Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H2392-001-000
Plan Organization Kansas Health Advantage
Plan Type Local HMO
Plan Name Kansas 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 Not enough data available
Plan Cost Sharing
Premium $31.50
Total Premium (Includes Part B) $167
Monthly Part D Basic Premium $31.50
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $31.50
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $7.90
Monthly Part D Premium 50% Assistance $15.70
Monthly Part D Premium 25% Assistance $23.60
Part D Drug Deductible $435.00
Annual Drug Deductible $435
Part D Initial Coverage Limit $4020
Part D Catastrophic Coverage Threshold $6350
Formulary Website Formulary Link

Medicare Advantage Plan Health Benefits


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

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