HAP Medicare Complete Assist
PPO-DSNP

Price: $6.30, per month

Plan Specifics

Star Rating
Coverage Type
Part A, Part B, Part D
Monthly Plan Premium
$6.30
Contract ID
H2322-020
Annual Medical Deductible
$0-$283 (Depending on level of Medicaid Eligibility)
Annual Prescription Deductible
$0 - $700 (Depending on LIS status)
Max Enrollee Out-of-Pocket
$9,850 Annual In-Network
$14,800 Combined In and Out-of-Network
Plan Details

Plan Covered Medical Benefits

Category In-Network Out-of-Network
Allowance for Eyewear Contact Lenses: Covered. Eyeglasses (Lenses and Frames): Covered. Eyeglass Lenses: Covered. Eyeglass Frames: Covered. Upgrades: Not Covered. $300 allowance. Must use Eyemed insight network. Contact Lenses: Covered. Eyeglasses (Lenses and Frames): Covered. Eyeglass Lenses: Covered. Eyeglass Frames: Covered. Upgrades: Not Covered. $300 allowance. Must use Eyemed insight network.
Allowance for Hearing Aids Hearing Aids (All Types): Covered. All Types: $1,000 allowance. Must use NationsHearing®. Hearing Aids (All Types): Covered. All Types: $1,000 allowance. Must use NationsHearing®.
Ambulance $0 or 20% coinsurance. $0 or $45 copay.
Ambulatory Surgical Center $0 or 20% coinsurance. $0 or 20% coinsurance.
Annual Physical $0 or 20% coinsurance. $0 or 20% coinsurance.
Chiropractic Services 1 Office visit per year: $0 - 20% coinsurance. 1 set of X-rays per year: $0 or 20% coinsurance. Manual Manipulation of Spine: $0 - 20% coinsurance. $0 or 20% coinsurance.
Dental Services Preventive & comprehensive dental through Delta Dental PPO Network- Includes $2,000 max for preventive and comprehensive services combined; 100% coverage for: 2 oral exams, 2 cleanings or 2 periodontal cleanings, 2 fluoride treatments, brush biopsy, 1 set of bitewings per year, root canals, fillings, bridges, bridge repairs, crown repairs, perio surgical/non surgical procedures, surigcal extractions/oral surgery, emergency palliative treatment, occlusal guards/adjustments, anesthesia and simple extractions. Doesn't apply to Ded or MOOP. No prior auth or referral required. Preventive & comprehensive dental through Delta Dental PPO Network- Includes $2,000 max for preventive and comprehensive services combined; 100% coverage for: 2 oral exams, 2 cleanings or 2 periodontal cleanings, 2 fluoride treatments, brush biopsy, 1 set of bitewings per year, root canals, fillings, bridges, bridge repairs, crown repairs, perio surgical/non surgical procedures, surigcal extractions/oral surgery, emergency palliative treatment, occlusal guards/adjustments, anesthesia and simple extractions. Doesn't apply to Ded or MOOP. No prior auth or referral required.
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. $0 or 20% coinsurance. Insulins covered under Medicare Part B are subject to a coinsurance cap of $35 for one month’s supply of insulin with no deductible.
Diagnostic Procedures (Includes Genetic Testing) /Lab Services/Imaging Diagnostic Procedures/Tests: $0 or 20% coinsurance. X-Ray Services: $0 or 20% coinsurance. Therapeutic Radiological Services: $0 or 20% coinsurance. Diagnostic Procedures/Tests: $0 or 20% coinsurance. X-Ray Services: $0 or 20% coinsurance. Therapeutic Radiological Services: $0 or 20% coinsurance.
High-Tech Diagnostic Radiology Services $0 or 20% coinsurance for peripheral vascular disease ultrasounds. $0 or 20% coinsurance for high tech diagnostic tests. (CT, MRI, PET scan). $0 or 20% coinsurance for peripheral vascular disease ultrasounds. $0 or 20% coinsurance for high tech diagnostic tests. (CT, MRI, PET scan).
Doctor's Office Visits $0 or 20% coinsurance. $0 or 20% coinsurance.
Emergency Care $0 or $115 copay. $0 or $115 copay.
Flexcard $114 per month for OTC, healthy food* /produce* & plan covered services such as: physician services, lab work, PT/OT/ST. (excludes supplemental benefits provided by a vendor & prescription drugs); includes retail. With rollover.

*This benefit is a special supplemental benefit for the chronically ill (SSBCI) and is made available to members with one or more qualifying chronic conditions. Not all members will qualify for this benefit. Qualifying chronic conditions include but are not limited to diabetes, cardiovascular disorders, chronic lung disorders, cancer, and dementia. For a complete list of qualifying chronic conditions please see the plan’s Evidence of Coverage (EOC).		 $114 per month; after 50% coinsurance for OTC, healthy food* /produce* & plan covered services such as: physician services, lab work, PT/OT/ST. (excludes supplemental benefits provided by a vendor & prescription drugs); includes retail. With rollover.

*This benefit is a special supplemental benefit for the chronically ill (SSBCI) and is made available to members with one or more qualifying chronic conditions. Not all members will qualify for this benefit. Qualifying chronic conditions include but are not limited to diabetes, cardiovascular disorders, chronic lung disorders, cancer, and dementia. For a complete list of qualifying chronic conditions please see the plan’s Evidence of Coverage (EOC).
Foot Care (Podiatry Services) Podiatry Services and Routine Foot Care: $0 or 20% coinsurance. Podiatry Services: $0 or 20% coinsurance. Routine Foot Care: $0 or 20% coinsurance.
Hearing Services Medicare-covered hearing Benefits: $0 or 20% coinsurance. Routine Hearing Exams: $0 . Fitting/Evaluation for Hearing Aid: $0. Must use NationsHearing®. Medicare-covered hearing Benefits: $0 or 20% coinsurance. Routine Hearing Exams:$0 . Fitting/Evaluation for Hearing Aid: $0. Must use NationsHearing®.
Inpatient Hospital Care $0 or $2,125 per stay for inpatient acute. $0 or $2,091 per stay for inpatient psyphiatric. $0 or 20% coinsurance per stay for inpatient acute.
Meal Benefit Limited to 2 discharges per year of 28 meals /14 days; max of 56 meals per year. Limited to 2 discharges per year of 28 meals /14 days; max of 56 meals per year.
Medical Equipment/Supplies Durable Medical Equipment and Prosthetic Devices: $0 or 20% coinsurance. Diabetic Supplies and Services: $0 or 20% coinsurance. Durable Medical Equipment and Prosthetic Devices: $0 or 20% coinsurance. Diabetic Supplies and Services: $0 or 20% coinsurance.
Mental Health Services $0 or 20% coinsurance. $0 or 20% coinsurance.
OTC Coverage available with Flex Card allowance. (See Flex Card details above). Coverage available with Flex Card allowance. (See Flex Card details above).
Other Diagnostic Test/Procedures Pacemaker testing, bone density testing, surgical supplies (splints and casts included): $0 copay. Pacemaker testing, bone density testing, surgical supplies (splints and casts included): $0 or 20% coinsurance.
Outpatient Hospital & Observation Services $0 or 20% coinsurance. $0 or 20% coinsurance.
Outpatient Therapy (Physical, Occupational, Speech, Cardiac) $0 or 20% coinsurance. $0 or 20% coinsurance.
Outpatient X-rays $0 or 20% coinsurance. $0 or 20% coinsurance.
Personal Emergency Response System (PERS) 24/7 monitoring service that can respond to emergency services, family or caregiver For members with an identified fall risk. Powered by NationsResponse®. 24/7 monitoring service that can respond to emergency services, family or caregiver For members with an identified fall risk. Powered by NationsResponse®.
Preventive Care Covered at 100%. $0 or 20% coinsurance.
Fitness Benefits As a member, you have a fitness benefit through One Pass ® at no additional cost. Access to one of the largest fitness networks in the nation. As a member, you have a fitness benefit through One Pass ® at no additional cost. Access to one of the largest fitness networks in the nation.
Skilled Nursing Facility $0 copay for days 1 to 20. $221 copay for days 21 to 100. $0 or 20% coinsurance for days 1 to 20. $0 or 20% coinsurance for days 21 to 100.
Therapeutic radiology services, such as radiation treatment for cancer $0 or 20% coinsurance. $0 or 20% coinsurance.
Ultrasounds $0 or 20% coinsurance. $0 or 20% coinsurance.
Urgently Needed Services Urgent Care: $0 or $40 copay. Urgent Care: $0 or $40 copay.
Vision Services Medicare-covered Benefits: $0 or 20% coinusrance. Routine Eye Exam: $0 through Eyemed Insight Network. Medicare-covered Benefits: $0 or 20% coinusrance. Routine Eye Exam: $0 through Eyemed Insight Network.
Wellness Programs Fitness Benefit, Nutritional/Dietary Counseling, Unlimited Sessions of Smoking & Tobacco Cessation Counseling. Population Health & Care Management Programs. Fitness Benefit, Nutritional/Dietary Counseling, Unlimited Sessions of Smoking & Tobacco Cessation Counseling. Population Health & Care Management Programs.

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
Tier 1 - Preferred Generic $0 $0 $0
Tier 2 - Generic 25% 25% 25%
Tier 3 - Preferred Brand 25% 25% 25%
Tier 4 - Non-Preferred Brand 25% 25% 25%
Tier 5 - Specialty Tier 25% 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.

Plan Documents

Medicare Star Ratings
Delta Dental (Find A Dentist)
Summary Of Benefits
Find a HAP Doctor
HAP Medicare Member Resources
HAP Medicare Options
Nations Hearing
Over-the-Counter Benefit