Amerivantage CareMore Care To You Plus (HMO I-SNP) H1423-007-000 is a 2021 Medicare Advantage Institutional Special Needs Plan provided by Amerigroup Ohio.

A Special Needs Plan (SNP) is a type of Medicare Advantage Plan designed for Medicare beneficiaries with specific conditions or characteristics.

Institutional Special Needs Plans are for beneficiaries who live in an institution, such as a long-term care (LTC) skilled nursing facility (SNF), a LTC nursing facility (NF), a SNF/NF, an intermediate care facility for individuals with intellectual disabilities (ICF/IDD), or an inpatient psychiatric facility. If you don't meet this criteria, consider other plan choices in your county.

Special Needs plans provide both health coverage and drug coverage, and each coverage type has different costs to consider.

This plan has a monthly premium of $0.00, which covers both the health and drug portions of the plan.

When it comes to out-of-pocket costs for drugs, this plan has a Part D drug Deductible of $0.00 and an Initial Coverage Limit of $4130. Each drug tier may be subject to different cost-sharing in each coverage phase, so keep that in mind when considering out-of-pocket costs. Check out the drug formulary below for more information, or reach out to a licensed Medicare agent for help using the call number on this page. Alternatively, if you know what plan you want, you can enroll online yourself using our site as well.


Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H1423-007-000
Plan Organization Amerigroup Ohio
Plan Type Local HMO
Plan Name Amerivantage CareMore Care To You Plus (HMO I-SNP)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors for Most Services
Benefit Type Enhanced Alternative
Special Needs Plan Yes
Special Needs Plan Type Institutional
Overall Star Rating Plan too new to be measured
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $107.50
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $0.00
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $0.00
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $0.00
Monthly Part D Premium 50% Assistance $0.00
Monthly Part D Premium 25% Assistance $0.00
Part D Drug Deductible $0.00
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00
Gap Coverage Y

Medicare Advantage Plan Health Benefits


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
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services Yes - Yes Yes $0 copay
Endodontics Yes - Yes Yes $0 copay
Extractions Yes - Yes Yes $0 copay
Non-routine services Yes - Yes Yes $0 copay
Periodontics Yes - Yes Yes $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Yes - Yes Yes $0 copay
Restorative services Yes - Yes Yes $0 copay
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - - Yes Yes $0-150 copay
Diagnostic tests and procedures - - Yes Yes $0 copay
Lab services - - Yes Yes $0 copay
Outpatient x-rays - - Yes Yes $0 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - $0 copay
Specialist - - Yes Yes $0 copay
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $120 copay per visit (always covered)
Urgent care - - - - $0 copay
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - - Yes Yes $0 copay
Routine foot care Yes - Yes Yes $0 copay
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $195 copay
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation Yes - Yes Yes $0 copay
Hearing aids Yes - Yes No $0 copay
Hearing exam - - Yes Yes $0 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes $200 per day for days 1 through 5$0 per day for days 6 through 90
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $2,700 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - - Yes - $0 copay
Durable medical equipment (e.g., wheelchairs, oxygen) - - Yes - 0-20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - - Yes - 0-20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - - Yes - 20% coinsurance
Other Part B drugs - - Yes - 0-20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - - Yes Yes $200 per day for days 1 through 5$0 per day for days 6 through 90
Outpatient group therapy visit - - Yes Yes $0 copay
Outpatient group therapy visit with a psychiatrist - - Yes Yes $0 copay
Outpatient individual therapy visit - - Yes Yes $0 copay
Outpatient individual therapy visit with a psychiatrist - - Yes Yes $0 copay
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Yes
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 Yes $0-125 copay per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes - No No $0 copay
Dental x-ray(s) Yes - No No $0 copay
Fluoride treatment Yes - No No $0 copay
Oral exam Yes - No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - - Yes Yes $0 copay
Physical therapy and speech and language therapy visit - - Yes Yes $0 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes $0 copay per stay
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes - Yes No $0 copay
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes - Yes Yes $0 copay
Eyeglass frames Yes - Yes Yes $0 copay
Eyeglass lenses Yes - Yes Yes $0 copay
Eyeglasses (frames and lenses) Yes - Yes Yes $0 copay
Other No - - - Not covered
Routine eye exam Yes - Yes Yes $0 copay
Upgrades - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes Covered

Medicare Plan Packages


Package #1
Category Cost Sharing Type Cost Share
Preventive dental Monthly Premium $12.00
Package #2
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium $25.00
Eyewear Monthly Premium $25.00
Preventive dental Monthly Premium $25.00
Package #3
Category Cost Sharing Type Cost Share
Comprehensive dental Monthly Premium $47.00
Eyewear Monthly Premium $47.00
Preventive dental Monthly Premium $47.00
Plan Drug Info
Formulary Link Drug Formulary Directory
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Pima County, Arizona

NOTE: Information on MedicarePolicyHelper.com is for educational purposes only. We are not affiliated with Medicare, or CMS. Medicare has not reviewed or endorsed the information on our site. All plan data on our site comes directly from medicare.gov and is subject to change.