Liberty Medicare Healthy at Home (HMO I-SNP) is a Medicare Advantage (Part C) Special Needs Plan by Liberty Medicare Advantage.
This page features plan details for 2022 Liberty Medicare Healthy at Home (HMO I-SNP) H6351 – 003 – 0 available in North Carolina (partial).
Liberty Medicare Healthy at Home (HMO I-SNP) is offered in the following locations.
Liberty Medicare Healthy at Home (HMO I-SNP) offers the following coverage and cost-sharing.
| Special Needs Plan Type: | Institutional |
| Conditions Covered: |
| Insurer: | Liberty Medicare Advantage |
| Health Plan Deductible: | $0 |
| MOOP: | $5,000 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Liberty Medicare Healthy at Home (HMO I-SNP) ?
| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $170.10 | $0.00 | $0.00 | $0.00 | $170.10 |
Liberty Medicare Healthy at Home (HMO I-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $4,430.00 |
| Catastrophic Coverage Limit: | $7,050.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | No Gap Coverage |
| Formulary Link: | Formulary Link |
| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00. Once you reach that amount, you will enter the next coverage phase.
After your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00, you will pay no more than the amounts below for any drug tier until you reach $7,050.00.
| Drug Type | Cost Share |
|---|---|
| Generic drugs | 25% |
| Brand-name drugs | 25% |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Tier | Cost |
|---|---|
| Generic | $4.15 copay or 5% (whichever costs more) |
| Brand-name | $10.35 copay or 5% (whichever costs more) |
Liberty Medicare Healthy at Home (HMO I-SNP) also provides the following benefits.
| In-Network: No |
| Diagnostic services: | Not covered |
| Endodontics: | Not covered |
| Extractions: | Not covered |
| Non-routine services: | Not covered |
| Periodontics: | Not covered |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Not covered |
| Restorative services: | Not covered |
| Cleaning: | Not covered |
| Dental x-ray(s): | Not covered |
| Fluoride treatment: | Not covered |
| Oral exam: | Not covered |
| Diagnostic radiology services (e.g., MRI): | 20% coinsurance (authorization required) |
| Diagnostic tests and procedures: | 20% coinsurance (authorization required) |
| Lab services: | $0 copay (authorization required) |
| Outpatient x-rays: | 20% coinsurance (authorization required) |
| Primary: | $0 copay |
| Specialist: | 20% coinsurance per visit |
| Emergency: | $90 copay per visit (always covered) |
| Urgent care: | $35 copay per visit (always covered) |
| Foot exams and treatment: | 20% coinsurance |
| Routine foot care: | Not covered |
| 20% coinsurance |
| $0.00 |
| In-Network: No |
| Fitting/evaluation: | Not covered |
| Hearing aids: | $0 copay (limits may apply) |
| Hearing exam: | 20% coinsurance (authorization required) |
| Contact plan for details (authorization required) |
| 20% coinsurance per visit (authorization required) |
| $5,000 In-network |
| Diabetes supplies: | 20% coinsurance per item |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 20% coinsurance per item (authorization required) |
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 20% coinsurance (authorization required) |
| Inpatient hospital – psychiatric: | Contact plan for details (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | 20% coinsurance |
| Outpatient group therapy visit: | 20% coinsurance (authorization required) |
| Outpatient individual therapy visit with a psychiatrist: | 20% coinsurance |
| Outpatient individual therapy visit: | 20% coinsurance (authorization required) |
| Yes |
| $0 copay |
| Occupational therapy visit: | 20% coinsurance (authorization required) |
| Physical therapy and speech and language therapy visit: | 20% coinsurance (authorization required) |
| Contact plan for details (authorization required) |
| $0 copay (limits may apply) |
| Contact lenses: | $0 copay (limits may apply) |
| Eyeglass frames: | Not covered |
| Eyeglass lenses: | Not covered |
| Eyeglasses (frames and lenses): | $0 copay (limits may apply) |
| Other: | Not covered |
| Routine eye exam: | Not covered |
| Upgrades: | Not covered |
| Covered (authorization required) (referral required) |
| Preventive dental: | Monthly Premium: | $30.00 |
| Preventive dental: | Deductible: | N/A |
| Comprehensive dental: | Monthly Premium: | $30.00 |
| Comprehensive dental: | Deductible: | N/A |
Ready to sign up for Liberty Medicare Healthy at Home (HMO I-SNP) ?
Get help enrolling in a Medicare Advantage or Medicare Prescription Drug Plan by calling a licensed insurance agent today.
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
SMID: MULTIPLAN_HCIHNDOGMED01_M
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