Plan Basics
Contract Year |
2021 |
Medicare Type |
Medicare Advantage Plan (Part C) |
CMS Plan ID |
H1112-038-000 |
Plan Organization |
WellCare |
Plan Type |
Local HMO |
Plan Name |
WellCare Value (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 |
3.5 |
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 |
$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) |
$3450.00 |
Gap Coverage |
Yes |
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 |
Yes |
$0 copay |
Endodontics |
Yes |
- |
Yes |
Yes |
$0 copay |
Extractions |
Yes |
- |
Yes |
Yes |
$0 copay |
Non-routine services |
Yes |
- |
Yes |
Yes |
$0 copay |
Periodontics |
Yes |
- |
Yes |
Yes |
$0 copay |
Prosthodontics, other oral/maxillofacial surgery, other services |
Yes |
- |
Yes |
Yes |
$0 copay |
Restorative services |
Yes |
- |
Yes |
Yes |
$0 copay |
Diagnostic Procedures/lab Services/imaging
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Diagnostic radiology services (e.g., MRI) |
- |
- |
Yes |
No |
$0-225 copay |
Diagnostic tests and procedures |
- |
- |
Yes |
No |
$0-100 copay |
Lab services |
- |
- |
Yes |
No |
$0 copay |
Outpatient x-rays |
- |
- |
Yes |
No |
$0 copay |
Doctor Visits
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Primary |
- |
- |
- |
- |
$0 copay |
Specialist |
- |
- |
Yes |
No |
$35 copay per visit |
Emergency Care/Urgent Care
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Emergency |
- |
- |
- |
- |
$120 copay per visit (always covered) |
Urgent care |
- |
- |
- |
- |
$25 copay per visit (always covered) |
Foot Care (podiatry Services)
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Foot exams and treatment |
- |
- |
Yes |
No |
$35 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 |
- |
Yes |
Yes |
$0 copay |
Hearing aids |
Yes |
- |
Yes |
Yes |
$0 copay |
Hearing exam |
- |
- |
Yes |
Yes |
$35 copay |
Inpatient Hospital Coverage
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
Yes |
No |
$340 per day for days 1 through 8$0 per day for days 9 through 90 |
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
- |
- |
$3,450 In-network |
Medical Equipment/supplies
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Diabetes supplies |
- |
- |
Yes |
- |
$0 copay 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 |
$2,200 per stay |
Outpatient group therapy visit |
- |
- |
Yes |
No |
$40 copay |
Outpatient group therapy visit with a psychiatrist |
- |
- |
Yes |
No |
$40 copay |
Outpatient individual therapy visit |
- |
- |
Yes |
No |
$40 copay |
Outpatient individual therapy visit with a psychiatrist |
- |
- |
Yes |
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 |
$225-300 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 |
- |
Yes |
Yes |
$0 copay |
Dental x-ray(s) |
Yes |
- |
Yes |
Yes |
$0 copay |
Fluoride treatment |
Yes |
- |
Yes |
Yes |
$0 copay |
Oral exam |
Yes |
- |
Yes |
Yes |
$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$165 per day for days 21 through 100 |
Transportation
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
Yes |
- |
Yes |
No |
$0 copay |
Vision
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Contact lenses |
Yes |
- |
Yes |
Yes |
$0 copay |
Eyeglass frames |
Yes |
- |
Yes |
Yes |
$0 copay |
Eyeglass lenses |
Yes |
- |
Yes |
Yes |
$0 copay |
Eyeglasses (frames and lenses) |
Yes |
- |
Yes |
Yes |
$0 copay |
Other |
No |
- |
- |
- |
Not covered |
Routine eye exam |
Yes |
- |
Yes |
Yes |
$0 copay |
Upgrades |
Yes |
- |
Yes |
Yes |
$0 copay |
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
Barrow County, Georgia,
Bartow County, Georgia,
Butts County, Georgia,
Carroll County, Georgia,
Cherokee County, Georgia,
Clarke County, Georgia,
Clayton County, Georgia,
Coweta County, Georgia,
Dekalb County, Georgia,
Douglas County, Georgia,
Fayette County, Georgia,
Forsyth County, Georgia,
Fulton County, Georgia,
Greene County, Georgia,
Gwinnett County, Georgia,
Haralson County, Georgia,
Heard County, Georgia,
Henry County, Georgia,
Jasper County, Georgia,
Lamar County, Georgia,
Morgan County, Georgia,
Newton County, Georgia,
Oconee County, Georgia,
Paulding County, Georgia,
Pickens County, Georgia,
Pike County, Georgia,
Polk County, Georgia,
Putnam County, Georgia,
Rockdale County, Georgia,
Spalding County, Georgia,
Upson County, Georgia,
Walton County, Georgia
NOTE: Information on MedicarePolicyHelper.com is for educational purposes only. We are not affiliated with Medicare, or CMS. Medicare has not reviewed or endorsed the information on our site. All plan data on our site comes directly from medicare.gov and is subject to change.