Wellpoint Extra Help (HMO)
Wellpoint Extra Help (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Wellpoint
Plan ID: H5828-008
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Wellpoint Extra Help (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Wellpoint
Plan ID: H5828-008
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Tennessee Counties Served
Basic Costs and Coverage
Coverage | Cost |
---|---|
Monthly Deductible | $545 |
Out of Pocket Max |
In-Network: $4900 Out-of-Network: N/A |
Initial Coverage Limit | $5030 |
Catastrophic Coverage Limit | $8,000 |
Primary Care Doctor Visit | In-Network: $0.00 copay |
Specialty Doctor Visit | In-Network: $25.00 copay |
Inpatient Hospital Care | In-Network: Days 1-6: $295.00 per day, per admission / Days 7-90: $0.00 per day, per admission Additional Hospital Days: Unlimited additional days |
Urgent Care | Urgent Care: $35.00 copay |
Emergency Room Visit | Emergency Care: $90.00 copay Worldwide Coverage: This plan covers urgent care and emergency services when traveling outside of the United States for less than six months. This benefit is limited to $100,000.00 per year. |
Ambulance Transportation | Ground Ambulance: $235.00 copay Per Trip Air Ambulance: $235.00 copay |
Health Care Services and Medical Supplies
Wellpoint Extra Help (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 | In-Network: Medicare Covered Chiropractic Services: $20.00 copay |
Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies: $0.00 copay |
Durable Medical Eqipment (DME) | In-Network: 20% coinsurance |
Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Lab Services: $0.00 copay - $10.00 copay X-Rays: $50.00 copay - $90.00 copay Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: $0.00 copay - $90.00 copay Diagnostic Radiological Services: $90.00 copay - $200.00 copay |
Home Health Care | In-Network: $0.00 copay |
Mental Health Inpatient Care | In-Network: Days 1-6: $260.00 per day, per admission / Days 7-90: $0.00 per day, per admission Additional Hospital Days: Unlimited additional days |
Mental Health Outpatient Care | In-Network: Individual and Group Sessions: $25.00 copay |
Outpatient Services / Surgery | In-Network: Outpatient Hospital - Surgery: $275.00 copay Observation Services: $275.00 copay Ambulatory Surgical Center: $200.00 copay |
Outpatient Substance Abuse Care | In-Network: Individual and Group Sessions: $25.00 copay |
Over-the-counter (OTC) Items | This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $230 every quarter. Unused OTC amounts do roll over to the next quarter. Unused OTC amounts do not roll over to the next calendar year. |
Podiatry Services | In-Network: Medicare Covered Podiatry Services: $0.00 copay - $25.00 copay Routine Foot Care: $0.00 copay Unlimited routine foot care visits each year. |
Skilled Nursing Facility Care | In-Network: SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $203.00 per day |
Dental Benefits
The following dental services are covered from in-network providers.
Coverage | Cost |
---|---|
Dental Care | In-Network: Preventive and Comprehensive Dental Combined Allowance This plan covers up to $1,500 for covered preventive and comprehensive dental services every year. Medicare Covered Dental: $0.00 copay Preventive Dental Services: $0.00 copay Comprehensive Dental Services: $0.00 copay |
Vision Benefits
The following vision services are covered from in-network providers.
Coverage | Cost |
---|---|
Vision Benefits | In-Network: Medicare Covered Eye Exam: $0.00 copay - $25.00 copay Routine Eye Exam: $0.00 copay This plan covers 1 routine eye exam(s) every year. Medicare Covered Eye Wear: $0.00 copay Routine Eye Wear: $0.00 copay This plan covers up to $250.00 for eyeglasses or contact lenses every year. |
Hearing Benefits
The following hearing services are covered from in-network providers.
Coverage | Cost |
---|---|
Hearing Benefits | In-Network: Medicare Covered Hearing Exam: $25.00 copay Routine Hearing Exam: $0.00 copay for routine hearing exam(s). $0.00 copay for hearing aids up to the maximum plan benefit amount. This plan covers 1 routine hearing exam every year. $300.00 maximum plan benefit for over-the-counter hearing aids OR 1 routine hearing aid fitting evaluation and a $3,000.00 maximum plan benefit for prescribed hearing aids every year. |
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 | In-Network: $0.00 copay for Medicare Covered Preventive Services |