|CareWell (HMO I-SNP) H4922-004 |
For Medicare beneficiaries residing in a contracted Skilled Nursing Facility
|Monthly Plan Premium||$0 or up to $42.40* (derived from Part D/LIS applicable)|
|Yearly Deductible/ MOOP||B: $0 or $203*/C: $0*/MOOP: $7,550* *2021 cost sharing will be updated when the 2022 numbers are released (Nov 2021)|
|Part D Yearly Deductible||$0, $99 or $480*|
|Alternative therapy||Offered in one (1) to two (2) group sessions covered each month, up to twenty (20) group sessions covered each year. Therapies may be done in person or online.|
|Chiropractor||$0 or 20% of the cost*|
|Dental||$0 Comprehensive Dental $1,350 limit per year|
|Diabetic Supplies||$0 or 20% of the cost* Precision, OneTouch and FreeStyle preferred brands. No prior auth. required.|
|Emergency Room/ Urgent Care||$0 or 20% of the cost* (US + Territories Only)|
|Hearing||$0 annual routine hearing exam; Our plan pays up to $1,500 every 3 years for Hearing Aids. 4 visits for fitting/evaluation for Hearing. Aids are covered within the first year after purchase of a Hearing Aid.|
|Hospital Inpatient/SNF||$0 or Same as Original Medicare for 2022*|
|Lab/X-Ray/ Test & Procedures||$0 or 20% of the cost* (prior auth. required for generic testing)|
|Outpatient Surgery||$0 or 20% of the cost*|
|Part D Coverage||$0, 15% or 25% coinsurance*. Members with LIS or Medicaid: Generic copay: $0; $1.35; $3.95* All other drugs copay: $0; $4.00; $9.85*|
|Primary Care Physician||$0 or 20% of the cost* Telehealth or in person|
|Screening & Immunization||$0 copay|
|Specialist||$0 or 20% of the cost* No referral required|
|Vision||$0 or 20% coinsurance* for routine eye exam; $150 each year for eyeglasses. Prior Authorization is required for eyeglasses.|
For more information about covered services associated and cost-sharing (e.g., co-payments, co-insurance and deductibles) including any conditions and limitations please refer to the 2022 CareWell Summary of Benefitsopens PDF file .
**Licensed Master Social Worker and a Nurse Practitioner are assigned to members
*Depending on your Medicaid eligibility, you may pay a lower cost share amount.
This plan uses a formulary. Limitations may apply.