 Download 2012 Benefits Sheet (Advantage I / Advantage Select) - EnglishH7731_2012_Benefit Comparison 001_007 CMS Approved 10042011 Download 2012 Benefits Sheet (Advantage I / Advantage Select) - SpanishH7731_2012_Benefit Comparison 001_007 Spanish CMS Approved 10042011 Skip to: Advantage I & Advantage Select Plans | Preferred Dual SNP Plan | National Coverage Determinations View recent updates to the services covered by Medicare |
| Benefits | Advantage I MAPD (HMO) | Advantage Select MA (HMO) |
|---|---|---|
| Summary of Benefits | Download - English H7731_2012_Adv I_Select SB CMS Approved 09202011 Download - SpanishH7731_2012_Adv I_Select SB_Spanish CMS Approved 09202011 | Download - English H7731_2012_Adv I_Select SB CMS Approved 09202011 Download - SpanishH7731_2012_Adv I_Select SB_Spanish CMS Approved 09202011 |
| Evidence of Coverage | Download - English H7731_090211_1027_12EOC-MAPD File & Use 09072011 Download - Spanish H7731_090211_1027_12EOC-MAPD Spanish File & Use 09072011 | Download - English H7731_090211_1027_12EOC-MA File & Use 09072011 Download - SpanishH7731_090211_1027_12EOC-MA Spanish File & Use 09072011 |
| Monthly Plan Premium | $0 | $0 |
| Primary Care Physician Visit | $0 copay | $0 copay |
| Specialist Physician Visit | $10 copay | $0 copay |
| Inpatient Hospital Care | $100 Days 1-4; $0 Copay Day 5-90 $1000 Out-of-pocket limit every year | $0 copay |
| Outpatient Services / Surgery | $0 copay | $0 copay |
| Emergency Room Visit | $50 Copay; waived if admitted to hospital | $50 Copay; waived if admitted to hospital |
| World Wide Emergency Coverage | $10,000 limit per year; emergency services only | $10,000 limit per year; emergency services only |
| Urgent Care Visit | $25 Copay; waived if admitted to hospital | $25 Copay; waived if admitted to hospital |
| Ambulance Services | $100 Copay; waived if admitted to hospital | $100 Copay; waived if admitted to hospital |
| Skilled Nursing Facility Stay Care | Days 1 - 14: $0 Copay per day Days 15 - 100: $75 Copay per day | $0 Copay |
| Inpatient Mental Health Care | $250 Copay per stay; 190 day lifetime limit | $250 Copay per stay; 190 day lifetime limit |
| Durable Medical Equipment | 15% of the cost | $0 Copay |
| Prosthetic Devices | 15% of the cost | $0 Copay |
| Lab Services | $0 Copay | $0 Copay |
| Routine X-rays | $0 Copay | $0 Copay |
| Diagnostic Radiology Services | $100 Copay | $0 Copay |
| Therapeutic Radiology Services | $55 Copay | $55 Copay |
| Eye Glasses | $0 Copay; up to $160 value every 2 years | $0 Copay; up to $250 value every 2 years |
| Plan Generic Drugs | $3 Copay 30-day supply ($6 Copay 90-day supply) | Not covered |
| Plan Preferred Brand Drugs | $25 Copay 30-day supply ($50 Copay 90-day Mail Order) | Not covered |
| Plan Non-Preferred Brand Drugs | $59 Copay 30-day supply ($118 Copay 90-day Mail Order) | Not covered |
| Plan Specialty Drugs | 33% of the drug cost to the plan Coinsurance | Not covered |
| Transportation Services | $0 Copay; 12 one-way trip(s) to plan-approved locations every year | $0 Copay; 24 one-way trip(s) to plan-approved locations every year |
| Maximum Out of Pocket (MOOP) | $2400 Out-of-pocket limit (hospital deductible included) | $1000 Out-of-pocket limit |
A Medicare Advantage organization with a Medicare contract. Individuals must have both Part A and Part B to enroll and not have been diagnosed with End Stage Renal Disease (ESRD). You must continue to pay your Medicare part B premium. You must reside in the counties of Los Angeles, Orange, or select zip codes in Riverside and San Bernardino Counties.
The benefit information provided herein is a brief summary, not a comprehensive description of available benefits. For more information contact the plan. Members may enroll in the plan only during specific times of the year, please contact MD Care for more information. If you need further information or need information in alternate format or languages, please contact MD Care Health Plan at 1-888-285-9676. From October 15th to March 1st, our call center hours are from 8:00 AM to 8:00 PM seven days a week. From March 2nd through October 14th, our call center hours are from 8:00 AM to 8:00 PM Monday through Friday. TTY Users should call 1-800-735-2929.
MD Care Health Plan offers a network of primary care doctors, specialists and hospitals. You must receive all routine care from in-network plan providers; except for emergent or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor MD Care Health Plan will be responsible for the costs. Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances. Limitations, copayments and restrictions may apply.
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day / 7 days a week; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call-1-800-325-0778 or your State Medicaid Office.
For beneficiaries' and plan's rights and responsibilities upon disenrollment, please refer to:
Download 2012 Benefits Sheet (Preferred Dual SNP) - English Download 2012 Benefits Sheet (Preferred Dual SNP) - Spanish| Benefits | Preferred Dual SNP (HMO SNP) |
|---|---|
| Summary of Benefits | Download - English H7731_2012_SNP SB CMS Approved 10042011 Download - Spanish H7731_2012_SNP SB_Spanish CMS Approved 10042011 |
| Evidence of Coverage | Download - English H7731_090711_1027_12EOC-SNP File & Use 09122011 Download - Spanish H7731_090711_1027_12EOC-SNP Spanish File & Use 09122011 |
| Primary Care Physician Visit | $0 copay |
| Specialist Physician Visit | $0 copay |
| Inpatient Hospital Care | $0 copay |
| Outpatient Services / Surgery | $0 copay |
| Emergency Room Visit | $0 Copay |
| World Wide Emergency Coverage | $10,000 limit per year; emergency services only |
| Urgent Care Visit | $0 Copay |
| Ambulance Services | $0 Copay |
| Skilled Nursing Facility Stay Care | $0 Copay; plan covers 100 days per each benefit period |
| Inpatient Mental Health Care | $0 Copay per stay; 190 day lifetime limit |
| Durable Medical Equipment | $0 Copay |
| Prosthetic Devices | $0 Copay |
| Lab Services | $0 Copay |
| Routine X-rays | $0 Copay |
| Diagnostic Radiology Services | $0 Copay |
| Therapeutic Radiology Services | $0 Copay |
| Eye Glasses | $0 Copay; up to $250 value every 2 years |
| Podiatry Services | $0 Copay |
| Preventive Dental Services | $0 Copay up to (1) oral exam(s) every six months $0 Copay up to (1) cleaning(s) every six months $0 Copay up to (1) dental x-ray(s) every two years |
| Dentures | $0 Copay |
| Plan Generic Drugs | $0 Copay |
| Plan Brand and Other Plan Drugs | $0 / $3.30 / $6.50 (depending on your income and institutional status) |
| Transportation Services | $0 Copay; 24 one-way trip(s) to plan-approved locations every year |
| Maximum Out of Pocket (MOOP) | $100 Out-of-pocket limit |
A Coordinated Care Plan with a Medicare Advantage contract but without a contract with the California Medicaid program. MD Care Health Plan is a Dual Eligible (Medicare/Medi-Cal) Special Needs Plan. This plan is available to anyone who has both Medical Assistance from the State (Medi-Cal) and Medicare. Eligible beneficiaries can enroll at any time. If you are a full-dual member, the Part B premium is covered by the State. Individuals must have both Part A and Part B to enroll and not have been diagnosed with End Stage Renal Disease (ESRD). You must reside in the counties of Los Angeles, Orange, or select zip codes in Riverside and San Bernardino Counties.
The benefit information provided herein is a brief summary, not a comprehensive description of available benefits. For more information contact the plan. If you need further information or need information in alternate format or languages, please contact MD Care Health Plan at 1-888-285-9676. From October 15th through March 1st, our call center hours are from 8:00 AM to 8:00 PM seven days a week. From March 2nd through October 14th, our call center hours are from 8:00 AM to 8:00 PM Monday through Friday. TTY Users should call 1-800-735-2929.
MD Care Health Plan offers a network of primary care doctors, specialists and hospitals. You must receive all routine care from in-network plan providers; except for emergent or urgent care situations or for out-of-area renal dialysis. If you obtain routine care from out-of-network providers neither Medicare nor MD Care Health Plan will be responsible for the costs. Eligible beneficiaries must use network pharmacies to access their prescription drug benefit, except under non-routine circumstances. Limitations, copayments and restrictions may apply.
MD Care Health Plan has been approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) until 12/31/2015. NCQA’s approval is based on a review of MD Care Health Plan Model of Care and is an indicator of compliance with CMS requirements. NCQA’s approval is not an endorsement by CMS and/or NCQA of MD Care Health Plan or the quality of service provided by MD Care Health Plan. MD Care Health Plan will still need to be approved each year by CMS in order to operate. If you have questions regarding our approval by the NCQA, please contact us at (888) 285-9676. TTY users should call (800) 735-2929.
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day / 7 days a week; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call-1-800-325-0778 or your State Medicaid Office.
For beneficiaries' and plan's rights and responsibilities upon disenrollment, please refer to:
If you get extra help from Medicare to help pay for your Medicare prescription drug plan costs, copays and co-insurance may vary based on the level of Extra help that you may receive. Please contact the plan for more details.
Out-of-Network 2012 Enrollment Form - English (H7731_2012_Enrollment Form CMS Approved 09302011) 2012 Enrollment Form - Spanish (H7731_2012_Enrollment Form Spanish CMS Approved 09302011)
2012 Drug Formulary - English (H7731_081611_5003File & Use 08222011) 2012 Drug Formulary - Spanish (H7731_081611_5003_Spanish File & Use 08222011) 2012 Pharmacy Directory - English (H7731_072811_1044 File & Use 08072011) 2012 Pharmacy Directory - Spanish (H7731_072811_1044_Spanish File & Use 08072011) 2012 Provider Directory - Los Angeles County (English) (H7731_2012_1004_LA Directory File & Use 10182011) 2012 Provider Directory - Los Angeles County (Spanish) (H7731_2012_1004_LA Directory SP File & Use 10182011) 2012 Provider Directory - Orange County (English) (H7731_2012_1004_OC Directory File & Use 10182011) 2012 Provider Directory - Orange County (Spanish) (H7731_2012_1004_OC Directory SP File & Use 10182011) 2012 Provider Directory - San Bernardino and Riverside Counties (English) (H7731_2012_1004_RV_SB Directory File & Use 10192011) 2012 Provider Directory - San Bernardino and Riverside Counties (Spanish) (H7731_2012_1004_RV_SB Directory SP File & Use 10192011)