2027 Medicare Advantage plan

ContigoEnMente (HMO C-SNP): 2027 benefits and costs

Triple S Advantage HMO C-SNP Special Needs Plan

CMS plan ID: H5774-046-0 · Plan year: 2027

ContigoEnMente (HMO C-SNP) is a 2027 Medicare Advantage plan offered by Triple S Advantage. It is listed in Puerto Rico.

2027 plan costs at a glance

Monthly plan premium$0.00

Drug deductible$0.00

In-network medical out-of-pocket maximum$4,200.00

Organization: Triple S Advantage
Plan organization: TRIPLE S ADVANTAGE, INC.
Parent company: Guidewell Mutual Holding Corporation
Plan type: HMO C-SNP
Part C premium: $0.00
Part D premium: $0.00
Prescription drug coverage: Yes
Special Needs Plan type: Chronic or Disabling Condition
2027 CMS Star Rating

Standard monthly Medicare Part B premium: $209.50 (estimated)
Monthly Part B premium after plan reduction: $149.50 (estimated)$209.50 standard premium less $60.00 plan reduction.

You must continue to pay your Medicare Part B premium.

In-network medical deductible: None
In-network medical maximum: $4,200.00

Part B premium reduction: $60.00

Who can join this Special Needs Plan?

This plan is for people with qualifying chronic or disabling conditions. The plan must confirm that your condition meets its eligibility rules.

Plan eligibility type: Chronic or Disabling Condition
Qualifying conditions: Dementia

2027 benefit summary

Doctor visits and medical care

Common medical services and member costs
Service	In-network	What to know
Primary care doctor	$0 Service-specific deductible No
Specialist visit	$0.00 to $3.00 copay Service-specific deductible No	Approval required Yes Referral required No
Telehealth	$0.00 to $3.00 copay Service-specific deductible No	Approval required No Referral required No
Emergency care	$50.00 copay
Urgent care	$0
Home health	$0 Service-specific deductible No	Approval required Yes Referral required No
Dialysis	20% coinsurance Service-specific deductible No	Approval required No Referral required No
Part B chemotherapy and radiation drugs	0% to 20% coinsurance Deductible applies No	Approval required Yes
Other Part B drugs	0% to 20% coinsurance Deductible applies No	Approval required Yes
Kidney disease education services	$0 Service-specific deductible No	Approval required No Referral required No
Medicare-covered chiropractic	$0.00 to $5.00 copay Service-specific deductible No	Approval required No Referral required No
Medicare-covered foot care	$0 Service-specific deductible No	Approval required No Referral required No
Other health professionals	$0.00 to $3.00 copay Service-specific deductible No	Approval required Yes Referral required No

Hospital, outpatient surgery and observation care

Inpatient stays and skilled nursing care

In-network stays. Charges can depend on the number of days and the benefit period.
Care	Your share of the cost	What to know
Inpatient hospital stay	$0.00 copay per stay	Approval required Yes Referral required No Benefit period Per Admission or Per Stay
Inpatient hospital stayCost option 2	$50.00 copay per stay	Approval required Yes Referral required No Benefit period Per Admission or Per Stay

See plan documents for out-of-network hospital and skilled nursing costs.

Hospital, outpatient surgery and observation care and member costs
Service	In-network	What to know
Outpatient hospital care	$25.00 to $50.00 copay Service-specific deductible No
Hospital observation services	$0 Service-specific deductible No
Ambulatory surgical center	$25.00 copay Service-specific deductible No	Approval required Yes Referral required No
Outpatient blood	$0 Service-specific deductible No	Approval required No Referral required No

Tests, imaging and laboratory services

Tests, imaging and laboratory services and member costs
Service	In-network	What to know
Diagnostic procedures and tests	0% to 15% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Laboratory services	0% to 15% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Diagnostic radiology (CT, MRI)	$0.00 to $25.00 copay Service-specific deductible No	Approval required Yes Referral required No
Therapeutic radiology	$0 Service-specific deductible No	Approval required Yes Referral required No
X-rays	$0 Service-specific deductible No	Approval required Yes Referral required No

Mental health and substance use treatment

Mental health and substance use treatment and member costs
Service	In-network	What to know
Partial hospitalization	$0 Service-specific deductible No	Approval required Yes Referral required No
Intensive outpatient program	$0 Service-specific deductible No	Approval required Yes Referral required No
Substance use treatment, individual sessions	$0 Service-specific deductible No	Approval required No Referral required No
Substance use treatment, group sessions	$0 Service-specific deductible No	Approval required No Referral required No
Opioid treatment program	$0 Service-specific deductible No	Approval required No Referral required No
Mental health, individual sessions	$0 Service-specific deductible No	Approval required No Referral required No
Mental health, group sessions	$0 Service-specific deductible No	Approval required No Referral required No
Psychiatry, individual sessions	$0 Service-specific deductible No	Approval required No Referral required No
Psychiatry, group sessions	$0 Service-specific deductible No	Approval required No Referral required No

Therapy and rehabilitation

Therapy and rehabilitation and member costs
Service	In-network	What to know
Occupational therapy	$5.00 copay Service-specific deductible No	Approval required Yes Referral required No
Physical and speech therapy	$0 Service-specific deductible No	Approval required Yes Referral required No
Cardiac rehabilitation	$0 Service-specific deductible No	Approval required Yes Referral required No
Intensive cardiac rehabilitation	$0 Service-specific deductible No	Approval required Yes Referral required No
Pulmonary rehabilitation	$0 Service-specific deductible No	Approval required Yes Referral required No
Supervised exercise for peripheral artery disease	$0 Service-specific deductible No	Approval required Yes Referral required No

Ambulance, medical equipment and supplies

Ambulance, medical equipment and supplies and member costs
Service	In-network	What to know
Ground ambulance	$0 Service-specific deductible No	Approval required Yes
Air ambulance	$0 Service-specific deductible No	Approval required Yes
Durable medical equipment	$0 Service-specific deductible No	Approval required Yes
Prosthetic devices	$0 Service-specific deductible No	Approval required Yes
Medical supplies	$0 Service-specific deductible No	Approval required Yes
Diabetic supplies	$0 Service-specific deductible No	Approval required Yes
Diabetic shoes and inserts	$0 Service-specific deductible No	Approval required Yes
Diabetic monitors	$0 Service-specific deductible No	Approval required Yes

Dental benefits

Dental benefits and member costs
Service	In-network	What to know
Medicare-covered dental	$0
Oral examsAdditional plan benefit	$0
Dental X-raysAdditional plan benefit	$0
Other diagnostic dentalAdditional plan benefit	$0
Dental cleaningAdditional plan benefit	$0
FluorideAdditional plan benefit	$0
Other preventive dentalAdditional plan benefit	$0
Restorative dental careAdditional plan benefit	$0
Root canal treatment (endodontics)Additional plan benefit	$0
Gum treatment (periodontics)Additional plan benefit	$0
Removable dentures (prosthodontics)Additional plan benefit	$0
Fixed dental restorations (prosthodontics)Additional plan benefit	$0
Oral surgeryAdditional plan benefit	$0
Other dental servicesAdditional plan benefit	$0

Vision benefits

Vision benefits and member costs
Service	In-network	What to know
Medicare-covered eye exams	$0 Service-specific deductible No	Approval required No Referral required No
Routine eye examsAdditional plan benefit	$0	Approval required No Referral required No
Medicare-covered eyewear	$0 Service-specific deductible No	Approval required No Referral required No
Contact lensesAdditional plan benefit	$0	Approval required No Referral required No
Eyeglasses, lenses and framesAdditional plan benefit	$0	Approval required No Referral required No
Eyeglass lensesAdditional plan benefit	$0	Approval required No Referral required No
Eyeglass framesAdditional plan benefit	$0	Approval required No Referral required No

Hearing benefits

Hearing benefits and member costs
Service	In-network	What to know
Medicare-covered hearing exams	$0 Service-specific deductible No	Approval required No Referral required No
Routine hearing examsAdditional plan benefit	$0	Approval required No Referral required No
Hearing aid fitting and evaluationAdditional plan benefit	$0	Approval required No Referral required No
Prescription hearing aids (all types)Additional plan benefit	$0 Service-specific deductible No	Approval required No Referral required No

Extra benefits

Extra benefits and member costs
Service	In-network	What to know
Supplemental acupunctureAdditional plan benefit	$0 Service-specific deductible No	Approval required No Referral required No
Over-the-counter health itemsAdditional plan benefit	$0 Service-specific deductible No

Allowances and optional benefits

Combined Supplemental Benefits 1

One shared limit covers the listed services, not a separate allowance for each service.

Services sharing this allowance: Acupuncture Treatments; Alternative Therapies
How benefits are provided: Claims Processing
Advance choice of benefits required: No
Shared limit on visits or trips: Yes
Indicate number of shared visits/trips: 12
How often this limit applies: Every year

Benefits for qualifying members

1

The plan must confirm eligibility, including any qualifying condition.

Qualifying conditions: Chronic alcohol use disorder and other substance use disorders (SUDs); Autoimmune disorders; Cancer; Cardiovascular disorders; Chronic heart failure; Dementia; Diabetes mellitus; Chronic gastrointestinal disease; Chronic kidney disease (CKD); Severe hematologic disorders; HIV/AIDS; Chronic lung disorders; Chronic and disabling mental health conditions; Neurologic disorders; Stroke
Included services: Over-the-counter health items; Food and produce; Pest control; Transportation for non-medical needs; Support for daily living; Other 1 Non-Primarily Health Related Benefit
Some package benefits are exempt from the deductible: No
Package limit: $75.00
How often this limit applies: Every month
How benefits are provided: Debit Card
Services sharing the package limit: Over-the-counter health items; Food and produce; Pest control; Transportation for non-medical needs; Support for daily living

2

The plan must confirm eligibility, including any qualifying condition.

Qualifying conditions: Other 1
Qualifying conditions: Bedridden patients
Included services: In-Home Support Services
Some package benefits are exempt from the deductible: No

Prescription drug coverage

Costs shown are for initial coverage.

Preferred retail costs

Preferred retail: initial-coverage cost per prescription fill
Drug tier	30 days	90 days
Tier 1Preferred Generic	$0.00	$0.00
Tier 2Generic	$0.00	$0.00
Tier 3Preferred Brand	$0.00	$0.00
Tier 4Non-Preferred Brand	$5.00	$10.00
Tier 5Specialty Tier	33%	33%
Tier 6Select Care Drugs	$0.00	$0.00

Standard retail costs

Standard retail: initial-coverage cost per prescription fill
Drug tier	30 days	90 days
Tier 1Preferred Generic	$5.00	$10.00
Tier 2Generic	$8.00	$16.00
Tier 3Preferred Brand	$20.00	$40.00
Tier 4Non-Preferred Brand	$55.00	$110.00
Tier 5Specialty Tier	33%	33%
Tier 6Select Care Drugs	$3.00	$6.00

Mail-order and other pharmacies

Out-of-network pricing: You pay the standard retail copay or coinsurance, plus any difference between the pharmacy’s billed charge and the amount the plan allows at a standard retail pharmacy.

Standard mail order costs

Standard mail order: initial-coverage cost per prescription fill
Drug tier	90 days
Tier 1Preferred Generic	$0.00
Tier 2Generic	$0.00
Tier 3Preferred Brand	$0.00
Tier 4Non-Preferred Brand	$10.00
Tier 5Specialty Tier	33%
Tier 6Select Care Drugs	$0.00

Long-term care pharmacy costs

Long-term care pharmacy: initial-coverage cost per prescription fill
Drug tier	31 days
Tier 1Preferred Generic	$0.00
Tier 2Generic	$0.00
Tier 3Preferred Brand	$0.00
Tier 4Non-Preferred Brand	$5.00
Tier 5Specialty Tier	33%
Tier 6Select Care Drugs	$0.00

Out-of-network pharmacy costs

Out-of-network pharmacy: initial-coverage cost per prescription fill
Drug tier	30 days
Tier 1Preferred Generic	$5.00
Tier 2Generic	$8.00
Tier 3Preferred Brand	$20.00
Tier 4Non-Preferred Brand	$55.00
Tier 5Specialty Tier	33%
Tier 6Select Care Drugs	$3.00

Drug coverage rules and exceptions

Tier 1: Preferred Generic

Drugs included in this tier: Both Part D and Excluded Drugs
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 2: Generic

Drugs included in this tier: Both Part D and Excluded Drugs
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 3: Preferred Brand

Drugs included in this tier: Both Part D and Excluded Drugs
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 4: Non-Preferred Brand

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: Yes

Tier 5: Specialty Tier

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: Yes

Tier 6: Select Care Drugs

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Special cost protections apply to covered insulin and recommended adult vaccines.

Where this plan is offered

CMS lists this plan in 1 state or territory. Availability can vary by county and ZIP code.

View all locations 78 county listings across 1 state or territory