Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H5015-001-000
Plan Organization Texas Independence Health Plan
Plan Type Local HMO
Plan Name Texas Independence Health Plan, Inc. (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 $20.80
Total Premium (Includes Part B) $156.30
Monthly Part D Basic Premium $20.80
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $20.80
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $5.20
Monthly Part D Premium 50% Assistance $10.40
Monthly Part D Premium 25% Assistance $15.60
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
Extractions Yes - No No $0 copay
Non-routine services Yes - No No $0 copay
Periodontics Yes - No No $0 copay
Diagnostic services Yes - No No $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Yes - No No $0 copay
Endodontics Yes - No No $0 copay
Restorative services Yes - No No $0 copay
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Outpatient x-rays - - Yes No 20%
Lab services - - Yes No 20%
Diagnostic tests and procedures - - Yes No 20%
Diagnostic radiology services (e.g., MRI) - - Yes No 20%
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Specialist - - No No 20% per visit
Primary - - - - 20% per visit
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)
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Hearing aids - outer ear Yes - No No $0 copay
Hearing aids - over the ear Yes - No No $0 copay
Hearing aids - inner ear Yes - No No $0 copay
Hearing exam - - No No 20%
Fitting/evaluation Yes - No No $0 copay
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Other Part B drugs - - Yes - 20%
Chemotherapy - - Yes - 20%
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Dental x-ray(s) Yes - No No $0 copay
Cleaning Yes - No No $0 copay
Fluoride treatment Yes - No No $0 copay
Oral exam 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
Foot exams and treatment - - No No 20%
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
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - - Yes No Coming soon
Outpatient individual therapy visit - - Yes No 20%
Outpatient group therapy visit with a psychiatrist - - Yes No 20%
Outpatient group therapy visit - - Yes No 20%
Outpatient individual therapy visit with a psychiatrist - - Yes No 20%
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No 20% per visit
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%
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes - No No $0 copay
Eyeglass lenses No - - - Not covered
Other No - - - Not covered
Routine eye exam Yes - No No $0 copay
Upgrades - - - - Not covered
Eyeglass frames No - - - Not covered
Eyeglasses (frames and lenses) Yes - No No $0 copay
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%
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Durable medical equipment (e.g., wheelchairs, oxygen) - - Yes - 20% per item
Diabetes supplies - - Yes - 20% per item
Prosthetics (e.g., braces, artificial limbs) - - Yes - 20% per item
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No Coming soon
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No $0 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No Coming soon
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes - 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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