Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H1924-002-000
Plan Organization Lasso Healthcare
Plan Type MSA *
Plan Name Lasso Healthcare (MSA)
Drugs Covered No
Doctors Choice Any Doctor
Overall Star Rating Plan too new to be measured
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $0.00

Medicare Advantage Plan Health Benefits


Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services - - - - Not covered
Prosthodontics, other oral/maxillofacial surgery, other services - - - - Not covered
Extractions - - - - Not covered
Non-routine services - - - - Not covered
Periodontics - - - - Not covered
Endodontics - - - - Not covered
Restorative services - - - - Not covered
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Lab services - - - - $0 copay after you pay your deductible
Diagnostic tests and procedures - - - - $0 copay after you pay your deductible
Diagnostic radiology services (e.g., MRI) - - - - $0 copay after you pay your deductible
Outpatient x-rays - - - - $0 copay after you pay your deductible
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Specialist - - - - $0 copay after you pay your deductible
Primary - - - - $0 copay after you pay your deductible
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Hearing aids - inner ear - - - - Not covered
Hearing aids - outer ear - - - - Not covered
Hearing aids - over the ear - - - - Not covered
Hearing exam - - - - $0 copay after you pay your deductible
Fitting/evaluation - - - - Not covered
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0 copay after you pay your deductible
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - - - - $0 copay after you pay your deductible
Durable medical equipment (e.g., wheelchairs, oxygen) - - - - $0 copay after you pay your deductible
Prosthetics (e.g., braces, artificial limbs) - - - - $0 copay after you pay your deductible
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Outpatient individual therapy visit - - - - $0 copay after you pay your deductible
Inpatient hospital - psychiatric - - - - $0 copay after you pay your deductible
Outpatient group therapy visit with a psychiatrist - - - - $0 copay after you pay your deductible
Outpatient group therapy visit - - - - $0 copay after you pay your deductible
Outpatient individual therapy visit with a psychiatrist - - - - $0 copay after you pay your deductible
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0 copay after you pay your deductible
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Other - - - - Not covered
Upgrades - - - - Not covered
Eyeglass lenses - - - - Not covered
Eyeglasses (frames and lenses) - - - - Not covered
Contact lenses - - - - Not covered
Eyeglass frames - - - - Not covered
Routine eye exam - - - - 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
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Urgent care - - - - $0 copay after you pay your deductible
Emergency - - - - $0 copay after you pay your deductible
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Routine foot care - - - - Not covered
Foot exams and treatment - - - - $0 copay after you pay your deductible
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0 copay after you pay your deductible
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $8,400 annual deductible
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning - - - - Not covered
Dental x-ray(s) - - - - Not covered
Fluoride treatment - - - - Not covered
Oral exam - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - - - - $0 copay after you pay your deductible
Other Part B drugs - - - - $0 copay after you pay your deductible
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Physical therapy and speech and language therapy visit - - - - $0 copay after you pay your deductible
Occupational therapy visit - - - - $0 copay after you pay your deductible
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not Applicable
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0 copay after you pay your deductible
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Abbeville County, South Carolina, Adams County, North Dakota, Anderson County, South Carolina, Appling County, Georgia, Avery County, North Carolina, Baker County, Georgia, Baldwin County, Georgia, Banks County, Georgia, Barnes County, North Dakota, Barrow County, Georgia, Bartow County, Georgia, Beadle County, South Dakota, Bennett County, South Dakota, Benson County, North Dakota, Berks County, Pennsylvania, Bibb County, Georgia, Billings County, North Dakota, Bladen County, North Carolina, Bowie County, Texas, Bowman County, North Dakota, Box Elder County, Utah, Bracken County, Kentucky, Brooks County, Texas, Brown County, South Dakota, Brule County, South Dakota, Bryan County, Georgia, Buffalo County, South Dakota, Buncombe County, North Carolina, Burke County, Georgia, Burleson County, Texas, Burnet County, Texas, Butler County, Kansas, Butts County, Georgia, Cache County, Utah, Calhoun County, South Carolina, Campbell County, South Dakota, Carbon County, Pennsylvania, Cass County, Texas, Cavalier County, North Dakota, Centre County, Pennsylvania, Charles Mix County, South Dakota, Charleston County, South Carolina, Chatham County, Georgia, Chattahoochee County, Georgia, Cherokee County, Georgia, Cherokee County, Kansas, Cherokee County, North Carolina, Cherokee County, South Carolina, Chester County, South Carolina, Chesterfield County, South Carolina, Clark County, Arkansas, Clarke County, Georgia, Clay County, Arkansas, Clay County, Georgia, Clay County, Illinois, Clay County, North Carolina, Clayton County, Georgia, Cleburne County, Arkansas, Clinton County, Pennsylvania, Cobb County, Georgia, Coffee County, Georgia, Coffey County, Kansas, Coles County, Illinois, Colquitt County, Georgia, Columbia County, Georgia, Columbia County, Pennsylvania, Conway County, Arkansas, Corson County, South Dakota, Coweta County, Georgia, Craighead County, Arkansas, Crawford County, Illinois, Crisp County, Georgia, Crittenden County, Arkansas, Cross County, Arkansas, Daggett County, Utah, Dallas County, Arkansas, Dawson County, Georgia, Dekalb County, Georgia, Dekalb County, Illinois, Desha County, Arkansas, Dewey County, South Dakota, Dickey County, North Dakota, Dooly County, Georgia, Dougherty County, Georgia, Douglas County, Georgia, Douglas County, South Dakota, Dunn County, North Dakota, Eddy County, North Dakota, Edmunds County, South Dakota, Edwards County, Illinois, Effingham County, Georgia, Elbert County, Georgia, Emmons County, North Dakota, Evans County, Georgia, Fairfield County, South Carolina, Fannin County, Georgia, Faulk County, South Dakota, Faulkner County, Arkansas, Fayette County, Georgia, Forsyth County, Georgia, Foster County, North Dakota, Franklin County, Georgia, Franklin County, Illinois, Fulton County, Georgia, Garland County, Arkansas, Gilmer County, Georgia, Glynn County, Georgia, Graham County, North Carolina, Grant County, Arkansas, Grant County, North Dakota, Greene County, Arkansas, Greenville County, South Carolina, Greenwood County, South Carolina, Gregory County, South Dakota, Griggs County, North Dakota, Gwinnett County, Georgia, Haakon County, South Dakota, Habersham County, Georgia, Hancock County, Georgia, Hancock County, Illinois, Hand County, South Dakota, Hanson County, South Dakota, Harding County, South Dakota, Harnett County, North Carolina, Harris County, Georgia, Hart County, Georgia, Harvey County, Kansas, Hawaii County, Hawaii, Haywood County, North Carolina, Heard County, Georgia, Henry County, Georgia, Hettinger County, North Dakota, Hoke County, North Carolina, Honolulu County, Hawaii, Hot Spring County, Arkansas, Hudspeth County, Texas, Hughes County, South Dakota, Hyde County, South Dakota, Independence County, Arkansas, Iroquois County, Illinois, Irwin County, Georgia, Jackson County, Arkansas, Jackson County, Georgia, Jackson County, Illinois, Jackson County, Kansas, Jackson County, North Carolina, Jackson County, South Dakota, Jasper County, Georgia, Jefferson County, Kansas, Jerauld County, South Dakota, Jim Hogg County, Texas, Johnson County, Georgia, Jones County, Georgia, Jones County, South Dakota, Juniata County, Pennsylvania, Kalawao County, Hawaii, Kauai County, Hawaii, Kenedy County, Texas, Kidder County, North Dakota, La Salle County, Illinois, Lamar County, Georgia, Lamoure County, North Dakota, Lancaster County, South Carolina, Laurens County, Georgia, Laurens County, South Carolina, Lee County, Arkansas, Lee County, Georgia, Lee County, North Carolina, Lehigh County, Pennsylvania, Leon County, Texas, Lexington County, South Carolina, Liberty County, Georgia, Limestone County, Texas, Lincoln County, Arkansas, Lincoln County, Georgia, Logan County, North Dakota, Lonoke County, Arkansas, Luzerne County, Pennsylvania, Lycoming County, Pennsylvania, Lyman County, South Dakota, Lyon County, Kansas, Macon County, Georgia, Macon County, North Carolina, Madison County, Georgia, Madison County, North Carolina, Madison County, Texas, Marion County, Georgia, Marshall County, South Dakota, Maui County, Hawaii, Mccook County, South Dakota, Mcdowell County, North Carolina, Mcduffie County, Georgia, Mchenry County, North Dakota, Mcintosh County, Georgia, Mcintosh County, North Dakota, Mclean County, North Dakota, Mcpherson County, South Dakota, Mellette County, South Dakota, Mercer County, North Dakota, Meriwether County, Georgia, Mifflin County, Pennsylvania, Mineral County, Nevada, Mitchell County, North Carolina, Monroe County, Arkansas, Monroe County, Georgia, Monroe County, Pennsylvania, Montgomery County, Arkansas, Montgomery County, Kentucky, Montgomery County, North Carolina, Montour County, Pennsylvania, Moore County, North Carolina, Morgan County, Georgia, Morgan County, Utah, Muscogee County, Georgia, Nelson County, North Dakota, Newton County, Georgia, Northampton County, Pennsylvania, Northumberland County, Pennsylvania, Oconee County, Georgia, Oconee County, South Carolina, Oglala Lakota County, South Dakota, Ogle County, Illinois, Oglethorpe County, Georgia, Oliver County, North Dakota, Osage County, Kansas, Peach County, Georgia, Pembina County, North Dakota, Perkins County, South Dakota, Perry County, Arkansas, Perry County, Pennsylvania, Phillips County, Arkansas, Pickens County, Georgia, Pickens County, South Carolina, Pierce County, North Dakota, Pike County, Georgia, Poinsett County, Arkansas, Polk County, Arkansas, Polk County, North Carolina, Pottawatomie County, Kansas, Potter County, South Dakota, Prairie County, Arkansas, Pulaski County, Arkansas, Quitman County, Georgia, Ramsey County, North Dakota, Randolph County, Arkansas, Randolph County, Georgia, Ransom County, North Dakota, Red River County, Texas, Rich County, Utah, Richland County, Illinois, Richmond County, Georgia, Richmond County, North Carolina, Robeson County, North Carolina, Rockdale County, Georgia, Rolette County, North Dakota, Rutherford County, North Carolina, Saint Francis County, Arkansas, Saline County, Arkansas, Saline County, Illinois, Saluda County, South Carolina, Sampson County, North Carolina, Sargent County, North Dakota, Schley County, Georgia, Schuylkill County, Pennsylvania, Scotland County, North Carolina, Sedgwick County, Kansas, Shawnee County, Kansas, Sheridan County, North Dakota, Sioux County, North Dakota, Slope County, North Dakota, Snyder County, Pennsylvania, Spalding County, Georgia, Spartanburg County, South Carolina, Stanley County, South Dakota, Stark County, North Dakota, Steele County, North Dakota, Stephens County, Georgia, Stewart County, Georgia, Stone County, Arkansas, Sullivan County, Pennsylvania, Sully County, South Dakota, Summit County, Utah, Sumter County, Georgia, Swain County, North Carolina, Taylor County, Georgia, Terrell County, Georgia, Tift County, Georgia, Tioga County, Pennsylvania, Titus County, Texas, Todd County, South Dakota, Tooele County, Utah, Toombs County, Georgia, Towner County, North Dakota, Towns County, Georgia, Traill County, North Dakota, Transylvania County, North Carolina, Treutlen County, Georgia, Tripp County, South Dakota, Turner County, Georgia, Twiggs County, Georgia, Union County, Georgia, Union County, Pennsylvania, Union County, South Carolina, Upson County, Georgia, Van Buren County, Arkansas, Wabash County, Illinois, Wabaunsee County, Kansas, Walsh County, North Dakota, Walton County, Georgia, Walworth County, South Dakota, Ward County, North Dakota, Ware County, Georgia, Warren County, Georgia, Wasatch County, Utah, Washington County, Georgia, Wayne County, Illinois, Wells County, North Dakota, White County, Arkansas, White County, Georgia, Williams County, North Dakota, Williamson County, Illinois, Woodruff County, Arkansas, Worth County, Georgia, Yancey County, North Carolina, Yell County, Arkansas, York County, South Carolina, Ziebach County, South Dakota

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