CCA Medicare Excel (HMO) is a Medicare Advantage (Part C) Plan by CCA Health Michigan.
This page features plan details for 2023 CCA Medicare Excel (HMO) H9861 – 001 – 0 available in .
CCA Medicare Excel (HMO) is offered in the following locations.
CCA Medicare Excel (HMO) offers the following coverage and cost-sharing.
| Insurer: | CCA Health Michigan |
| Health Plan Deductible: | $0.00 |
| MOOP: | $4,500 In-network |
| Drugs Covered: |
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| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $164.90 | $0.00 | $ | $164.90 |
| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $164.90 | $0.00 | $0.00 | $ | $164.90 |
CCA Medicare Excel (HMO) also provides the following benefits.
| In-Network: No |
| Diagnostic services: | Not covered (no limits) |
| Endodontics: | 75% coinsurance (limits may apply) (authorization required) (referral not required) |
| Extractions: | 50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Non-routine services: | Not covered (no limits) |
| Periodontics: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | 0-50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Restorative services: | 50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Cleaning: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Dental x-ray(s): | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Fluoride treatment: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Oral exam: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Diagnostic radiology services (e.g., MRI): | $0-100 copay (authorization required) (referral not required) |
| Diagnostic tests and procedures: | $20 copay (authorization required) (referral not required) |
| Lab services: | $0 copay (authorization required) (referral not required) |
| Outpatient x-rays: | $35 copay (authorization required) (referral not required) |
| Primary: | $0 copay |
| Specialist: | $30 copay per visit (authorization required) (referral not required) |
| Emergency: | $90 copay per visit (always covered) |
| Urgent care: | $45 copay per visit (always covered) |
| Foot exams and treatment: | $30 copay (authorization required) (referral not required) |
| Routine foot care: | Not covered |
| $205 copay |
| $0.00 |
| In-Network: No |
| Fitting/evaluation: | $0 copay (no limits) (authorization not required) (referral not required) |
| Hearing aids: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Hearing exam: | $0 copay (authorization not required) (referral not required) |
| $295 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization required) (referral not required) |
| $200 copay per visit (authorization required) (referral not required) |
| $4,500 In-network |
| Diabetes supplies: | $0 copay (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 20% coinsurance per item (authorization required) |
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 20% coinsurance (authorization required) |
| Inpatient hospital – psychiatric: | $295 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization required) (referral not required) |
| Outpatient group therapy visit: | $0 copay (authorization required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | $0 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit: | $0 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | $0 copay (authorization required) (referral not required) |
| No |
| $0 copay (authorization not required) (referral not required) |
| Occupational therapy visit: | $30 copay (authorization required) (referral not required) |
| Physical therapy and speech and language therapy visit: | $30 copay (authorization required) (referral not required) |
| $0 per day for days 1 through 20 $170 per day for days 21 through 100 (authorization required) (referral not required) |
| $0 copay (no limits) (authorization required) (referral not required) |
| Contact lenses: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass frames: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglass lenses: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Eyeglasses (frames and lenses): | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Other: | Not covered (no limits) |
| Routine eye exam: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Upgrades: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Covered (authorization not required) (referral not required) |
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SMID: MULTIPLAN_HCIHNDOGMED01_M
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