Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H0838-045-000
Plan Organization Brand New Day
Plan Type Local HMO
Plan Name Brand New Day Select Choice II Plan (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 3.5
Plan Cost Sharing
Premium $31.50
Total Premium (Includes Part B) $167.00
Monthly Part C Premium $0.00
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 $15.80
Monthly Part D Premium 25% Assistance $23.60
Part D Drug Deductible $445.00
Annual Drug Deductible $445.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00

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 No - Yes Yes $0 copay
Endodontics No - Yes Yes $0 copay
Extractions No - Yes Yes $0 copay
Non-routine services No - Yes Yes $0 copay
Periodontics No - Yes Yes $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services No - Yes Yes $0 copay
Restorative services No - 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 20% coinsurance
Diagnostic tests and procedures - - Yes Yes 20% coinsurance
Lab services - - Yes Yes $0 copay
Outpatient x-rays - - Yes Yes 20% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - 20% coinsurance per visit
Specialist - - Yes Yes 0-20% coinsurance per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 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 - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - 20% coinsurance
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 No - - - Not covered
Hearing aids Yes - No No $149 copay
Hearing exam - - Yes Yes $0 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes Coming soon
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $7,550 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 - 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - - Yes - 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 - 20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - - Yes Yes Coming soon
Outpatient group therapy visit - - Yes Yes 20% coinsurance
Outpatient group therapy visit with a psychiatrist - - Yes Yes $40 copay
Outpatient individual therapy visit - - Yes Yes 20% coinsurance
Outpatient individual therapy visit with a psychiatrist - - Yes Yes $40 copay
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 - - Yes
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes 20% coinsurance 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 No - - - Not covered
Oral exam Yes - No No $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - - Yes Yes $35 copay
Physical therapy and speech and language therapy visit - - Yes Yes $40 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes Coming soon
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
No - Yes Yes $0 copay
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes - No No $0 copay
Eyeglass frames 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
Routine eye exam Yes - No No $0 copay
Upgrades Yes - No No $0 copay
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes Covered
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

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