Wellcare Patriot Giveback (HMO)

WellCare Health Plans, Inc.
Wellcare Patriot Giveback (HMO) H0562-044 Plan Details
4 out of 5 stars

Wellcare Patriot Giveback (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H0562-044.

$0.00
Monthly Premium

Wellcare Patriot Giveback (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H0562-044.

WellCare Health Plans, Inc.
Wellcare Patriot Giveback (HMO) H0562-044 Plan Details
4 out of 5 stars

Wellcare Patriot Giveback (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H0562-044.

$0.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $-1
Out of Pocket Max In-Network: $3400
Out-of-Network: N/A
Initial Coverage Limit $0
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
$5
Specialty Doctor Visit
$10
Inpatient Hospital Care
$200 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
$125

Health Care Services and Medical Supplies

Wellcare Patriot Giveback (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: $10 per visit. $10 / 36 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 $200.00
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 $200.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $50.00
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
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 $100 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 cover hearing exams only

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.