Wellcare No Premium Open (PPO)

WellCare Health Plans, Inc.
Wellcare No Premium Open (PPO) H0088-003 Plan Details
Plan too new to be measured

Wellcare No Premium Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H0088-003.

$0.00
Monthly Premium

Wellcare No Premium Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H0088-003.

WellCare Health Plans, Inc.
Wellcare No Premium Open (PPO) H0088-003 Plan Details
Plan too new to be measured

Wellcare No Premium Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H0088-003.

$0.00
Monthly Premium

New York Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $6700
Out-of-Network: 7600
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
$0 copay

Out-of-Network
$25
Specialty Doctor Visit
$40

Out-of-Network
$60
Inpatient Hospital Care
$325 copay per day for days 1-6 and a $0 copay per day for days 7-90

Out-of-Network
30% of the total cost for days 1-90
Urgent Care
$35

Out-of-Network
$35
Emergency Room Visit
$90

Out-of-Network
$90
Ambulance Transportation
$285

Out-of-Network
$285

Health Care Services and Medical Supplies

Wellcare No Premium Open (PPO) 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. $20 / unlimited visits every year in addition to Medicare covered.

Out-of-Network
Medicare Covered Chiropractic Services: 30% per visit. 30% / unlimited 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%

Out-of-Network
Diabetes Supplies: 20% / Diabetes Self-Management Training: $0 / Diabetic Therapeutic Shoes or Inserts: 20%
Durable Medical Eqipment (DME)
20%

Out-of-Network
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.

Out-of-Network
X-Ray Services: 30% / Lab Services: 30%. $0 for COVID-related testing. For other services, please refer to the Evidence of Coverage for more information.
Home Health Care
$0 copay

Out-of-Network
30%
Mental Health Inpatient Care
$300 copay per day for days 1-6 and a $0 copay per day for days 7-90

Out-of-Network
30% of the total cost for days 1-90
Mental Health Outpatient Care
$25 for individual or group

Out-of-Network
30% for individual or group
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $300.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $90.00 to $300.00
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
Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 30%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 30%
Outpatient Substance Abuse Care
$25 for individual or group

Out-of-Network
30% for individual or group
Over-the-counter (OTC) Items
$85 every quarter OTC Retail/Catalog. Unused amounts do not carry over to the next month/quarter.

Out-of-Network
$85 every quarter OTC Retail/Catalog. Unused amounts do not carry over to the next month/quarter.
Podiatry Services
Medicare Covered Podiatry Services: $40

Out-of-Network
Medicare Covered Podiatry Services: $60
Skilled Nursing Facility Care
$0 copay per day for days 1-20 and a $165 copay per day for days 21-100

Out-of-Network
$0 copay per day for days 1-20 and a $250 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 $1000, 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.

Out-of-Network
The dental benefits on this plan include coverage of preventive and comprehensive services up to $1000, 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 50% member cost-share.

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

Out-of-Network
The vision benefits on this plan cover routine eye exams and up to $200 with a 40% coinsurance for all services and eyewear received OON, 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 $1,500 a year towards hearing aids A maximum of one hearing aid per ear will apply

Out-of-Network
The hearing benefits on this plan include, but are not limited to, an annual exam, hearing aid fitting and evaluation with a 40% coinsurance OON, and up to $1,500 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.

Out-of-Network
Most services offered at $0 cost share, please refer to your Evidence of Coverage for more information.