Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H8093-001-000
Plan Organization Georgia Health Advantage
Plan Type Local HMO
Plan Name Georgia Health Advantage (HMO I-SNP)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors for Most Services
Benefit Type Defined Standard Benefit
Special Needs Plan Yes
Special Needs Plan Type Institutional
Overall Star Rating Plan too new to be measured
Plan Cost Sharing
Premium $29.80
Total Premium (Includes Part B) $165.30
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $29.80
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $29.80
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $7.40
Monthly Part D Premium 50% Assistance $14.90
Monthly Part D Premium 25% Assistance $22.30
Part D Drug Deductible $445.00
Annual Drug Deductible $445.00
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 - - - Not covered
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 No - - - Not covered
Restorative services No - - - Not covered
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - - Yes No 20% coinsurance
Diagnostic tests and procedures - - Yes No 20% coinsurance
Lab services - - Yes No $0 copay
Outpatient x-rays - - Yes No 20% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - $0 copay
Specialist - - No No 20% coinsurance per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - 20% coinsurance per visit (always covered)
Urgent care - - - - 20% coinsurance per visit (always covered)
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - - No No 20% coinsurance
Routine foot care Yes - No No $0 copay
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
- - - - Coming soon
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 20% coinsurance
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No 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 - 20% coinsurance per item
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 Coming soon
Outpatient group therapy visit - - No No 20% coinsurance
Outpatient group therapy visit with a psychiatrist - - No No 20% coinsurance
Outpatient individual therapy visit - - No No 20% coinsurance
Outpatient individual therapy visit with a psychiatrist - - No No 20% coinsurance
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 20% coinsurance 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 No - - - Not covered
Dental x-ray(s) No - - - Not covered
Fluoride treatment No - - - Not covered
Oral exam No - - - Not covered
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - - Yes No 20% coinsurance
Physical therapy and speech and language therapy visit - - Yes No 20% coinsurance
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No Tier 1$0 copay per stayTier 2Coming soon
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes - No No $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
- - - - Not 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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