Plan Comparison

Benefit / Cost Category Original Medicare
Fee-For -Service*
Super Plus
HMO C-SNP
(H4869-001)
Dialysis Plus
HMO-POS C-SNP
(H4869-003)
Honest Care
HMO
(H4869-005)
Super Complete
HMO C-SNP
(H4869-002)
Dialysis Complete
HMO-POS C-SNP
(H4869-004)
MEMBER VALUE-ADDED ITEMS
Part B Premium Reduction (Buydown or Money back in their Social Security check)
N/A
$25.00
$0
$25
$0
$0
MEMBER COST SHARES
MEDICARE+MEDICAID / MEDICARE ONLY
Plan Premium
N/A
$0
$0
$0
$0 / $42.60
$0 / $42.60
Maximum out-of-pocket - MOOP
N/A
$3,000
$2,700
$3,000
$8,300
$8,300
Primary Care Physician - PCP
20%
$0
$0
$0
0% / 20%
0% / 20%
Specialist (Nephrologist, Cardiologist, Endocrinologist, and Cardiovascular surgeons)
20%
$0
$0
$20
0% / 20%
0% / 20%
Specialist (all other)
20%
$20
$20
$20
0% / 20%
0% / 20%
Urgent Care
20%
$0
$40
$20
$0 / $60
$0 / $60
Emergency
20%
$90
$120
$90
$0 / $95
$0 / $95
Inpatient Hospital
• $1,556 deductible per benefit period
• $0 for the first 60 days of each benefit period
• $389 per day for days 61–90 of each benefit period”
$100 for Days 1-7
$175 for Days 1-7
$175 for Days 1-7
$0 / Medicare cost shares
$0 / Medicare cost shares
Outpatient Hospital
20%
"$0 for diagnostic colonscopy $195 per day for all other services"
"$0 for diagnostic colonscopy $195 per day for all other services"
"$0 for diagnostic colonscopy $195 per day for all other services"
0% / 20%
0% / 20%
Outpatient ASC
20%
$100 per visit
$100 per visit
$150 per visit
0% / 20%
0% / 20%
Tests (Diagnostic Radiology)
20%
$50
$50
$50
0% / 20%
0% / 20%
Lab Services
20%
$0
$0
$0
$0
0% / 20%
Dialysis
20%
20%
$0
20%
0% / 20%
0% / 20%
EXTRA’S INCLUDED:
Dental
Routine dental not covered
"Preventive & Comprehensive Services $2,000 benefit coverage amount per year"
"Preventive & Comprehensive Services $2,000 benefit coverage amount per year"
"Preventive & Comprehensive Services $2,000 benefit coverage amount per year"
"Preventive & Comprehensive Services $4,000 benefit coverage amount per year"
"Preventive & Comprehensive Services $4,000 benefit coverage amount per year"
Transportation
Non-emergency transportation not covered**
$0 for 36 one-way trips per year
$0 for 104 one-way trips per year
$0 for 24 one-way trips per year
$0 for 54 one-way trips per year
$0 for 104 one-way trips per year
Over-the-Counter
Not covered
$50 quarterly allowance
$50 quarterly allowance
$50 quarterly allowance
$400 quarterly allowance
$400 quarterly allowance
Fitness
Not covered
$0 for Silver & Fit Gym Membership
$0 for Silver & Fit Gym Membership
$0 for Silver & Fit Gym Membership
$0 for Silver & Fit Gym Membership
$0 for Silver & Fit Gym Membership
Companion Care
Not covered
$0 for home-based care visits
$0 for home-based care visits
$0 for home-based care visits
$0 for home-based care visits
$0 for home-based care visits
Prescription Drugs - 30-day supply at retail (Varies by Tier Level or Coverage Stage)
Not covered
$0 | $5 | $45 | $100 | 33% | $0
$0 | $5 | $45 | $100 | 33% | $0
$0 | $5 | $45 | $100 | 33% | $0
"$0 - $10.35 / 25% | 15%"
25% | > of 5% of $4.15 | $10.35
Senior Savings Participation
Not covered
Yes
Yes
Yes
No
No
ǂCost share applies after deductible and any inpatient hospital copays that are required
**Based on medical necessity; requires doctor order
H4869_PBP Brochure_0822M CMS Approval 09_21_2022