Wellcare Patriot No Premium (HMO)
Wellcare Patriot No Premium (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H5294-014.
$0.00
Monthly Premium
Wellcare Patriot No Premium (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H5294-014.
Texas Counties Served
Aransas
Armstrong
Atascosa
Bailey
Bandera
Bastrop
Bee
Bexar
Blanco
Borden
Bosque
Briscoe
Brooks
Burnet
Caldwell
Calhoun
Cameron
Castro
Cochran
Coke
Collin
Colorado
Comal
Crosby
Dallas
Denton
DeWitt
Dickens
Dimmit
Donley
Duval
El Paso
Erath
Fayette
Fisher
Floyd
Garza
Gillespie
Glasscock
Goliad
Gonzales
Grayson
Grimes
Guadalupe
Hale
Hamilton
Hays
Hidalgo
Hill
Hockley
Hunt
Irion
Jack
Jim Hogg
Jim Wells
Karnes
Kendall
Kenedy
Kent
Kimble
Kleberg
La Salle
Lamb
Lee
Leon
Limestone
Lubbock
Lynn
Martin
Mason
Maverick
McCulloch
McMullen
Medina
Milam
Mills
Mitchell
Navarro
Nolan
Nueces
Palo Pinto
Real
Refugio
Rockwall
San Patricio
San Saba
Shackelford
Somervell
Starr
Sterling
Swisher
Tarrant
Terry
Throckmorton
Uvalde
Van Zandt
Victoria
Webb
Willacy
Williamson
Wilson
Zapata
Zavala
Basic Costs and Coverage
Coverage | Cost |
---|---|
Monthly Deductible | $-1 |
Out of Pocket Max |
In-Network: $3450 Out-of-Network: N/A |
Initial Coverage Limit | $0 |
Catastrophic Coverage Limit | $7,050 |
Primary Care Doctor Visit | $0 copay |
Specialty Doctor Visit | $25 |
Inpatient Hospital Care | $225 copay per day for days 1-5 and a $0 copay per day for days 6-90 |
Urgent Care | $40 |
Emergency Room Visit | $120 |
Ambulance Transportation | $250 |
Health Care Services and Medical Supplies
Wellcare Patriot 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 | $225 copay per day for days 1-5 and a $0 copay per day for days 6-90 |
Mental Health Outpatient Care | $25 for individual or group |
Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $225.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $120.00 to $225.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $175.00 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required |
Outpatient Substance Abuse Care | $25 for individual or group |
Over-the-counter (OTC) Items | $120 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 $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 $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 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 $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. |