Wellcare No Premium (HMO)
Wellcare No Premium (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H0562-012.
Wellcare No Premium (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H0562-012.
Wellcare No Premium (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H0562-012.
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $3000 Out-of-Network: N/A |
| Initial Coverage Limit | $4430 |
| Catastrophic Coverage Limit | $7,050 |
| Primary Care Doctor Visit | $0 copay |
| Specialty Doctor Visit | $10 |
| Inpatient Hospital Care | $180 copay per day for days 1-5 and a $0 copay per day for days 6-90 |
| Urgent Care | $10 |
| Emergency Room Visit | $120 |
| Ambulance Transportation | $270 |
Health Care Services and Medical Supplies
Wellcare No Premium (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 | Medicare Covered Chiropractic Services: $0 per visit. $0 / 24 visits every year in addition to Medicare covered. |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | Diabetes Supplies: $0 / Diabetes Self-Management Training: $0 / Diabetic Therapeutic Shoes or Inserts: 20% |
| Durable Medical Eqipment (DME) | 20% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | X-Ray Services: $0 / Lab Services: $0. $0 for COVID-related testing. For other services, please refer to the Evidence of Coverage for more information. |
| Home Health Care | $0 copay |
| Mental Health Inpatient Care | $900 copay per stay |
| Mental Health Outpatient Care | $25 for individual or group |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $225.00 Prior Authorization Required for Outpatient Hospital Services Referral Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $120.00 to $225.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $150.00 Prior Authorization Required for Ambulatory Surgical Center Services Referral Required for Ambulatory Surgical Center Services Prior authorization required |
| Outpatient Substance Abuse Care | $25 for individual or group |
| Over-the-counter (OTC) Items | $40 every quarter OTC Retail/Catalog. Unused amounts do not carry over to the next month/quarter. |
| Podiatry Services | Medicare Covered Podiatry Services: $10 / Routine Podiatry Services: $10 for 12 visits every year. |
| Skilled Nursing Facility Care | $0 copay per day for days 1-20 and a $75 copay per day for days 21-100 |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | This plan does not offer supplemental dental coverage. |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | The vision benefits on this plan cover routine eye exams and up to $400 for unlimited contacts, glasses, lenses, and/or frames per year |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | The hearing benefits on this plan include, but are not limited to, an annual exam, hearing aid fitting and evaluation, and up to $1000 a year towards hearing aids A maximum of one hearing aid per ear will apply |
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 | Most services offered at $0 cost share, please refer to your Evidence of Coverage for more information. |
