Wellcare Patriot Giveback Open (PPO)
Wellcare Patriot Giveback Open (PPO) H6348-005 Plan Details
Wellcare Patriot Giveback Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H6348-005.
$0.00
Monthly Premium
Wellcare Patriot Giveback Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H6348-005.
Wellcare Patriot Giveback Open (PPO) H6348-005 Plan Details
Wellcare Patriot Giveback Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H6348-005.
$0.00
Monthly Premium
Indiana Counties Served
Adams
Allen
Bartholomew
Benton
Blackford
Boone
Brown
Carroll
Cass
Clark
Clay
Clinton
Crawford
Daviess
Dearborn
Decatur
Delaware
Dubois
Elkhart
Floyd
Fountain
Franklin
Fulton
Gibson
Grant
Greene
Hamilton
Hancock
Harrison
Hendricks
Henry
Howard
Jackson
Jasper
Jay
Jefferson
Jennings
Johnson
Knox
La Porte
Lake
Lawrence
Madison
Marion
Martin
Miami
Monroe
Montgomery
Morgan
Newton
Ohio
Orange
Owen
Parke
Perry
Pike
Porter
Posey
Pulaski
Putnam
Randolph
Ripley
Scott
Shelby
Spencer
St. Joseph
Starke
Steuben
Sullivan
Switzerland
Tippecanoe
Tipton
Vanderburgh
Warren
Warrick
Washington
Wells
White
Whitley
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $-1 |
| Out of Pocket Max |
In-Network: $5500 Out-of-Network: 10000 |
| Initial Coverage Limit | $0 |
| Catastrophic Coverage Limit | $7,050 |
| Primary Care Doctor Visit | $5 Out-of-Network $50 |
| Specialty Doctor Visit | $40 Out-of-Network $50 |
| Inpatient Hospital Care | $400 copay per day for days 1-5 and a $0 copay per day for days 6-90 Out-of-Network 20% of the total cost for days 1-90 |
| Urgent Care | $40 Out-of-Network $40 |
| Emergency Room Visit | $90 Out-of-Network $90 |
| Ambulance Transportation | $300 Out-of-Network $300 |
Health Care Services and Medical Supplies
Wellcare Patriot Giveback 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 Out-of-Network Medicare Covered Chiropractic Services: 40% per visit |
| 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: 40% / Lab Services: 40%. $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 40% |
| Mental Health Inpatient Care | $350 copay per day for days 1-5 and a $0 copay per day for days 6-90 Out-of-Network 40% of the total cost for days 1-90 |
| Mental Health Outpatient Care | $25 for individual or group Out-of-Network $50 for individual or group |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $350.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $90.00 to $350.00 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 40% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40% |
| Outpatient Substance Abuse Care | $25 for individual or group Out-of-Network 40% for individual or group |
| Over-the-counter (OTC) Items | $100 every quarter OTC Retail/Catalog. Unused amounts do not carry over to the next month/quarter. Out-of-Network $100 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: $50 |
| Skilled Nursing Facility Care | $0 copay per day for days 1-20 and a $188 copay per day for days 21-100 Out-of-Network 40% of the total cost for days 1-100 |
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 $2000, 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 co-pay for preventive and 20% cost-share for comprehensive services. Out-of-Network The dental benefits on this plan include coverage of preventive and comprehensive services up to $2000, 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% 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 $2000 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 $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. Out-of-Network Most services offered at $0 cost share, please refer to your Evidence of Coverage for more information. |
