Imperial Courage Plan (HMO)
H5496 - 016 - 0
(3 / 5)
Imperial Courage Plan (HMO) is a Medicare Advantage (Part C) Plan by Imperial Health Plan of California, Inc..
This page features plan details for 2024 Imperial Courage Plan (HMO) H5496 – 016 – 0 available in Northern, Central, Southern California.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Imperial Courage Plan (HMO) is offered in the following locations.
Plan Overview
Imperial Courage Plan (HMO) offers the following coverage and cost-sharing.
| Insurer: | Imperial Health Plan of California, Inc. |
| Health Plan Deductible: | $0.00 |
| MOOP: | $2,999 In-network |
| Drugs Covered: | No |
Ready to sign up for Imperial Courage Plan (HMO) ?
Medicare Part B Give Back Benefit
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
Imperial Courage Plan (HMO) qualifies for a monthly Medicare Give Back Benefit of $75.00.
| Premium Reduction: | $75.00 |
Premium Breakdown
Imperial Courage 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 | $75.00 | $99.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Imperial Courage Plan (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $2,999 In-network |
| No |
| In-network | No |
| $200 copay per visit (Authorization is required.) (Referral is required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $5 copay per visit (Authorization is required.) (Referral is required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $125 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $0 copay (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | 0-10% coinsurance (Authorization is required.) (Referral is required.) |
| Lab services | 0-10% coinsurance (Authorization is required.) (Referral is required.) |
| Diagnostic radiology services (e.g., MRI) | $0 copay (Authorization is required.) (Referral is required.) |
| Outpatient x-rays | $0 copay (Authorization is required.) (Referral is required.) |
| Hearing exam | $0 copay (Authorization is required.) (Referral is required.) |
| Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Hearing aids | $0 copay (Limits may apply.) (Authorization is required.) (Referral is 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 | $0 copay (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 | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Endodontics | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Periodontics | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Extractions | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (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 | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| Occupational therapy visit | $10 copay (Authorization is required.) (Referral is required.) |
| Physical therapy and speech and language therapy visit | 20% coinsurance (Authorization is required.) (Referral is required.) |
| $150 copay (Not applicable.) (Not applicable.) |
| $0 copay (Limits may apply.) (Authorization is required.) (Referral is required.) |
| Foot exams and treatment | $5 copay (Authorization is required.) (Referral is required.) |
| Routine foot care | $0 copay (Limits may apply.) (Authorization is 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 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 copay (Authorization is required.) (Not applicable.) |
| $150 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is required.) |
| Inpatient hospital – psychiatric | $150 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is required.) |
| Outpatient group therapy visit with a psychiatrist | $0 copay (Authorization is required.) (Referral is required.) |
| Outpatient individual therapy visit with a psychiatrist | $0 copay (Authorization is required.) (Referral is required.) |
| Outpatient group therapy visit | 20% coinsurance (Authorization is required.) (Referral is required.) |
| Outpatient individual therapy visit | 20% coinsurance (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 Imperial Courage Plan (HMO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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