HAP CareSource MI Coordinated Health
HMO D-SNP

Price: $0.00, per month

Plan Specifics

Coverage Type
Part A, Part B, Part D
Monthly Plan Premium
$0
Contract ID
H4193-001
Annual Medical Deductible
$0
Annual Prescription Deductible
$0
Plan Details

Medicare-Covered Medical Benefits

Category In-Network
Preventive Care Covered at 100%.
Doctor's Office Visits Primary Care Provider Office Visit: $0 copay. Specialist Office Visit: $0 copay.
Annual Physical $0 copay.
Inpatient Hospital Care Medicare-covered Benefits: Covered.
Emergency Care Emergency Room: $0 copay.
Urgently Needed Services $0 copay.
Ambulance $0 copay.
Ambulatory Surgical Center $0 copay.
Chiropractic Services Manual Manipulation of Spine: $0 copay
for Medicare-covered Chiropractic Services (Office visit & X-rays are not covered).
Diabetes Screening, Diabetes Self- Management Training, Diabetic Services & Supplies $0 copay. Insulins covered under Medicare Part B are subject to a coinsurance cap of $35 for one month’s supply of insulin with no deductible.
Outpatient Therapy (Physical, Occupational, Speech, Cardiac) $0 copay.
Diagnostic Procedures (Includes Genetic Testing) /Lab Services/Imaging Diagnostic Procedures/Tests: $0 copay. X-Ray Services: $0 copay. Therapeutic Radiological Services: $0 copay.
Outpatient Hospital & Observation Services $0 copay.
Medical Equipment/Supplies Durable Medical Equipment and Prosthetic Devices: $0 copay. Diabetic Supplies and Services: $0 copay.
High-Tech Diagnostic Radiology Services $0 copay.
Other Diagnostic Test/Procedures $0 copay.
Ultrasounds $0 copay.
Outpatient X-rays $0 copay.
Therapeutic radiology services, such as radiation treatment for cancer $0 copay.
Mental Health Services $0 copay.
Foot Care (Podiatry Services) Podiatry Services and Routine Foot Care: $0 copay.
Skilled Nursing Facility $0 copay.
Additional Services
Not Covered By Medicare
  
Hearing Services Routine Hearing Exams: $0. Fitting/Evaluation for Hearing Aid: $0.
Allowance for Hearing Aids Two hearing aids every 3 years. (limit one hearing aid per ear every 3 years).
Vision Services No cost routine eye exam every 2 years. Eyeglasses and contacts are covered: 1 paid every 2 years.
Allowance for Eyewear No cost routine eye exam every 2 years. Eyeglasses and contacts are covered: 1 paid every 2 years.
Dental Services Preventive care (eg, exams, cleanings, x-rays and fluoride) and comprehensive dental (eg, simple extractions, minor restorations, periodontics and other non-Medicare covered comprehensive dental services including extractions, crowns, implants, and dentures). Plan limit of $5,000 towards supplemental fluoride treatments and dental implants.
Wellness Programs Fitness Benefit, Nutritional/Dietary Counseling, Two Sessions of Smoking & Tobacco Cessation Counseling. Population Health & Care Management Programs.
Personal Emergency Response System (PERS) $0 copay.
Fitness Benefits Includes membership at participating fitness centers and home fitness kit, as well as online features (on-demand workout videos, virtual events, and specialized coaching sessions).
Transportation Unlimited one-way health related trips to provider visits, pharmacy, gym, grocery and community/wellness services.
Flexcard Members use Healthy Benefits+ debit card to purchase up to $210 per month for approved services and items from eligible locations, including: Food & Produce*, Over the Counter (OTC) Items, Utility Expenses*, Personal Care Items*, Pet Care Items* (excluding veterinary care and grooming), Household Cleaning Items*, Pest Control Items*, Indoor Air Quality Items*, Home and Bathroom Safety Items*, and Dental, Vision and Hearing services and accessories. Unused amounts rollover to the following month and will expire at the end of the year.

*The benefits mentioned are part of special supplemental benefits for the chronically ill. Not all members qualify. Professional Services are not included for pest control, indoor air quality and home and bathroom safety devices.
OTC $0 copay.
Meal Benefit Two meals a day for 14 days after each inpatient hospitalization or skilled nursing facilility stay (Community Well Only).

Prescription Drug Benefits

Coverage Type: Part D
Disclaimer
If you’re in a program that helps pay for your drugs (Extra Help), the information about costs for Part D drugs may not apply to you.
Pre-initial coverage limit
Standard Retail Cost Sharing - One Month Supply
Standard Retail Cost Sharing - Three Month Supply
Standard Mail Order Cost Sharing - Three Month Supply
Preferred Retail Cost Sharing - One Month Supply
Preferred Retail Cost Sharing - Three Month Supply
Preferred Mail Order Cost Sharing - Three Month Supply
Tier 1 - Preferred Generic $0 $0 $0 N/A N/A N/A
Tier 2 - Generic N/A N/A N/A N/A N/A N/A
Tier 3 - Preferred Brand N/A N/A N/A N/A N/A N/A
Tier 4 - Non-Preferred Brand N/A N/A N/A N/A N/A N/A
Tier 5 - Specialty Tier N/A N/A N/A N/A N/A N/A

Important Message About What You Pay for Insulin - You won’t pay more than $35 for a one-month supply of each covered insulin product regardless of the cost-sharing tier, even if you haven’t paid your deductible.

Insulins administered with an infusion pump are covered as a Part B medical benefit. You won’t pay more than $35 for one-month supply of insulin, with no deductible.