Wellcare No Premium (HMO-POS)
Wellcare No Premium (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H1416-077.
$0.00
Monthly Premium
Wellcare No Premium (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H1416-077.
Tennessee Counties Served
Anderson
Bedford
Benton
Bledsoe
Blount
Bradley
Campbell
Cannon
Carroll
Carter
Cheatham
Chester
Claiborne
Clay
Cocke
Coffee
Crockett
Cumberland
Decatur
DeKalb
Dickson
Dyer
Fentress
Gibson
Giles
Grainger
Greene
Grundy
Hamblen
Hamilton
Hancock
Hardeman
Hardin
Hawkins
Haywood
Henderson
Henry
Hickman
Houston
Humphreys
Jackson
Jefferson
Johnson
Knox
Lake
Lauderdale
Lawrence
Lewis
Lincoln
Loudon
Macon
Madison
Marion
Marshall
Maury
McMinn
McNairy
Meigs
Monroe
Montgomery
Moore
Morgan
Obion
Overton
Perry
Pickett
Polk
Putnam
Rhea
Roane
Robertson
Rutherford
Scott
Sequatchie
Sevier
Smith
Stewart
Sullivan
Sumner
Trousdale
Unicoi
Union
Van Buren
Warren
Washington
Wayne
Weakley
White
Wilson
Basic Costs and Coverage
Coverage | Cost |
---|---|
Monthly Deductible | $0 |
Out of Pocket Max |
In-Network: $5500 Out-of-Network: 5500 |
Initial Coverage Limit | $4430 |
Catastrophic Coverage Limit | $7,050 |
Primary Care Doctor Visit | $0 copay |
Specialty Doctor Visit | $25 |
Inpatient Hospital Care | $300 copay per day for days 1-6 and a $0 copay per day for days 7-90 |
Urgent Care | $40 |
Emergency Room Visit | $90 |
Ambulance Transportation | $300 |
Health Care Services and Medical Supplies
Wellcare No Premium (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 | 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 | $300 copay per day for days 1-6 and a $0 copay per day for days 7-90 |
Mental Health Outpatient Care | $40 for individual or group |
Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $325.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $90.00 to $325.00 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 Prior authorization required POS (Out-of-Network): Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 40% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40% |
Outpatient Substance Abuse Care | $40 for individual or group |
Over-the-counter (OTC) Items | $205 every quarter OTC Retail/Catalog. Unused amounts do not carry over to the next month/quarter. |
Podiatry Services | Medicare Covered Podiatry Services: $25 |
Skilled Nursing Facility Care | $0 copay per day for days 1-20 and a $188 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 $0 member co-pay. |
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. |