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: H3499-002.
$0.00
Monthly Premium
Wellcare No Premium (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H3499-002.
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. |