Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H1651-026-000
Plan Organization Medical Associates Health Plan, Inc.
Plan Type Cost *
Plan Name Medical Associates Nebraska Senior Plan (Cost)
Drugs Covered No
Doctors Choice Plan Doctors for Most Services
Overall Star Rating 5
Plan Cost Sharing
Premium $147.00
Total Premium (Includes Part B) $282.50
Monthly Part C Premium $147.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $0.00

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) - - No No $0 copay
Diagnostic tests and procedures - - No No $0 copay
Lab services - - No No $0 copay
Outpatient x-rays - - No No $0 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - $0 copay
Specialist - - No No $0 copay
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $0 copay
Urgent care - - - - $0 copay
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - - No No $0 copay
Routine foot care Yes - No No $0 copay
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0 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 No - - - Not covered
Hearing aids - inner ear No - - - Not covered
Hearing aids - outer ear No - - - Not covered
Hearing aids - over the ear No - - - Not covered
Hearing exam - - No No $0 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No $0 copay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not Applicable
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - - No - $0 copay
Durable medical equipment (e.g., wheelchairs, oxygen) - - No - $0 copay
Prosthetics (e.g., braces, artificial limbs) - - No - $0 copay
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - - No No $0 copay
Outpatient group therapy visit - - No No $0 copay
Outpatient group therapy visit with a psychiatrist - - No No $0 copay
Outpatient individual therapy visit - - No No $0 copay
Outpatient individual therapy visit with a psychiatrist - - No No $0 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
- - No No $0 copay
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 - - No No $0 copay
Physical therapy and speech and language therapy visit - - No No $0 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No $0 copay
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) No - - - Not covered
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
- - - - Not covered
Plan Drug Info
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048

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