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Wellcare No Premium (HMO)

WellCare Health Plans, Inc.
Wellcare No Premium (HMO) H3499-002 Plan Details
Plan too new to be measured

Wellcare No Premium (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H3499-002.

$0.00
Monthly Premium

Wellcare No Premium (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H3499-002.

WellCare Health Plans, Inc.
Wellcare No Premium (HMO) H3499-002 Plan Details
Plan too new to be measured

Wellcare No Premium (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H3499-002.

$0.00
Monthly Premium

Indiana Counties Served

Adams Allen Bartholomew Blackford Boone Brown Carroll Cass Clark Clinton Crawford Daviess Dearborn Delaware Dubois Elkhart Floyd Fulton Grant Greene Hamilton Hancock Harrison Hendricks Henry Howard Jackson Jay Jefferson Johnson Knox Kosciusko La Porte Lake Lawrence Madison Marion Marshall Martin Miami Monroe Morgan Newton Ohio Orange Owen Perry Pike Porter Posey Putnam Ripley Scott Shelby St. Joseph Starke Steuben Sullivan Switzerland Tippecanoe Tipton Vanderburgh Warrick Wells White Whitley

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $3900
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
$0 copay
Specialty Doctor Visit
$35
Inpatient Hospital Care
$295 copay per day for days 1-6 and a $0 copay per day for days 7-90
Urgent Care
$25
Emergency Room Visit
$90
Ambulance Transportation
$285

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: $20 per visit
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
$295 copay per day for days 1-5 and a $0 copay per day for days 6-90
Mental Health Outpatient Care
$40 for individual or group
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $275.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $90.00 to $275.00
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
$40 for individual or group
Over-the-counter (OTC) Items
$65 every quarter OTC Retail/Catalog. Unused amounts do not carry over to the next month/quarter.
Podiatry Services
Medicare Covered Podiatry Services: $35 / Routine Podiatry Services: $35 for 12 visits every year.
Skilled Nursing Facility Care
$0 copay per day for days 1-20 and a $184 copay per day for days 21-100

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
The dental benefits on this plan include coverage of preventive and comprehensive services up to $1500, including but not limited to cleanings, x-ray(s), oral exams, fluoride treatments, fillings, dentures or a bridge or a crown and a root canal with a 40% member cost-share for comprehensive and $0 co-pay for preventive services.

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 $200 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 $2000 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.
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