WellCare Value (HMO) - 2021

WellCare Value (HMO) - WellCare - Local HMO

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
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
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

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