2027 Medicare Advantage plan

Trinity Health Plan of Michigan Glory No RX (HMO): 2027 benefits and costs

Trinity Health Plan of Michigan HMO

CMS plan ID: H9179-003-0 · Plan year: 2027

Trinity Health Plan of Michigan Glory No RX (HMO) is a 2027 Medicare Advantage plan offered by Trinity Health Plan of Michigan. It is listed in Michigan.

2027 plan costs at a glance

Monthly plan premium$0.00

In-network medical out-of-pocket maximum$6,500.00

Organization: Trinity Health Plan of Michigan
Plan organization: TRINITY HEALTH PLAN OF MICHIGAN INC
Parent company: Trinity Health Corporation
Plan type: HMO
Part C premium: $0.00
Prescription drug coverage: No
2027 CMS Star Rating

Standard monthly Medicare Part B premium: $209.50 (estimated)
Monthly Part B premium after plan reduction: $109.50 (estimated)$209.50 standard premium less $100.00 plan reduction.

You must continue to pay your Medicare Part B premium.

In-network medical deductible: None
In-network medical maximum: $6,500.00

Part B premium reduction: $100.00

2027 benefit summary

Doctor visits and medical care

Common medical services and member costs
Service	In-network	What to know
Primary care doctor	$0.00 copay Service-specific deductible No
Specialist visit	$30.00 copay Service-specific deductible No	Approval required No Referral required No
Telehealth	$0.00 to $30.00 copay Service-specific deductible No	Approval required No Referral required No
Emergency care	$130.00 copay
Urgent care	$45.00 copay
Home health	$0.00 copay Service-specific deductible No	Approval required No Referral required No
Dialysis	20% coinsurance Service-specific deductible No	Approval required No Referral required No
Part B chemotherapy and radiation drugs	0% to 20% coinsurance Deductible applies No	Approval required Yes
Other Part B drugs	0% to 20% coinsurance Deductible applies No	Approval required Yes
Kidney disease education services	$0.00 copay Service-specific deductible No	Approval required No Referral required No
Medicare-covered chiropractic	$10.00 copay Service-specific deductible No	Approval required Yes Referral required No
Medicare-covered foot care	$30.00 copay Service-specific deductible No	Approval required No Referral required No
Other health professionals	$0.00 to $30.00 copay Service-specific deductible No	Approval required No Referral required No

Hospital, outpatient surgery and observation care

Inpatient stays and skilled nursing care

In-network stays. Charges can depend on the number of days and the benefit period.
Care	Your share of the cost	What to know
Inpatient hospital stay	$0.00 copay per stay Days 1–7: $325.00 copay per day Days 8–90: $0.00 copay per day	Approval required Yes Referral required No Benefit period Original Medicare
Inpatient mental health care	$0.00 copay per stay Days 1–7: $325.00 copay per day Days 8–90: $0.00 copay per day	Approval required No Referral required No Benefit period Original Medicare
Skilled nursing facility	Days 1–20: $0.00 copay per day Days 21–65: $221.00 copay per day Days 66–100: $0.00 copay per day	Approval required No Referral required No Benefit period Original Medicare

See plan documents for out-of-network hospital and skilled nursing costs.

Hospital, outpatient surgery and observation care and member costs
Service	In-network	What to know
Outpatient hospital care	$0.00 to $295.00 copay Service-specific deductible No
Hospital observation services	$315.00 copay Service-specific deductible No
Ambulatory surgical center	$295.00 copay Service-specific deductible No	Approval required No Referral required No
Outpatient blood	$0.00 copay Service-specific deductible No	Approval required No Referral required No

Tests, imaging and laboratory services

Tests, imaging and laboratory services and member costs
Service	In-network	What to know
Diagnostic procedures and tests	$50.00 copay Service-specific deductible No	Approval required No Referral required No
Laboratory services	$0.00 copay Service-specific deductible No	Approval required No Referral required No
Diagnostic radiology (CT, MRI)	$300.00 copay Service-specific deductible No	Approval required No Referral required No
Therapeutic radiology	$60.00 copay Service-specific deductible No	Approval required No Referral required No
X-rays	$30.00 copay Service-specific deductible No	Approval required No Referral required No

Mental health and substance use treatment

Mental health and substance use treatment and member costs
Service	In-network	What to know
Partial hospitalization	$55.00 copay Service-specific deductible No	Approval required No Referral required No
Intensive outpatient program	$55.00 copay Service-specific deductible No	Approval required No Referral required No
Substance use treatment, individual sessions	$30.00 copay Service-specific deductible No	Approval required No Referral required No
Substance use treatment, group sessions	$30.00 copay Service-specific deductible No	Approval required No Referral required No
Opioid treatment program	$30.00 copay Service-specific deductible No	Approval required No Referral required No
Mental health, individual sessions	$30.00 copay Service-specific deductible No	Approval required No Referral required No
Mental health, group sessions	$30.00 copay Service-specific deductible No	Approval required No Referral required No
Psychiatry, individual sessions	$30.00 copay Service-specific deductible No	Approval required No Referral required No
Psychiatry, group sessions	$30.00 copay Service-specific deductible No	Approval required No Referral required No

Therapy and rehabilitation

Therapy and rehabilitation and member costs
Service	In-network	What to know
Occupational therapy	$20.00 copay Service-specific deductible No	Approval required No Referral required No
Physical and speech therapy	$20.00 copay Service-specific deductible No	Approval required No Referral required No
Cardiac rehabilitation	$10.00 copay Service-specific deductible No	Approval required No Referral required No
Intensive cardiac rehabilitation	$10.00 copay Service-specific deductible No	Approval required No Referral required No
Pulmonary rehabilitation	$10.00 copay Service-specific deductible No	Approval required No Referral required No
Supervised exercise for peripheral artery disease	$10.00 copay Service-specific deductible No	Approval required No Referral required No

Ambulance, medical equipment and supplies

Ambulance, medical equipment and supplies and member costs
Service	In-network	What to know
Ground ambulance	$275.00 copay Service-specific deductible No	Approval required Yes
Air ambulance	$325.00 copay Service-specific deductible No	Approval required Yes
Durable medical equipment	20% coinsurance Service-specific deductible No	Approval required Yes
Prosthetic devices	20% coinsurance Service-specific deductible No	Approval required Yes
Medical supplies	20% coinsurance Service-specific deductible No	Approval required Yes
Diabetic supplies	$0.00 copay Service-specific deductible No	Approval required Yes
Diabetic shoes and inserts	20% coinsurance Service-specific deductible No	Approval required Yes
Diabetic monitors	$0.00 copay Service-specific deductible No	Approval required Yes

Dental benefits

Dental benefits and member costs
Service	In-network	What to know
Medicare-covered dental	$30.00 copay
Oral examsAdditional plan benefit	Confirm with the plan (copay)
Dental X-raysAdditional plan benefit	Confirm with the plan (copay)
Other diagnostic dentalAdditional plan benefit	Confirm with the plan (copay)
Dental cleaningAdditional plan benefit	Confirm with the plan (copay)
FluorideAdditional plan benefit	Confirm with the plan (copay)
Other preventive dentalAdditional plan benefit	Confirm with the plan (copay)
Restorative dental careAdditional plan benefit	50% coinsurance
Root canal treatment (endodontics)Additional plan benefit	70% coinsurance
Gum treatment (periodontics)Additional plan benefit	70% coinsurance
Oral surgeryAdditional plan benefit	50% coinsurance
Other dental servicesAdditional plan benefit	$0.00 copay

Vision benefits

Vision benefits and member costs
Service	In-network	What to know
Medicare-covered eye exams	$0.00 to $30.00 copay Service-specific deductible No	Approval required No Referral required No
Routine eye examsAdditional plan benefit	$0.00 copay	Approval required No Referral required No
Medicare-covered eyewear	$0.00 copay Service-specific deductible No	Approval required No Referral required No
Contact lensesAdditional plan benefit	$0.00 copay	Approval required No Referral required No
Eyeglasses, lenses and framesAdditional plan benefit	$0.00 copay	Approval required No Referral required No
Eyeglass lensesAdditional plan benefit	$0.00 copay	Approval required No Referral required No
Eyeglass framesAdditional plan benefit	$0.00 copay	Approval required No Referral required No

Hearing benefits

Hearing benefits and member costs
Service	In-network	What to know
Medicare-covered hearing exams	$30.00 copay Service-specific deductible No	Approval required No Referral required No
Routine hearing examsAdditional plan benefit	$0.00 copay	Approval required No Referral required No
Hearing aid fitting and evaluationAdditional plan benefit	$0.00 copay	Approval required No Referral required No
Prescription hearing aids (all types)Additional plan benefit	$599.00 to $899.00 copay Service-specific deductible No	Approval required No Referral required No

Extra benefits

Extra benefits and member costs
Service	In-network	What to know
Supplemental acupunctureAdditional plan benefit	$20.00 copay Service-specific deductible No	Approval required Yes Referral required No
Over-the-counter health itemsAdditional plan benefit	$0.00 copay Service-specific deductible No
Limited-duration mealsAdditional plan benefit	$0.00 copay Service-specific deductible No	Approval required No Referral required No
Annual physical examAdditional plan benefit	$0.00 copay Service-specific deductible No	Approval required No Referral required No
Fitness benefitAdditional plan benefit	$0.00 copay Service-specific deductible No	Approval required No Referral required No

Allowances and optional benefits

Optional packages that cost extra

Dental Gold $39.00 extra per month

Dental Gold

The limits below apply only to this optional package.

Benefit allowance: $1,000.00
How often this limit applies: Every year
Do the Optional Supplemental benefits in this package apply to the MOOP for this plan?: No
Deductible applies: No
Included services: Other Diagnostic Dental Services; Other Preventive Dental Services; Restorative dental care; Root canal treatment (endodontics); Gum treatment (periodontics); Removable dentures (prosthodontics); Fixed dental restorations (prosthodontics); Oral and Maxillofacial Surgery; Adjunctive General Services

Dental Silver $15.00 extra per month

Dental Silver

The limits below apply only to this optional package.

Benefit allowance: $500.00
How often this limit applies: Every year
Do the Optional Supplemental benefits in this package apply to the MOOP for this plan?: No
Deductible applies: No
Included services: Other Diagnostic Dental Services; Other Preventive Dental Services; Restorative dental care; Root canal treatment (endodontics); Gum treatment (periodontics); Oral and Maxillofacial Surgery; Adjunctive General Services

Prescription drug coverage

This plan does not include a Part D prescription drug benefit.

Where this plan is offered

CMS lists this plan in 1 state or territory. Availability can vary by county and ZIP code.

View all locations 25 county listings across 1 state or territory