Plan Allowance of $3500.00 every year for Preventive and Non-Medicare Covered Comprehensive combined Prior Authorization Required for Comprehensive Dental Prior authorization required |
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 Plan Benefit of $250.00 every year for Eye Exams and Eyewear combined Eyewear: Copayment for Medicare-Covered Benefits $0.00 Copayment for Contact Lenses $0.00 Copayment for Eyeglasses (lenses and frames) $0.00 Copayment for Eyeglass Lenses $0.00 Copayment for Eyeglass Frames $0.00 Copayment for Upgrades $0.00 Prior Authorization Required for Eyewear Prior authorization required |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Coinsurance for Medicare Covered Benefits 20% Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for Hearing Aids $0.00 Maximum Plan Benefit of $2500.00 every two years both ears combined Prior Authorization Required for Hearing Aids Prior authorization required |
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 Molina Medicare Choice Care (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $480 (excludes Tier 1) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $480 (excludes Tier 1) |
| Preferred Generic |
|
| Annual Drug Deductible | $480 (excludes Tier 1) |
| Preferred Generic |
|
| Annual Drug Deductible | $480 (excludes Tier 1) |
| Preferred Generic |
|
