Medical Associates Freedom Plan (Cost)
H5256 - 004 - 0
(0 / 5)
Medical Associates Freedom Plan (Cost) is a Medicare Advantage (Part C) Plan by Medical Associates Clinic Health Plan of Wisconsin.
This page features plan details for 2024 Medical Associates Freedom Plan (Cost) H5256 – 004 – 0 available in Grant, Crawford, Iowa, Lafayette Counties.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Medical Associates Freedom Plan (Cost) is offered in the following locations.
Plan Overview
Medical Associates Freedom Plan (Cost) offers the following coverage and cost-sharing.
| Insurer: | Medical Associates Clinic Health Plan of Wisconsin |
| Health Plan Deductible: | $0.00 |
| MOOP: | Not Applicable |
| Drugs Covered: | No |
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Premium Breakdown
Medical Associates Freedom Plan (Cost) has a monthly premium of $203.00. 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 | $203.00 | $0.00 | $377.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Medical Associates Freedom Plan (Cost) also provides the following benefits.
| $0 |
| In-network | No |
| Not Applicable |
| No |
| In-network | No |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $0 copay (Authorization is not required.) (Referral is not required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $0 copay (Not applicable.) (Not applicable.) |
| Urgent care | $0 copay (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $0 copay (Authorization is not required.) (Referral is not required.) |
| Lab services | $0 copay (Authorization is not required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | $0 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient x-rays | $0 copay (Authorization is not required.) (Referral is not required.) |
| Hearing exam | $0 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – inner ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – outer ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – over the ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Oral exam | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Cleaning | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Fluoride treatment | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Dental x-ray(s) | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Restorative services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Endodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Periodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Extractions | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| 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 | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglasses (frames and lenses) | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| 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 | $0 copay (Authorization is not required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $0 copay (Authorization is not required.) (Referral is not required.) |
| $0 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| Foot exams and treatment | $0 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | $0 copay (Authorization is not required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | $0 copay (Authorization is not required.) (Not applicable.) |
| Diabetes supplies | $0 copay (Authorization is not required.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| Chemotherapy | $0 copay (Not applicable.) (Not applicable.) |
| Other Part B drugs | $0 copay (Not applicable.) (Not applicable.) |
| Part B Insulin drugs | $0 copay (Not applicable.) (Not applicable.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Inpatient hospital – psychiatric | $0 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | $0 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $0 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit | $0 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit | $0 copay (Authorization is not required.) (Referral is not required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
Optional Benefits
Package #1
| Other 1: | Monthly Premium: | $35.00 |
| Other 1: | Deductible: | N/A |
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Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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