Clear Spring Health Choice Plan (PPO) - 2021

Clear Spring Health Choice Plan (PPO) - Clear Spring Health - Local PPO

Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H9589-003-000
Plan Organization Clear Spring Health
Plan Type Local PPO
Plan Name Clear Spring Health Choice Plan (PPO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating Not enough data available
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
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 $250.00
Annual Drug Deductible $250.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $7550.00
Gap Coverage No

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 Out-of-Network Yes No 20% coinsurance
Endodontics No - - - Not covered
Extractions No - - - Not covered
Non-routine services No - - - Not covered
Periodontics No - - - Not covered
Prosthodontics, other oral/maxillofacial surgery, other services Yes Out-of-Network Yes No 20% coinsurance
Restorative services Yes Out-of-Network Yes No 20% coinsurance
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - Out-of-Network Yes No 20% coinsurance
Diagnostic tests and procedures - Out-of-Network Yes No 20% coinsurance
Lab services - Out-of-Network Yes No $10 copay
Outpatient x-rays - Out-of-Network Yes No 40% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - $20 copay per visit
Specialist - Out-of-Network No No $45 copay per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 copay per visit (always covered)
Urgent care - - - - $35 copay per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network No No $45 copay
Routine foot care No Out-of-Network No No $45 copay
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - 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 Yes Out-of-Network No No 50% coinsurance
Hearing aids Yes Out-of-Network No No 50% coinsurance
Hearing exam - Out-of-Network No No 20% coinsurance
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $395 per day for days 1 through 4$0 per day for days 5 through 90
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $7,550 In and Out-of-network$7,550 In-network$7,550 Out-of-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network Yes - 20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 45% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 20% coinsurance
Other Part B drugs - Out-of-Network Yes - 20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No $395 per day for days 1 through 4$0 per day for days 5 through 90
Outpatient group therapy visit - Out-of-Network No No $40 copay
Outpatient group therapy visit with a psychiatrist - Out-of-Network No No $40 copay
Outpatient individual therapy visit - Out-of-Network No No $40 copay
Outpatient individual therapy visit with a psychiatrist - Out-of-Network No No $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 - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 20% coinsurance per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network No No $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes Out-of-Network No No 50% coinsurance
Dental x-ray(s) Yes Out-of-Network No No 50% coinsurance
Fluoride treatment No - - - Not covered
Oral exam Yes Out-of-Network No No 50% coinsurance
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - Out-of-Network Yes No $40 copay
Physical therapy and speech and language therapy visit - Out-of-Network Yes No $40 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $195 per day for days 1 through 35$0 per day for days 36 through 100
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses No - - - Not covered
Eyeglass frames No - - - Not covered
Eyeglass lenses No - - - Not covered
Eyeglasses (frames and lenses) Yes Out-of-Network No No 50% coinsurance
Other No - - - Not covered
Routine eye exam Yes Out-of-Network No No 50% coinsurance
Upgrades - - - - Not covered
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No 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
Plan Available in these Counties
Baker County, Georgia, Baldwin County, Georgia, Banks County, Georgia, Barrow County, Georgia, Bibb County, Georgia, Bleckley County, Georgia, Bryan County, Georgia, Butts County, Georgia, Chatham County, Georgia, Cherokee County, Georgia, Clayton County, Georgia, Clinch County, Georgia, Crawford County, Georgia, Dawson County, Georgia, Dekalb County, Georgia, Dodge County, Georgia, Dooly County, Georgia, Fayette County, Georgia, Forsyth County, Georgia, Franklin County, Georgia, Greene County, Georgia, Hancock County, Georgia, Hart County, Georgia, Heard County, Georgia, Henry County, Georgia, Houston County, Georgia, Jasper County, Georgia, Jones County, Georgia, Lamar County, Georgia, Lumpkin County, Georgia, Macon County, Georgia, Madison County, Georgia, Mcintosh County, Georgia, Meriwether County, Georgia, Monroe County, Georgia, Morgan County, Georgia, Newton County, Georgia, Oconee County, Georgia, Oglethorpe County, Georgia, Peach County, Georgia, Pickens County, Georgia, Pike County, Georgia, Pulaski County, Georgia, Putnam County, Georgia, Rabun County, Georgia, Rockdale County, Georgia, Schley County, Georgia, Screven County, Georgia, Stephens County, Georgia, Talbot County, Georgia, Taliaferro County, Georgia, Taylor County, Georgia, Twiggs County, Georgia, Walton County, Georgia, White County, Georgia, Wilcox County, Georgia, Wilkinson County, Georgia

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