Community Health Plan of WA MA Freedom Plan (HMO)
H5826 - 006 - 0
(3.5 / 5)
Community Health Plan of WA MA Freedom Plan (HMO) is a Medicare Advantage (Part C) Plan by Community Health Plan of WA Medicare Advantage.
This page features plan details for 2024 Community Health Plan of WA MA Freedom Plan (HMO) H5826 – 006 – 0 available in Western Washington and Spokane Counties.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Community Health Plan of WA MA Freedom Plan (HMO) is offered in the following locations.
Plan Overview
Community Health Plan of WA MA Freedom Plan (HMO) offers the following coverage and cost-sharing.
| Insurer: | Community Health Plan of WA Medicare Advantage |
| Health Plan Deductible: | $0.00 |
| MOOP: | $8,850 In-network |
| Drugs Covered: | No |
Ready to sign up for Community Health Plan of WA MA Freedom Plan (HMO) ?
Premium Breakdown
Community Health Plan of WA MA Freedom Plan (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 | $0.00 | $174.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Community Health Plan of WA MA Freedom Plan (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $8,850 In-network |
| No |
| In-network | Yes, contact plan for further details |
| $250 copay per visit (Authorization is required.) (Referral is required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $40 copay per visit (Authorization is required.) (Referral is required.) |
| $0 copay (Authorization is not required.) (Referral is required.) |
| Emergency | $100 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $0 copay (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| Outpatient x-rays | $15 copay (Authorization is required.) (Referral is not required.) |
| Hearing exam | $20 copay (Authorization is required.) (Referral is required.) |
| Fitting/evaluation | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – inner ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – outer ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – over the ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Oral exam | $0 copay (There are no limits.) (Authorization is required.) (Referral is required.) |
| Cleaning | $0 copay (There are no limits.) (Authorization is required.) (Referral is required.) |
| Fluoride treatment | $0 copay (There are no limits.) (Authorization is required.) (Referral is required.) |
| Dental x-ray(s) | $0 copay (There are no limits.) (Authorization is required.) (Referral is required.) |
| Non-routine services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Diagnostic services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Endodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is required.) |
| Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is required.) |
| Occupational therapy visit | $30 copay (Authorization is required.) (Referral is required.) |
| Physical therapy and speech and language therapy visit | $30 copay (Authorization is required.) (Referral is required.) |
| $300 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| Foot exams and treatment | $0 copay (Authorization is not required.) (Referral is required.) |
| Routine foot care | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is required.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% 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.) |
| $500 per day for days 1 through 4 $0 per day for days 5 through 90 (Authorization is required.) (Referral is required.) |
| Inpatient hospital – psychiatric | $175 per day for days 1 through 10 $0 per day for days 11 through 90 (Authorization is required.) (Referral is required.) |
| Outpatient group therapy visit with a psychiatrist | $30 copay (Authorization is required.) (Referral is required.) |
| Outpatient individual therapy visit with a psychiatrist | $30 copay (Authorization is required.) (Referral is required.) |
| Outpatient group therapy visit | $30 copay (Authorization is required.) (Referral is required.) |
| Outpatient individual therapy visit | $30 copay (Authorization is required.) (Referral is required.) |
| $0 per day for days 1 through 20 $200 per day for days 21 through 100 (Authorization is required.) (Referral is required.) |
Ready to sign up for Community Health Plan of WA MA Freedom Plan (HMO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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