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 |
