2023 Encompass 65® Core HMO

Plan Highlights

MONTHLY PREMIUM
PRIMARY/SPECIALTY COPAY
(In-Network)
INPATIENT HOSPITAL COPAY
(In-Network)
PART D PRESCRIPTION BENEFIT
(Tier 1 / 2 / 3 / 4 / 5)
MONTHLY PREMIUM

$65

PRIMARY/SPECIALTY COPAY
(In-Network)

$0/$30

INPATIENT HOSPITAL COPAY
(In-Network)

Days 1-6: $300 per day. Additional days: $0. Unlimited Days for Medicare covered stays. ($1,800 Annual Member Copay Maximum).

PART D PRESCRIPTION BENEFIT

$50 deductible on tiers 3, 4 & 5 only. $0/$12/$42/44%/32% to initial coverage limit of $4,660.

Plan Details

Monthly Premium

$65

Plan Premium with Full 100% Low Income Subsidy (LIS)

$26.10

Part D Prescription Benefit Tier 1 / 2 / 3 / 4 / 5

$50 deductible on tiers 3, 4 & 5 only. $0/$12/$42/44%/32% to initial coverage limit of $4,660.

Primary Copay

$0

Specialty Copay

$30

Preventive Services

$0

Inpatient Hospital Copay

Days 1-6: $300 per day. Additional days: $0. Unlimited Days for Medicare covered stays. ($1,800 Annual Member Copay Maximum).

Worldwide Emergency / Urgent Care*

$95$60

Lab Copay**

$5

General X-ray / Advanced Radiology Copay

$35$175

Wellness Benefits†

Over-the-Counter (OTC)***

$35 per quarter

SilverSneakers® Fitness Benefit (from a participating facility that offers SilverSneakers)

$0 copayment (memberships will not roll over from 2022 to 2023 or 2023 to 2024. Memberships will restart on January 1st of each year).

Vision (from a network provider)

$0 routine eye exam. $30 Medicare covered vision services. $200 allowance for routine eyewear. $0 for diabetic retinopathy exam for diabetics. $0 for Ophthalmologist too.

Dental (from a network provider)

$0 per visit for preventive dental: Two routine cleanings, exams, fluoride treatments and bitewing X-rays per calendar year. One full-mouth series every 36 months.

Optional supplemental dental: 2 options offered for additional premium billed separately. 

Option 1: $24 per month premium, $750 every 3 months - Jan, April, July, Oct. $3,000 max limit, $0 deductible, 50% coinsurance.  Option 2: $40 per month premium, $1,000 every 3 months - Jan, April, July, Oct.  $4,000 max limit, $0 deductible, 50% coinsurance.

Hearing Aid Benefit (from a network provider)

$45 hearing aid evaluation exam. Member pays: $499 - $2,199 (per ear) for hearing aid device. The average cost for hearing aids without coverage is $2,445 - $3,125 per ear.

Personal Emergency Response System (PERS)

$0

Enhanced Annual Wellness Visit (EAV)

$0

Telemedicine (with a Teladoc® provider)

$25 copay per session.  Speak with a doctor anytime, anywhere by phone or online.

These benefits will help members with diabetes manage their special needs, live healthier and save money. Learn More

Non-Emergency Transportation

$0 copay for up to 6 one-way trips to an Independent Health network approved location.  30-mile limit applies per trip.

Home Delivered Meals

$0 copay for up to 28 meals (14 consecutive days) following an overnight stay in a hospital or skilled nursing facility.

All of our Medicare Advantage plans come with additional benefits to help you maintain an active, healthy lifestyle. Learn More

Disclaimers

* $10,000 annual maximum plan limit for emergency care, urgent care or ambulance outside the USA and its territories.

** Member pays 20% of the cost of genetic testing.

***Allowance is made available by quarter. Allowance carries over quarter to quarter, however does not carry over plan year to plan year. Costs over the allowed amount are the member’s responsibility. This benefit can only be used for covered items through NationsOTC.®

† Limitations, copayments and restrictions may apply. Applicable copays may apply for these benefits. Member must use in-network providers to take advantage of these benefits (excluding Independent Health’s Medicare Passport Advantage PPO plan or Independent Health’s Medicare Passport Prime PPO plan). Must see a Start Hearing network provider to use the hearing aid benefit.

Benefits vary by plan and some plans do not include coverage for these benefits. Benefits, premiums, rewards and/or copayments may change on January 1 of each year. This information is not a complete description of benefits. Call (716) 250-4401 or 1-800-665-1502 (TTY users call 711) for more information.

IN = In-Network, OON = Out-of-Network

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Last Updated 10/01/2022