Molina Medicare Complete Care Select (HMO D-SNP)

Molina Medicare Complete Care Select (HMO D-SNP) H5628-012 Plan Details
3 out of 5 stars

Molina Medicare Complete Care Select (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Molina Healthcare, Inc.,
Plan ID: H5628-012

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

$30.80
Monthly Premium

Molina Medicare Complete Care Select (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Molina Healthcare, Inc.,
Plan ID: H5628-012

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Molina Medicare Complete Care Select (HMO D-SNP) H5628-012 Plan Details
3 out of 5 stars

Molina Medicare Complete Care Select (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Molina Healthcare, Inc.,
Plan ID: H5628-012

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

$30.80
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $8850
Out-of-Network: N/A
Initial Coverage Limit $0
Catastrophic Coverage Limit $8,000
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 $0.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
Our plan covers 90 days for a hospital stay per benefit period. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days per benefit period, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days per benefit period.
  • $325 copay per day for days 1 through 6 of the benefit period.
  • $0 copay per day for days 7 through 90 of the benefit period.
  • $0 copay for Medicare-covered lifetime reserve days
Prior authorization may be required.
Prior authorization required
Urgent Care
Copayment for Urgent Care $0.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0.00
Maximum Plan Benefit of $10,000
Emergency Room Visit
Copayment for Emergency Care $0.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $0.00
Copayment for Worldwide Emergency Transportation $0.00
Maximum Plan Benefit of $10,000

Health Care Services and Medical Supplies

Molina Medicare Complete Care Select (HMO D-SNP) 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 $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:
Copayment for Medicare-covered Durable Medical Equipment $0.00
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:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00
Copayment for Medicare-covered Lab Services $0.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00
Copayment for Medicare-covered Therapeutic Radiological Services $0.00
Copayment for Medicare-covered X-Ray Services $0.00
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
Please see Evidence of Coverage for Additional Home Health Benefits
Prior authorization required
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.
Our plan covers 90 days for an inpatient hospital stay. Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.
In 2023 the amounts for each benefit period were $0 or:
  • $1,600 deductible per benefit period
  • $0 for the first 60 days of each benefit period
  • $400 per day for days 61–90 of each benefit period
  • $800 per “lifetime reserve day” after day 90 of each benefit period (up to a maximum of 60 days over your lifetime)
These amounts may change for 2024.
Prior authorization may be required.
Prior authorization required
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services $0.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00
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
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $0.00
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 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:
Copayment for Oral Exams $0.00
  • Maximum 2 visits every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 2 visits every year
Copayment for Fluoride Treatment $0.00
  • Maximum 2 visits every year
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Comprehensive Dental:
Maximum Plan Allowance of $1000.00 every year for Non-Medicare Covered Comprehensive

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:
Copayment for Medicare-Covered Benefits $0.00
Maximum Plan Allowance of $500.00 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 $0.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 1 visit every year

Hearing Aids:
Copayment for Hearing Aids $0.00
  • Maximum 2 Hearing Aids every two years

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:
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
Tobacco use cessation
Yearly "Wellness" visit