Medica Advantage Solution H0798-002 (HMO I-SNP)
H0798 - 002 - 0
Plan Not Rated
Medica Advantage Solution H0798-002 (HMO I-SNP) is a Medicare Advantage (Part C) Special Needs Plan by Medica.
This page features plan details for 2022 Medica Advantage Solution H0798-002 (HMO I-SNP) H0798 – 002 – 0 available in Select counties in NE.
IMPORTANT: This page features the 2022 version of this plan. See the 2024 version using the link below:
No 2024 version found. You can use the location links below to find 2024 plans in your area.
Locations
Medica Advantage Solution H0798-002 (HMO I-SNP) is offered in the following locations.
Plan Overview
Medica Advantage Solution H0798-002 (HMO I-SNP) offers the following coverage and cost-sharing.
| Special Needs Plan Type: | Institutional |
| Conditions Covered: |
| Insurer: | Medica |
| Health Plan Deductible: | |
| MOOP: | $7,550 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Medica Advantage Solution H0798-002 (HMO I-SNP) ?
Premium Breakdown
Medica Advantage Solution H0798-002 (HMO I-SNP) has a monthly premium of $38.9. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $170.10 | $0.00 | $38.90 | $0.00 | $209.00 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Medica Advantage Solution H0798-002 (HMO I-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $480.00 |
| Initial Coverage Limit: | $4,430.00 |
| Catastrophic Coverage Limit: | $7,050.00 |
| Drug Benefit Type: | Basic |
| Gap Coverage: | No Gap Coverage |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs. The table below shows how the LIS impacts the Part D premium of this plan.| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $38.90 | $29.20 | $19.50 | $9.70 | $0.00 |
Initial Coverage Phase
After you pay your $480.00 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.
30 Day
60 Day
90 Day
30 Day
60 Day
90 Day
Gap 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.
30 Day
90 Day
30 Day
90 Day
| Drug Type | Cost Share |
|---|---|
| Generic drugs | 25% |
| Brand-name drugs | 25% |
Catastrophic Coverage Phase
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) |
Additional Benefits
Medica Advantage Solution H0798-002 (HMO I-SNP) 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: | $0 copay (limits may apply) |
| Endodontics: | $0 copay (limits may apply) |
| Extractions: | $0 copay (limits may apply) |
| Non-routine services: | $0 copay (limits may apply) |
| Periodontics: | $0 copay (limits may apply) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | $0 copay (limits may apply) |
| Restorative services: | $0 copay (limits may apply) |
Dental (preventive)
| Cleaning: | $0 copay (limits may apply) |
| Dental x-ray(s): | $0 copay (limits may apply) |
| Fluoride treatment: | $0 copay (limits may apply) |
| Oral exam: | $0 copay (limits may apply) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | 20% coinsurance |
| Diagnostic tests and procedures: | 20% coinsurance |
| Lab services: | 20% coinsurance |
| Outpatient x-rays: | 20% coinsurance |
Doctor visits
| Primary: | 20% coinsurance per visit |
| Specialist: | 20% coinsurance per visit |
Emergency care/Urgent care
| Emergency: | 20% coinsurance per visit (always covered) |
| Urgent care: | 20% coinsurance per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | 20% coinsurance |
| Routine foot care: | $0 copay |
Ground ambulance
| 20% coinsurance |
Health plan deductible
| Contact plan for details |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | $0 copay (limits may apply) |
| Hearing aids: | $0 copay (limits may apply) |
| Hearing exam: | 20% coinsurance |
Hospital coverage (inpatient)
| Contact plan for details (authorization required) |
Hospital coverage (outpatient)
| 20% coinsurance per visit (authorization required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $7,550 In-network |
Medical equipment/supplies
| 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) |
Medicare Part B drugs
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | Contact plan for details (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | 20% coinsurance |
| Outpatient group therapy visit: | 20% coinsurance |
| Outpatient individual therapy visit with a psychiatrist: | 20% coinsurance |
| Outpatient individual therapy visit: | 20% coinsurance |
Optional supplemental benefits
| No |
Preventive care
| $0 copay |
Rehabilitation services
| Occupational therapy visit: | 20% coinsurance |
| Physical therapy and speech and language therapy visit: | 20% coinsurance |
Skilled Nursing Facility
| Contact plan for details (authorization required) |
Transportation
| $0 copay (limits may apply) (authorization required) |
Vision
| Contact lenses: | $0 copay (limits may apply) |
| Eyeglass frames: | $0 copay (limits may apply) |
| Eyeglass lenses: | $0 copay (limits may apply) |
| Eyeglasses (frames and lenses): | $0 copay (limits may apply) |
| Other: | Not covered |
| Routine eye exam: | $0 copay (limits may apply) |
| Upgrades: | $0 copay (limits may apply) |
Wellness programs (e.g., fitness, nursing hotline)
| Not covered |
Ready to sign up for Medica Advantage Solution H0798-002 (HMO I-SNP) ?