PrimeTime Health Plan Basic - MA Only (HMO-POS)

PrimeTime Health Plan Basic - MA Only (HMO-POS) H3664-014 Plan Details
4.5 out of 5 stars

PrimeTime Health Plan Basic - MA Only (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aultman Health Foundation.
Plan ID: H3664-014.

$0.00
Monthly Premium

PrimeTime Health Plan Basic - MA Only (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aultman Health Foundation.
Plan ID: H3664-014.

PrimeTime Health Plan Basic - MA Only (HMO-POS) H3664-014 Plan Details
4.5 out of 5 stars

PrimeTime Health Plan Basic - MA Only (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Aultman Health Foundation.
Plan ID: H3664-014.

$0.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $-1
Out of Pocket Max In-Network: $3400
Out-of-Network: 0
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 $40.00
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$275.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Urgent Care
Copayment for Urgent Care $65.00
Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 23 hours

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $85.00
Emergency Room Visit
Copayment for Emergency Care $85.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 23 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $85.00
Copayment for Worldwide Emergency Transportation $200.00
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $200.00

Air Ambulance:
Copayment for Air Ambulance Services $200.00

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required

Health Care Services and Medical Supplies

PrimeTime Health Plan Basic - MA Only (HMO-POS) 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 Testing Supplies 0% Coinsurance for other Medicare-covered Diabetic Supplies 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Prior Authorization Required for Diabetic Supplies and Services
Prior authorization required
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
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 $100.00
Copayment for Medicare-covered Lab Services $0.00 to $35.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $250.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $100.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required
POS (Out-of-Network):

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare Covered Lab Services $0.00 to $35.00
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $20.00
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$175.00 per day for days 1 to 10
$0.00 per day for days 11 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $35.00
Copayment for Medicare-covered Group Sessions $35.00
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 25%
Maximum out of Pocket $1200.00 every year
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Coinsurance for Medicare Covered Observation Services 25%
Maximum out of Pocket $1200.00 every year
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Coinsurance for Ambulatory Surgical Center Services 25%
Maximum out of Pocket $1200.00 every year
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $35.00
Copayment for Medicare-covered Group Sessions $35.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $35.00
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$20.00 per day for days 1 to 20
$150.00 per day for days 21 to 39
$0.00 per day for days 40 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 Non-Medicare Covered Preventive Dental $0.00*

Copayment for Non-Medicare Covered Comprehensive Dental $0.00*

*Maximum Plan Benefit of $300.00 every year combined with vision services

Comprehensive Dental:
Copayment for Medicare-covered Benefits $40.00
Copayment for Non-Medicare Covered Preventive Dental $0.00*
Copayment for Non-Medicare Covered Comprehensive Dental $0.00*

*Maximum Plan Benefit of $300.00 every year combined with vision services
Prior Authorization Required for Comprehensive Dental

POS (Out-of-Network):

Non-Medicare Covered Dental Services:
Copayment for Non-Medicare Covered Preventive Dental $0.00*
Copayment for Non-Medicare Covered Comprehensive Dental $0.00*
*Maximum Plan Benefit of $300.00 every year combined with vision services
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 $40.00
Copayment for Routine Eye Exams $0.00*
Eyewear:
Coinsurance for Medicare-Covered Benefits 20%
Copayment for Contact Lenses $0.00*
Copayment for Eyeglasses (lenses and frames) $0.00*

POS (Out-of-Network):

Non-Medicare Covered Vision Services:
Copayment for Non-Medicare Covered Eye Exams $0.00*
Copayment for Non-Medicare Covered Eyewear $0.00*
*Maximum Plan Benefit of $300.00 every year combined with dental services

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 three years

Hearing Aids:
Copayment for Hearing Aids $595.00 to $895.00
  • Maximum 2 Hearing Aids every three years
Hearing aids purchased from an Amplifon provider have a minimum copayment of $595 and maximum copayment of $895 per hearing aid every three years dependent on the brand and model selected. Hearing aids purchased from a non-Amplifon provider receive up to $100 reimbursement per hearing aid every three years.

POS (Out-of-Network):

Non-Medicare Covered Hearing Services:
Copayment for Non-Medicare Covered Hearing Exams $0.00
Copayment for Non-Medicare Covered Hearing Aids $0.00
Hearing aids purchased from a non-Amplifon provider receive up to $100 reimbursement per hearing aid every three 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:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit