Clear Spring Health Select Plus (HMO) - 2021

Clear Spring Health Select Plus (HMO) - Clear Spring Health - Local HMO

Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H6672-005-000
Plan Organization Clear Spring Health
Plan Type Local HMO
Plan Name Clear Spring Health Select Plus (HMO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors for Most Services
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating Not enough data available
Plan Cost Sharing
Premium $19.00
Total Premium (Includes Part B) $154.50
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $19.00
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $19.00
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $4.70
Monthly Part D Premium 50% Assistance $9.50
Monthly Part D Premium 25% Assistance $14.20
Part D Drug Deductible $0.00
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 - Yes No $0 copay
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 - Yes No $0 copay
Restorative services Yes - Yes No $0 copay
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - - Yes No $0-100 copay
Diagnostic tests and procedures - - Yes No 20% coinsurance
Lab services - - Yes No $0 copay
Outpatient x-rays - - Yes No $0-100 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - $0 copay
Specialist - - No No $40 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 - - No No $40 copay
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $265 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 - No No $0 copay
Hearing aids Yes - No No $0 copay
Hearing exam - - No No $0-40 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $295 per day for days 1 through 7$0 per day for days 8 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-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 No $250 per day for days 1 through 7$0 per day for days 8 through 90
Outpatient group therapy visit - - No No $40 copay
Outpatient group therapy visit with a psychiatrist - - No No $40 copay
Outpatient individual therapy visit - - No No $40 copay
Outpatient individual therapy visit with a psychiatrist - - 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
- - Yes No $250 copay per visit
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No $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 No $40 copay
Physical therapy and speech and language therapy visit - - Yes No $40 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $0 per day for days 1 through 20$167 per day for days 21 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 - No No $0 copay
Other No - - - Not covered
Routine eye exam Yes - No No $0 copay
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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