Health Alliance Medicare HMO Basic (HMO)
H1463 - 008 - 0
(4 / 5)
Health Alliance Medicare HMO Basic (HMO) is a Medicare Advantage (Part C) Plan by Health Alliance Medicare.
This page features plan details for 2024 Health Alliance Medicare HMO Basic (HMO) H1463 – 008 – 0 available in N. Ctr, S. Ctr, Ctr IL, W/E IN, W. OH, Scott, IA.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Health Alliance Medicare HMO Basic (HMO) is offered in the following locations.
Plan Overview
Health Alliance Medicare HMO Basic (HMO) offers the following coverage and cost-sharing.
| Insurer: | Health Alliance Medicare |
| Health Plan Deductible: | $0.00 |
| MOOP: | $6,700 In-network |
| Drugs Covered: | No |
Ready to sign up for Health Alliance Medicare HMO Basic (HMO) ?
Premium Breakdown
Health Alliance Medicare HMO 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 | $0.00 | $174.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Health Alliance Medicare HMO Basic (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $6,700 In-network |
| No |
| In-network | No |
| 20% coinsurance per visit (Authorization is required.) (Referral is not required.) |
| Primary | $10 copay per visit (Not applicable.) (Not applicable.) |
| Specialist | $45 copay per visit (Authorization is not required.) (Referral is not required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $100 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $55 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| Lab services | 0-20% coinsurance (Authorization is required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | $150 copay (Authorization is required.) (Referral is not required.) |
| Outpatient x-rays | 20% coinsurance (Authorization is required.) (Referral is not required.) |
| Hearing exam | $25 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| Hearing aids | $699-999 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 | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Diagnostic services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Restorative services | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Endodontics | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Periodontics | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Extractions | 20% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | 20-50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not 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 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 | $40 copay (Authorization is required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
| $275 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| Foot exams and treatment | $50 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 0-20% 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 | 0-20% coinsurance per item (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.) |
| $300 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is required.) (Referral is not required.) |
| Inpatient hospital – psychiatric | $250 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | $40 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $40 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit | $40 copay (Authorization is not required.) (Referral is not required.) |
| $0 per day for days 1 through 20 $203 per day for days 21 through 100 (Authorization is required.) (Referral is required.) |
Ready to sign up for Health Alliance Medicare HMO Basic (HMO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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