HAP CareSource MI Coordinated Health
HMO D-SNP

Price: $0.00, per month

Plan Specifics

Star Rating
Coverage Type
Part A, Part B, Part D
Monthly Plan Premium
$0
Contract ID
H4193-001
Annual Medical Deductible
$0
Annual Prescription Deductible
$0 - $700 (Depending on LIS status)
Max Enrollee Out-of-Pocket
$9,850 Annual In-Network
Plan Details

Plan Covered Medical Benefits

Category In-Network
Allowance for Eyewear No cost routine eye exam every 2 years. Eyeglasses and contacts are covered, $250 allowance.
Allowance for Hearing Aids Two hearing aids every 3 years. (limit one hearing aid per ear every 3 years).
Ambulance $0 copay.
Ambulatory Surgical Center $0 copay.
Annual Physical $0 copay.
Chiropractic Services $0 copay.
Companion Care $0 copay. Eligible waiver members may receive up to
4 hours of in-home IADL support services each month at no
additional cost. Unused hours do not carry over to the following
month.
Dental Services Preventive care (e.g., exams, cleanings, x-rays and fluoride) and comprehensive dental (e.g., simple extractions, minor restorations, periodontics and other non-Medicare covered comprehensive dental services including extractions, crowns, implants, and dentures). Plan limit of $3,000 towards supplemental 2 fluoride treatments and dental implants. Routine dental care must be received from a participating Delta Dental provider. Non-routine services must be received from a participating HAP CareSource provider.
Diabetes Screening, Diabetes Self- Management Training, Diabetic Services & Supplies $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.
High-Tech Diagnostic Radiology Services $0 copay.
Doctor's Office Visits Primary Care Provider Office Visit: $0 copay. Specialist Office Visit: $0 copay.

Additional Telehealth: $0 Copay. Mental health and general medical services are available through Teladoc.
Emergency Care Emergency Room: $0 copay.

World Wide Emergency Coverage: Coverage maximum is Limit $10,000 per year.
Flexcard Members use Healthy Benefits+ debit card to purchase up to $205 per month for approved services and items from eligible locations, including:Over-the-counter items, Dental, Vision & Hearing.

For members approved for Special Supplemental Benefits for the Chronically Ill (SSBCI), members may use the Healthy Benefits+ card for the following qualifying items and services at eligible locations: Healthy Food*, Utilities*, Rent & mortgage assistance*, Household cleaning supplies*, Personal Care Items*
Unused amounts rollover to the following month and will expire at the end of the year.

*The benefits mentioned are Special Supplemental Benefits for the Chronically Ill (SSBCI). You may qualify for SSBCI if you are at high risk for hospitalization and require intensive care coordination to manage one or more chronic conditions such as cardiovascular disorders, diabetes, overweight/obesity/metabolic syndrome, chronic and disabling mental health conditions or neurologic disorders. For a full list of qualifying chronic conditions or to learn more about other eligibility requirements for SSBCI, please contact Member Services or your Care Coordinator. Certain restrictions may apply. Only at participating locations.
Foot Care (Podiatry Services) Podiatry Services: $0 copay.
Hearing Services Routine Hearing Exams: $0. Fitting/Evaluation for Hearing Aid: $0.
No cost annual routine hearing exam and fitting through NationsHearing.
Inpatient Hospital Care $0 copay.
Meal Benefit Two meals a day for 14 days after each inpatient hospitalization or skilled nursing facilility stay (Community Well Only). *Only for community-well members who are getting their long-term services and support in their own homes or communities. Excludes those in home- and community-based services waiver and long-term care members.
Medical Equipment/Supplies Durable Medical Equipment and Prosthetic Devices: $0 copay. Diabetic Supplies and Services: $0 copay.
Mental Health Services $0 copay.
OTC Coverage available with Flex Card allowance. (See Flex Card details above).
Other Diagnostic Test/Procedures $0 copay.
Outpatient Hospital & Observation Services $0 copay.
Outpatient Therapy (Physical, Occupational, Speech, Cardiac) $0 copay.
Outpatient X-rays $0 copay.
Personal Emergency Response System (PERS) $0 Copay Alert system that connects individuals to a 24-hour response center with the push of a button (Community Well Only*). *Only for community-well members who are getting their long-term services and support in their own homes or communities. Excludes those in home- and community-based services waiver and long-term care members.
Preventive Care $0 copay.
Fitness Benefits Members have access to the Silver&Fit® Healthy Aging and Exercise program at no cost.
Includes membership at participating fitness centers and 1 home fitness kit, as well as online features (on-demand workout videos, virtual events, and specialized coaching sessions).
Skilled Nursing Facility $0 copay.
Therapeutic radiology services, such as radiation treatment for cancer $0 copay.
Transportation Unlimited one-way health related trips to provider visits, pharmacy, gym, grocery and community/wellness services.
Ultrasounds $0 copay.
Urgently Needed Services $0 copay.
Vision Services $0 Copay for one routine eye exam every two years. Members receive a $250 annual allowance for eyewear, including glasses and contact lenses. You must use participating EyeMed provider.
Wellness Programs Nutritional/Dietary Counseling, Two Sessions of Smoking & Tobacco Cessation Counseling. Population Health & Care Coordination 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
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 $0 $0 $0 N/A N/A N/A
Tier 3 - Preferred Brand $0 $0 $0 N/A N/A N/A
Tier 4 - Non-Preferred Brand $0 $0 $0 N/A N/A N/A
Tier 5 - Specialty Tier $0 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.

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