Wellcare Patriot Giveback Open (PPO)

H0969 - 004 - 0

(3 / 5)

Wellcare Patriot Giveback Open (PPO) is a Medicare Advantage (Part C) Plan by Wellcare.

This page features plan details for 2023 Wellcare Patriot Giveback Open (PPO) H0969 – 004 – 0 available in Select counties in NH.

IMPORTANT: This page features the 2023 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

Wellcare Patriot Giveback Open (PPO) is offered in the following locations.

Belknap County, New Hampshire

Carroll County, New Hampshire

Cheshire County, New Hampshire

Click to see more locations

Plan Overview

Wellcare Patriot Giveback Open (PPO) offers the following coverage and cost-sharing.

Insurer:	Wellcare
Health Plan Deductible:	$0.00
MOOP:	$10,000 In and Out-of-network $7,550 In-network
Drugs Covered:	No

Ready to sign up for Wellcare Patriot Giveback Open (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 TTY 711.

8am – 11pm EST. 7 days a week

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.

Wellcare Patriot Giveback Open (PPO) qualifies for a monthly Medicare Give Back Benefit of $45.00.

Premium Reduction:

$45.00

Premium Breakdown

Wellcare Patriot Giveback Open (PPO) 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
$164.90	$0.00	$45.00	$119.90

Please Note:

Your Part B premium may differ based on factors including late enrollment, income, and disability status.

Additional Benefits

Wellcare Patriot Giveback Open (PPO) 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:	In-Network: 20% coinsurance (limits may apply) (authorization required) (referral not required)
Diagnostic services:	Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required)
Endodontics:	In-Network: 20% coinsurance (limits may apply) (authorization required) (referral not required)
Endodontics:	Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required)
Extractions:	In-Network: 20% coinsurance (limits may apply) (authorization required) (referral not required)
Extractions:	Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required)
Non-routine services:	In-Network: 20% coinsurance (limits may apply) (authorization required) (referral not required)
Non-routine services:	Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required)
Periodontics:	In-Network: 20% coinsurance (limits may apply) (authorization required) (referral not required)
Periodontics:	Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required)
Prosthodontics, other oral/maxillofacial surgery, other services:	In-Network: 20% coinsurance (limits may apply) (authorization required) (referral not required)
Prosthodontics, other oral/maxillofacial surgery, other services:	Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required)
Restorative services:	In-Network: 20% coinsurance (limits may apply) (authorization required) (referral not required)
Restorative services:	Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required)

Dental (preventive)

Cleaning:	In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Cleaning:	Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required)
Dental x-ray(s):	In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Dental x-ray(s):	Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required)
Fluoride treatment:	In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Fluoride treatment:	Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required)
Oral exam:	In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Oral exam:	Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required)

Diagnostic procedures/lab services/imaging

Diagnostic radiology services (e.g., MRI):	In-Network: $0-350 copay (authorization required) (referral not required)
Diagnostic radiology services (e.g., MRI):	Out-of-Network: $0-350 copay (authorization required) (referral not required)
Diagnostic tests and procedures:	In-Network: $0-100 copay (authorization required) (referral not required)
Diagnostic tests and procedures:	Out-of-Network: $0-350 copay (authorization required) (referral not required)
Lab services:	In-Network: $0 copay (authorization required) (referral not required)
Lab services:	Out-of-Network: $0 copay (authorization required) (referral not required)
Outpatient x-rays:	In-Network: $0 copay (authorization required) (referral not required)
Outpatient x-rays:	Out-of-Network: $0 copay (authorization required) (referral not required)

Doctor visits

Primary:	In-Network: $0 copay
Primary:	Out-of-Network: $0 copay
Specialist:	In-Network: $40 copay per visit (authorization required) (referral not required)
Specialist:	Out-of-Network: $40 copay per visit (authorization required) (referral not required)

Emergency care/Urgent care

Emergency:	$95 copay per visit (always covered)
Urgent care:	$40 copay per visit (always covered)

Foot care (podiatry services)

Foot exams and treatment:	In-Network: $40 copay (authorization required) (referral not required)
Foot exams and treatment:	Out-of-Network: $40 copay (authorization required) (referral not required)
Routine foot care:	Not covered

Ground ambulance

	In-Network: $245 copay
	Out-of-Network: $245 copay

Health plan deductible

$0.00

Health plan deductibles (other)

In-Network: No

Hearing

Fitting/evaluation:	In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Fitting/evaluation:	Out-of-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required)
Hearing aids:	In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Hearing aids:	Out-of-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required)
Hearing exam:	In-Network: $40 copay (authorization required) (referral not required)
Hearing exam:	Out-of-Network: $40 copay (authorization required) (referral not required)

Hospital coverage (inpatient)

	In-Network: $350 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral not required)
	Out-of-Network: 40% per day for days 1 through 90 (authorization required) (referral not required)

Hospital coverage (outpatient)

	In-Network: $350 copay per visit (authorization required) (referral not required)
	Out-of-Network: $350 copay per visit (authorization required) (referral not required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

$10,000 In and Out-of-network
$7,550 In-network

Medical equipment/supplies

Diabetes supplies:	In-Network: $0 copay per item (authorization required)
Diabetes supplies:	Out-of-Network: 20-40% coinsurance per item (authorization required)
Durable medical equipment (e.g., wheelchairs, oxygen):	In-Network: 20% coinsurance per item (authorization required)
Durable medical equipment (e.g., wheelchairs, oxygen):	Out-of-Network: 20-40% coinsurance per item (authorization required)
Prosthetics (e.g., braces, artificial limbs):	In-Network: 20% coinsurance per item (authorization required)
Prosthetics (e.g., braces, artificial limbs):	Out-of-Network: 20-40% coinsurance per item (authorization required)

Medicare Part B drugs

Chemotherapy:	In-Network: 20% coinsurance (authorization required)
Chemotherapy:	Out-of-Network: 20-40% coinsurance (authorization required)
Other Part B drugs:	In-Network: 20% coinsurance (authorization required)
Other Part B drugs:	Out-of-Network: 20-40% coinsurance (authorization required)

Mental health services

Inpatient hospital – psychiatric:	In-Network: $350 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral not required)
Inpatient hospital – psychiatric:	Out-of-Network: 40% per day for days 1 through 90 (authorization required) (referral not required)
Outpatient group therapy visit:	In-Network: $40 copay (authorization required) (referral not required)
Outpatient group therapy visit:	Out-of-Network: $40 copay (authorization required) (referral not required)
Outpatient group therapy visit with a psychiatrist:	In-Network: $40 copay (authorization required) (referral not required)
Outpatient group therapy visit with a psychiatrist:	Out-of-Network: $40 copay (authorization required) (referral not required)
Outpatient individual therapy visit:	In-Network: $40 copay (authorization required) (referral not required)
Outpatient individual therapy visit:	Out-of-Network: $40 copay (authorization required) (referral not required)
Outpatient individual therapy visit with a psychiatrist:	In-Network: $40 copay (authorization required) (referral not required)
Outpatient individual therapy visit with a psychiatrist:	Out-of-Network: $40 copay (authorization required) (referral not required)

Optional supplemental benefits

Preventive care

	In-Network: $0 copay (authorization not required) (referral not required)
	Out-of-Network: $0 copay (authorization not required) (referral not required)

Rehabilitation services

Occupational therapy visit:	In-Network: $40 copay (authorization required) (referral not required)
Occupational therapy visit:	Out-of-Network: $40 copay (authorization required) (referral not required)
Physical therapy and speech and language therapy visit:	In-Network: $40 copay (authorization required) (referral not required)
Physical therapy and speech and language therapy visit:	Out-of-Network: $40 copay (authorization required) (referral not required)

Skilled Nursing Facility

	In-Network: $0 per day for days 1 through 20 $196 per day for days 21 through 60 $0 per day for days 61 through 100 (authorization required) (referral not required)
	Out-of-Network: 40% per day for days 1 through 100 (authorization required) (referral not required)

Transportation

	In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
	Out-of-Network: 75% coinsurance (limits may apply) (authorization required) (referral not required)

Vision

Contact lenses:	In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Contact lenses:	Out-of-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required)
Eyeglass frames:	In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Eyeglass frames:	Out-of-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required)
Eyeglass lenses:	In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Eyeglass lenses:	Out-of-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required)
Eyeglasses (frames and lenses):	In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Eyeglasses (frames and lenses):	Out-of-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required)
Other:	Not covered (no limits)
Routine eye exam:	In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Routine eye exam:	Out-of-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required)
Upgrades:	In-Network: $0 copay (limits may apply) (authorization required) (referral not required)
Upgrades:	Out-of-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required)

Wellness programs (e.g., fitness, nursing hotline)

Covered (authorization not required) (referral not required)