ConnectiCare Choice Plan 2 (HMO)
H3528 - 003 - 0
(3.5 / 5)
ConnectiCare Choice Plan 2 (HMO) is a Medicare Advantage (Part C) Plan by ConnectiCare.
This page features plan details for 2023 ConnectiCare Choice Plan 2 (HMO) H3528 – 003 – 0 available in State of Connecticut.
IMPORTANT: This page features the 2023 version of this plan. See the 2024 version using the link below:
Locations
ConnectiCare Choice Plan 2 (HMO) is offered in the following locations.
Plan Overview
ConnectiCare Choice Plan 2 (HMO) offers the following coverage and cost-sharing.
| Insurer: | ConnectiCare |
| Health Plan Deductible: | $0.00 |
| MOOP: | $6,000 In-network |
| Drugs Covered: | No |
Ready to sign up for ConnectiCare Choice Plan 2 (HMO) ?
Premium Breakdown
ConnectiCare Choice Plan 2 (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 |
|---|---|---|---|
| $164.90 | $0.00 | $0.00 | $164.90 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
ConnectiCare Choice Plan 2 (HMO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | 20% coinsurance (limits may apply) (authorization required) (referral not required) |
| Endodontics: | 50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Extractions: | 50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Non-routine services: | 20% coinsurance (limits may apply) (authorization required) (referral not required) |
| Periodontics: | 50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | 50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Restorative services: | 20% coinsurance (limits may apply) (authorization required) (referral not required) |
Dental (preventive)
| 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 procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | $175 copay (authorization required) (referral not required) |
| Diagnostic tests and procedures: | $25 copay (authorization required) (referral not required) |
| Lab services: | $0-10 copay (authorization required) (referral not required) |
| Outpatient x-rays: | $15 copay (authorization required) (referral not required) |
Doctor visits
| Primary: | $0 copay |
| Specialist: | $10 copay per visit (authorization not required) (referral not required) |
Emergency care/Urgent care
| Emergency: | $95 copay per visit (always covered) |
| Urgent care: | $10 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | $10 copay (authorization not required) (referral not required) |
| Routine foot care: | Not covered |
Ground ambulance
| $50 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: Yes |
Hearing
| Fitting/evaluation: | Not covered (no limits) |
| Hearing aids – inner ear: | Not covered (no limits) |
| Hearing aids – outer ear: | Not covered (no limits) |
| Hearing aids – over the ear: | Not covered (no limits) |
| Hearing exam: | $10 copay (authorization not required) (referral not required) |
Hospital coverage (inpatient)
| $295 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization required) (referral not required) |
Hospital coverage (outpatient)
| $200 copay per visit (authorization required) (referral not required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $6,000 In-network |
Medical equipment/supplies
| Diabetes supplies: | $0 copay (authorization not required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 0-20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | $0 copay (authorization required) |
Medicare Part B drugs
| Chemotherapy: | 10-20% coinsurance (authorization required) |
| Other Part B drugs: | 10-20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | $1,871 per stay (authorization required) (referral not required) |
| Outpatient group therapy visit: | $10 copay (authorization required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | $10 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit: | $10 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | $10 copay (authorization required) (referral not required) |
Optional supplemental benefits
| No |
Preventive care
| $0 copay (authorization not required) (referral not required) |
Rehabilitation services
| Occupational therapy visit: | $10 copay (authorization not required) (referral not required) |
| Physical therapy and speech and language therapy visit: | $10 copay (authorization not required) (referral not required) |
Skilled Nursing Facility
| $0 per day for days 1 through 20 $196 per day for days 21 through 100 (authorization required) (referral not required) |
Transportation
| Not covered |
Vision
| 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: | $10 copay (limits may apply) (authorization not required) (referral not required) |
| Upgrades: | Not covered |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization not required) (referral not required) |
Ready to sign up for ConnectiCare Choice Plan 2 (HMO) ?