Basic (HMO)
H5774 - 003 - 0
(4.5 / 5)
Basic (HMO) is a Medicare Advantage (Part C) Plan by Triple S Advantage.
This page features plan details for 2024 Basic (HMO) H5774 – 003 – 0 available in Puerto Rico.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Basic (HMO) is offered in the following locations.
Plan Overview
Basic (HMO) offers the following coverage and cost-sharing.
| Insurer: | Triple S Advantage |
| Health Plan Deductible: | $0.00 |
| MOOP: | $3,650 In-network |
| Drugs Covered: | No |
Ready to sign up for Basic (HMO) ?
Medicare Part B Give Back Benefit
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
Basic (HMO) qualifies for a monthly Medicare Give Back Benefit of $100.00.
| Premium Reduction: | $100.00 |
Premium Breakdown
Basic (HMO) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $0.00 | $100.00 | $74.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Basic (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $3,650 In-network |
| No |
| In-network | No |
| $0 copay (Authorization is required.) (Referral is not required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $0-5 copay per visit (Authorization is required.) (Referral is not required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $50 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $0 copay (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | 0-10% coinsurance (Authorization is required.) (Referral is not required.) |
| Lab services | 0-10% coinsurance (Authorization is required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | $0-50 copay (Authorization is required.) (Referral is not required.) |
| Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
| Hearing exam | $0 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Hearing aids | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Diagnostic services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Endodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Occupational therapy visit | $5 copay (Authorization is required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $0 copay (Authorization is required.) (Referral is not required.) |
| $0 copay (Not applicable.) (Not applicable.) |
| $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Foot exams and treatment | $0 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | $0-3 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 0-10% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 0-10% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | $0 copay (Authorization is not required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | 0-20% coinsurance (up to $35) (Authorization is required.) (Not applicable.) |
| Tier 1 $0 copay per stay Tier 2 $50 per stay (Authorization is not required.) (Referral is not required.) |
| Inpatient hospital – psychiatric | $0 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | $0 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $0 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit | $0 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit | $0 copay (Authorization is not required.) (Referral is not required.) |
| $0 copay (Authorization is required.) (Referral is not required.) |
Ready to sign up for Basic (HMO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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