The Health Plan SecureCare Capitol Plan (HMO)

The Health Plan SecureCare Capitol Plan (HMO) H3672-023 Plan Details
4 out of 5 stars

The Health Plan SecureCare Capitol Plan (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Health Plan of the Upper Ohio Valley.
Plan ID: H3672-023.

$0.00
Monthly Premium

The Health Plan SecureCare Capitol Plan (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Health Plan of the Upper Ohio Valley.
Plan ID: H3672-023.

The Health Plan SecureCare Capitol Plan (HMO) H3672-023 Plan Details
4 out of 5 stars

The Health Plan SecureCare Capitol Plan (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Health Plan of the Upper Ohio Valley.
Plan ID: H3672-023.

$0.00
Monthly Premium

West Virginia Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $100
Out of Pocket Max In-Network: $6700
Out-of-Network: N/A
Initial Coverage Limit $4430
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 $45.00
Prior Authorization Required for Doctor Specialty Visit
Prior authorization required
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$265.00 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
Urgent Care
Copayment for Urgent Care $45.00
Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours
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
Copayment for Worldwide Emergency Transportation $250.00 to $500.00
Maximum Plan Benefit of $25,000
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $250.00

Air Ambulance:
Copayment for Air Ambulance Services $500.00

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

Health Care Services and Medical Supplies

The Health Plan SecureCare Capitol Plan (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:
Copayment for Medicare-covered Chiropractic Services $20.00
Prior Authorization Required for Chiropractic Services
Prior authorization required
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $7.50
Coinsurance for Medicare-covered Diabetic Supplies 0% to 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
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
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 $50.00
Copayment for Medicare-covered Lab Services $0.00

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $150.00
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
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:
$265.00 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
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
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 to $250.00
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 $250.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $45.00
Copayment for Medicare-covered Group Sessions $45.00
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
Maximum Plan Benefit of $60.00 every three months
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $45.00
Copayment for Routine Foot Care $45.00
  • Maximum 2 visits every year
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
$178.00 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:
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 (Please see Evidence of Coverage for details)

Comprehensive Dental:
Copayment for Medicare-covered Benefits $45.00
Coinsurance for Restorative Services 20% to 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Endodontics 50%
Coinsurance for Periodontics 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Extractions 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services 50%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $1000.00 every year for Non-Medicare Covered Comprehensive
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 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Contact Lenses $0.00
  • Maximum 1 Pair every two years
Copayment for Eyeglass Lenses $0.00
  • Maximum 1 Pair every two years
Copayment for Eyeglass Frames $0.00
  • Maximum 1 Pair every two years
Maximum Plan Benefit of $100.00 every two years 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 $45.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00

Hearing Aids:
Copayment for Hearing Aids $599.00 to $899.00
  • Maximum 2 Hearing Aids every two years
Up to two TruHearing-branded hearing aids every 2 years (one per ear every 2 years). Benefit is limited to TruHearing's Advanced and Premium hearing aids, which come in various styles and colors. Premium hearing aids are available in rechargeable style options for an additional $50 per aid. You must see a TruHearing provider to use this benefit. Hearing aid purchase includes: - First year of follow-up provider visits - 60-day trial period - 3-year extended warranty - 2-year supply of batteries per hearing aid for non-rechargeable models Benefit does not include or cover any of the following: - Additional cost for optional hearing aid rechargeability - Ear molds - Hearing aid accessories - Additional provider visits - Additional batteries, batteries when a rechargeable hearing aid is purchased - Hearing aids that are not TruHearing-branded hearing aids - Costs associated with loss and damage warranty claims Costs associated with excluded items are th

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

    Prescription Drug Costs and Coverage

    The The Health Plan SecureCare Capitol Plan (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $100 (excludes Tiers 1 and 2) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $100 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $3.00
    • Standard retail $13.00
    • Preferred mail order $3.00
    • Standard mail order $13.00
    Generic
    • Preferred retail $10.00
    • Standard retail $20.00
    • Preferred mail order $10.00
    • Standard mail order $20.00
    Annual Drug Deductible $100 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $6.00
    • Standard retail $26.00
    • Preferred mail order $0.00
    • Standard mail order $26.00
    Generic
    • Preferred retail $20.00
    • Standard retail $40.00
    • Preferred mail order $0.00
    • Standard mail order $40.00
    Annual Drug Deductible $100 (excludes Tiers 1 and 2)
    Preferred Generic
    • Preferred retail $9.00
    • Standard retail $39.00
    • Preferred mail order $0.00
    • Standard mail order $39.00
    Generic
    • Preferred retail $30.00
    • Standard retail $60.00
    • Preferred mail order $0.00
    • Standard mail order $60.00