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 |
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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