Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H8093-001-000
Plan Organization Georgia Assurance
Plan Type Local HMO
Plan Name Georgia Health Advantage (HMO I-SNP)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors for Most Services
Benefit Type Defined Standard Benefit
Special Needs Plan Yes
Special Needs Plan Type Institutional
Overall Star Rating Plan too new to be measured
Plan Cost Sharing
Premium $25.30
Total Premium (Includes Part B) $160.80
Monthly Part D Basic Premium $25.30
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $25.30
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $6.30
Monthly Part D Premium 50% Assistance $12.60
Monthly Part D Premium 25% Assistance $19.00
Part D Drug Deductible $435.00
Annual Drug Deductible $435.00
Part D Initial Coverage Limit $4020.00
Part D Catastrophic Coverage Threshold $6350.00
Formulary Website Formulary Link

Medicare Advantage Plan Health Benefits


Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Extractions No - - - Not covered
Non-routine services No - - - Not covered
Periodontics No - - - Not covered
Diagnostic services No - - - Not covered
Prosthodontics, other oral/maxillofacial surgery, other services No - - - Not covered
Endodontics No - - - Not covered
Restorative services No - - - Not covered
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic tests and procedures - - No No 20%
Lab services - - No No $0 copay
Diagnostic radiology services (e.g., MRI) - - Yes No 20%
Outpatient x-rays - - Yes No 20%
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Hearing aids - outer ear No - - - Not covered
Hearing aids - over the ear No - - - Not covered
Hearing exam - - No No 20%
Hearing aids - inner ear No - - - Not covered
Fitting/evaluation No - - - Not covered
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $6,700 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Prosthetics (e.g., braces, artificial limbs) - - Yes - 20% per item
Diabetes supplies - - Yes - 20% per item
Durable medical equipment (e.g., wheelchairs, oxygen) - - Yes - 20% per item
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - - Yes No Coming soon
Outpatient group therapy visit with a psychiatrist - - No No 20%
Outpatient individual therapy visit with a psychiatrist - - No No 20%
Outpatient group therapy visit - - No No 20%
Outpatient individual therapy visit - - No No 20%
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Dental x-ray(s) No - - - Not covered
Fluoride treatment No - - - Not covered
Cleaning No - - - Not covered
Oral exam No - - - Not covered
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - - Yes No 20%
Physical therapy and speech and language therapy visit - - Yes No 20%
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No Coming soon
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Eyeglass frames Yes - No No $0 copay
Routine eye exam Yes - No No $0 copay
Eyeglass lenses Yes - No No $0 copay
Eyeglasses (frames and lenses) Yes - No No $0 copay
Other No - - - Not covered
Upgrades Yes - No No $0 copay
Contact lenses Yes - No No $0 copay
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Urgent care - - - - 20% per visit (always covered)
Emergency - - - - 20% per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - - No No 20%
Routine foot care Yes - No No $0 copay
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - 20%
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No Coming soon
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes - No No $0 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - 20% per visit
Specialist - - No No 20% per visit
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No 20% per visit
Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Coming soon
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - - Yes - 20%
Other Part B drugs - - Yes - 20%
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048

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