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Benefit Category
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Original Medicare
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KelseyCare Advantage Essential+Choice
(HMO-POS)
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Important Information
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1 - Premium and Other Important
Information
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In 2011, the monthly Part B Premium is $110.50 and the yearly Part B deductible
amount is $162.
If a doctor or supplier does not accept assignment, their costs are often higher,
which means you pay more.
Most people will pay the standard monthly Part B premium. However, some people will
pay a higher premium because of their yearly income (over $85,000 for singles, $170,000
for married couples). For more information about Part B premiums based on income,
call Medicare at 1-800-MEDICARE 1-800-633- 4227). TTY users should call 1- 877-486-2048.
You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
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General
$0 monthly plan premium in addition to your monthly Medicare Part B premium
Most people will pay the standard monthly Part B premium in addition to their MA
plan premium. However, some people will pay a higher premium because of their yearly
income (over $85,000 for singles, $170,000 for married couples). For more information
about Part B premiums based on income, call Medicare at 1-800-MEDICARE (1-800-633-4227).
TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213.
TTY users should call 1-800-325-0778.
This plan covers all Medicare-covered preventive services with zero cost sharing.
In-Network
$3,400 out-of-pocket limit
This limit includes only Medicare-covered services.
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2 - Doctor and Hospital Choice
(For more information, see Emergency -
#15 and Urgently Needed Care - #16.)
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You may go to any doctor, specialist or hospital that accepts Medicare.
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In-Network
Referral required for network hospitals and specialists (for certain benefits)
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Summary of Benefits
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Inpatient Care
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3 - Inpatient Hospital Care
(includes Substance Abuse and Rehabilitation
Services)
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In 2011, the amounts for each benefit period are:
Days 1 - 60: $1,132 deductible
Days 61 - 90: $283 per day
Days 91 - 150: $566 per lifetime reserve day
Call 1-800-MEDICARE
(1-800-633-4227) for information about lifetime reserve days.
Lifetime reserve days can only be used once.
A “benefit period” starts the day you go into a hospital or skilled nursing facility.
It ends when you go for 60 days in a row without hospital or skilled nursing care.
If you go into the hospital after one benefit period has ended, a new benefit period
begins. You must pay the inpatient hospital deductible for each benefit period.
There is no limit to the number of benefit periods you can have.
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In-Network
No limit to the number of days covered by the plan each benefit period
$375 copay for each Medicare-covered hospital stay
$0 copay for additional hospital days
$375 out-of-pocket limit every stay
Except in an emergency, your doctor must tell the plan that you are going to be
admitted to the hospital.
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4 - Inpatient Mental Health Care
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Same deductible and copay as inpatient hospital care (see “Inpatient Hospital Care”
above).
190-day lifetime limit in a Psychiatric Hospital
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In-Network
You get up to 190 days in a Psychiatric Hospital in a lifetime.
$375 copay for each Medicare-covered hospital stay
The maximum out-of-pocket limit is covered under “Inpatient Hospital Care”.
Except in an emergency, your doctor must tell the plan that you are going to be
admitted to the hospital.
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5 - Skilled Nursing Facility (SNF)
(in a Medicare-certified skilled
nursing facility)
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In 2011, the amounts for each benefit period after at least a 3-day covered hospital
stay are:
Days 1 - 20: $0 per day
Days 21 - 100: $141.50 per day
100 days for each benefit period
A “benefit period” starts the day you go into a hospital or SNF. It ends when you
go for 60 days in a row without hospital or skilled nursing care. If you go into
the hospital after one benefit period has ended, a new benefit period begins. You
must pay the inpatient hospital deductible for each benefit period. There is no
limit to the number of benefit periods you can have.
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General
Authorization rules may apply
In-Network
Plan covers up to 100 days each benefit period
No prior hospital stay is required.
For SNF stays:
Days 1 - 20: $0 copay per day
Days 21 - 100: $125 copay per day
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6 - Home Health Care
(includes medically necessary intermittent
skilled nursing care, home health aide services, and rehabilitation services, etc.)
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$0 copay
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General
Authorization rules may apply
In-Network
$0 copay for Medicare-covered
home health visits
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7 - Hospice
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You pay part of the cost for outpatient drugs and inpatient respite care.
You must get care from a Medicare-certified hospice.
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General
You must get care from a Medicare-certified hospice.
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Outpatient Care
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8 - Doctor Office Visits
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20% coinsurance
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General
See “Welcome to Medicare; and Annual Wellness Visit,” for more information.
Authorization rules may apply
In-Network
$0 copay for each primary care doctor visit for Medicare-covered benefits
$0 copay for each specialist doctor visit for Medicare-covered benefits
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9 - Chiropractic Services
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Routine care not covered
20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement
or misalignment of a joint or body part) if you get it from a chiropractor or other
qualified providers
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General
Authorization rules may apply
In-Network
$0 copay for Medicare-covered
chiropractic visits
Medicare-covered chiropractic
visits are for manual manipulation of the spine to correct subluxation (a displacement
or misalignment
of a joint or body part) if you get it from a chiropractor or other qualified providers.
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10 - Podiatry Services
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Routine care not covered.
20% coinsurance for medically necessary foot care, including care for medical conditions
affecting the lower limbs
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General
Authorization rules may apply
In-Network
$0 copay for Medicare-covered
podiatry benefits
Medicare-covered podiatry
benefits are for medically-necessary foot care
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11 - Outpatient Mental Health Care
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45% coinsurance for most outpatient mental health services
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General
Authorization rules may apply
In-Network
$35 copay for each Medicare-covered individual therapy visit
$20 copay for each Medicare-covered group therapy visit
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12 - Outpatient Substance Abuse
Care
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20% coinsurance
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General
Authorization rules may apply
In-Network
$35 copay for Medicare-covered individual visits
$20 copay for Medicare-covered group visits
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13 - Outpatient Services/Surgery
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20% coinsurance for the doctor
Specified copayment for outpatient hospital facility charges. Copay cannot exceed
Part A inpatient hospital deductible.
20% copayment for ambulatory surgical center facility charges
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General
Authorization rules may apply
In-Network
$150 copay for each Medicare-covered ambulatory surgical center visit
$150 copay for each Medicare-covered outpatient hospital facility visit
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14 - Ambulance Services
(medically necessary ambulance services)
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20% coinsurance
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General
Authorization rules may apply
In-Network
$100 copay for Medicare-covered ambulance benefits
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15 - Emergency Care
(You may go to any emergency room if you reasonably believe you need emergency care.)
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20% coinsurance for the doctor
Specified copayment for outpatient hospital emergency room (ER) facility charge.
ER Copay cannot exceed Part A inpatient hospital deductible.
You don’t have to pay the emergency room copay if you are admitted to the hospital
for the same condition within 3 days of the emergency room visit.
Not covered outside the U.S. except under limited circumstances.
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General
$50 copay for Medicare-covered emergency room visits
Worldwide coverage
If you are admitted to the hospital within 3-day(s) for the same condition, you
pay $0 for the emergency room visit.
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16 - Urgently Needed Care
(This is NOT emergency care, and in most
cases, is out of the service area.)
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20% coinsurance, or a set copay
NOT covered outside the U.S. except under limited circumstances.
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General
$50 copay for Medicare-covered urgently needed care visits
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17 - Outpatient
Rehabilitation Services
(Occupational Therapy, Physical Therapy, Speech and Language Therapy, Respiratory
Therapy Services, Social/Psychological Services, and more)
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20% coinsurance
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General
Authorization rules may apply
In-Network
$0 copay for Medicare-covered Occupational Therapy visits
$0 copay for Medicare-covered
Physical and/or Speech/Language Therapy visits
$15 copay for Medicare-covered Cardiac Rehab services
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Outpatient Medical Services and Supplies
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18 - Durable Medical Equipment
(includes wheelchairs, oxygen, etc.)
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20% coinsurance
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General
Authorization rules may apply
In-Network
10% of the cost for Medicare-covered items
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19 - Prosthetic Devices
(includes braces, artificial limbs and
eyes, etc.)
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20% coinsurance
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General
Authorization rules may apply
In-Network
20% of the cost for Medicare-covered items
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20 - Diabetes Self-Monitoring Training,
Nutrition Therapy, and Supplies
(includes coverage for glucose monitors,
test strips, lancets, screening tests, self-management training, retinal exam/glaucoma
test, and foot exam/therapeutic soft shoes)
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20% coinsurance
Nutrition therapy is for people who have diabetes or kidney disease (but aren’t
on dialysis or haven’t had a kidney transplant) when referred by a doctor. These
services can be given by a registered dietitian or include a nutritional assessment
and counseling to help you manage your diabetes or kidney disease.
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General
Authorization rules may apply
In-Network
$0 copay for diabetes
self-monitoring training
$0 copay for Nutrition Therapy
for diabetes
0% to 10% of the cost for diabetes supplies
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21 - Diagnostic Tests, X-Rays, Lab Services,
and Radiology Services
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20% coinsurance for diagnostic tests and x-rays
$0 copay for Medicare-covered lab services
Lab Services: Medicare covers medically necessary diagnostic lab services that are
ordered by your treating doctor when they are provided by a Clinical Laboratory
Improvement Amendments (CLIA) certified laboratory that participates in Medicare.
Diagnostic lab services are done to help your doctor diagnose or rule out a suspected
illness or condition.
Medicare does not cover most routine screening tests, like checking your cholesterol.
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General
Authorization rules may apply
In-Network
$0 copay for Medicare-covered
lab services
$0 to $100 copay for Medicare-covered diagnostic procedures and tests
$0 copay for Medicare-covered
X-rays
$0 to $100 copay for Medicare-covered diagnostic radiology services (not including
x-rays)
$25 copay for Medicare-covered therapeutic radiology services
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Preventive Services
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22 - Bone Mass Measurement
(for people with Medicare who are
at risk)
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No coinsurance, copayment or deductible.
Covered once every 24 months (more often if medically necessary) if you meet certain
medical conditions.
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General
Authorization rules may apply
In-Network
$0 copay for Medicare-covered
bone mass measurement
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23 - Colorectal Screening Exams
(for people with Medicare age 50
and older)
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No coinsurance, copayment or deductible for screening colonoscopy or screening flexible
sigmoidoscopy.
Covered when you are high risk or when you are age 50 and older.
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General
Authorization rules may apply
In-Network
$0 copay for Medicare-covered
colorectal screenings
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24 - Immunizations
(Flu vaccine, Hepatitis B vaccine - for
people with Medicare who are at risk, Pneumonia vaccine)
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$0 copay for Flu, Pneumonia and Hepatitis B vaccines
You may only need the Pneumonia vaccine once in your lifetime. Call your doctor
for more information.
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General
Authorization rules may apply
In-Network
$0 copay for Flu and Pneumonia vaccines
$0 copay for Hepatitis B vaccine
No referral needed for Flu and Pneumonia vaccines
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25 - Mammograms
(Annual Screening)
(for women with Medicare age 40 and older)
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No coinsurance, copayment or deductible
No referral needed
Covered once a year for all women with Medicare age 40 and older. One baseline mammogram
covered for women with Medicare between age 35 and 39.
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In-Network
$0 copay for Medicare-covered screening mammograms
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26 - Pap Smears and Pelvic Exams
(for women with Medicare)
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No coinsurance, copayment, or deductible for Pap smears
No coinsurance, copayment, or deductible for Pelvic and clinical breast exams
Covered once every 2 years
Covered once a year for women with Medicare at high risk
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In-Network
$0 copay for Medicare-covered
Pap smears and pelvic exams
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27 - Prostate Cancer Screening Exams
(for men with Medicare age 50 and older)
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20% coinsurance for the digital rectal exam
$0 for the PSA test; 20% coinsurance for other related services
Covered once a year for all men with Medicare over age 50
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In-Network
$0 copay for Medicare-covered prostate cancer screening
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28 - End-Stage Renal Disease
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20% coinsurance for renal dialysis
20% coinsurance for Nutrition Therapy for End Stage Renal Disease
Nutrition therapy is for people who have diabetes or kidney disease (but aren’t
on dialysis or haven’t had a kidney transplant) when referred by a doctor. These
services can be given by a registered dietitian or include a nutritional assessment
and counseling to help you manage your diabetes or kidney disease.
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General
Authorization rules may apply
In-Network
$25 copay for renal dialysis
$0 copay for Nutrition Therapy for End Stage Renal Disease
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29 - Prescription Drugs
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Most drugs are not covered under Original Medicare. You can add prescription drug
coverage to Original Medicare by joining a Medicare Prescription Drug Plan, or you
can get all your Medicare coverage, including prescription drug coverage, by joining
a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug
coverage.
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Drugs Covered Under
Medicare Part B
General
Most drugs not covered
10% of the cost for Part B-covered chemotherapy drugs and other Part B-covered drugs
Drugs Covered Under
Medicare Part D
General
This plan does not offer prescription drug coverage.
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30 - Dental Services
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Preventive dental services (such as cleaning) not covered.
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General
Authorization rules may apply
In-Network
$0 copay for Medicare-covered dental benefits
In general, preventive dental benefits (such as cleaning) not covered.
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31 - Hearing Services
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Routine hearing exams and hearing aids not covered
20% coinsurance for diagnostic hearing exams
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General
Authorization rules may apply
In-Network
$0 copay for Medicare-covered diagnostic hearing exams
$0 copay for
- up to 1 routine hearing test every year
- up to 1 fitting-evaluation for a hearing aid every two years
$0 copay for up to 2 hearing aids every two years.
$1,000 plan coverage limit for hearing aids every two years.
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32 - Vision Services
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20% coinsurance for diagnosis and treatment of diseases and conditions of the eye
Routine eye exams and glasses not covered
Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery.
Annual glaucoma screenings covered for people at risk
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General
Authorization rules may apply
In-Network
$0 copay for diagnosis and treatment for diseases and conditions of the eye
- and for up to 1 routine eye exam(s) every year
$0 copay for
- one pair of eyeglasses or contact lenses after cataract surgery
- up to 1 pair(s) of glasses every two years
- up to 1 pair(s) of contacts every two years
$150 plan coverage limit for eye wear every two years
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33 - Welcome to Medicare; and Annual Wellness
Visit
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When you join Medicare Part B, then you are eligible as follows:
During the first 12 months of your new Part B coverage, you can get either a Welcome
to Medicare exam or an Annual Wellness visit.
After your first 12 months, you can get one Annual Wellness visit every 12 months.
There is no coinsurance, copayment or deductible for either the Welcome to Medicare
exam or the Annual Wellness visit.
The Welcome to Medicare exam does not include lab tests.
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In-Network
$0 copay for routine exams
Limited to 1 exam(s) every year
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34 - Health/Wellness Education
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Smoking Cessation:
Covered if ordered by your doctor. Includes two counseling attempts within a 12-month
period if you are diagnosed with a smoking-related illness or are taking medicine
that may be affected by tobacco. Each counseling attempt includes up to four face-to-face
visits. You pay coinsurance, and Part B deductible applies.
$0 copay for the HIV screening, but you generally pay 20% of the
Medicare-approved amount for the doctor’s visit. HIV screening is
covered for people with Medicare who are pregnant and people at
increased risk for the infection, including anyone who asks for the test. Medicare
covers this test once every 12 months or up to three times during a pregnancy.
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In-Network
The plan covers the following health/wellness education benefits:
Written health education materials, including Newsletters
- Nutritional Training
- Nursing Hotline
$0 copay for each Medicare-covered smoking cessation counseling session
$0 copay for each medicare covered HIV screening.
HIV screening is covered for people with Medicare who are pregnant and people at
increased risk for the infection, including anyone who asks for the test. Medicare
covers this test once every 12 months or up to three times during a pregnancy.
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Transportation
(Routine)
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Not covered
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In-Network
$0 copay for up to 20 one-way trips to plan-approved location every year
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Acupuncture
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Not covered
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In-Network
This plan does not cover acupuncture.
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Point of Service
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You may go to any doctor, specialist or hospital that accepts Medicare.
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General
Authorization rules may apply
Out-of-Network
Point of Service coverage is available for the following benefits:
- Inpatient Hospital - Acute
- Chiropractic Services
- Physician Specialist Services
- Podiatry Services
Outpatient Diag Procedures/Tests/Lab Services
Diagnostic Radiological Services
- Outpatient X-Rays
- Outpatient Hospital Services
Ambulatory Surgical Center (ASC) Services
$1,000 copay per hospital stay
For hospital stays:
Days 1 - 60: $0 copay per day
Days 61 - 90: $250 copay per day
Days 91 - 150: $500 copay per day
20% of the cost for:
- Chiropractic Services
- Physician Specialist Services
- Podiatry Services
Outpatient Diag Procedures/Tests/Lab Services
- Diagnostic Radiological Services
- Outpatient X-Rays
- Outpatient Hospital Services
Ambulatory Surgical Center (ASC) Services
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