Wellcare Patriot No Premium (HMO)
H0913 - 020 - 0
(3.5 / 5)
Wellcare Patriot No Premium (HMO) is a Medicare Advantage (Part C) Plan by Wellcare.
This page features plan details for 2024 Wellcare Patriot No Premium (HMO) H0913 – 020 – 0 available in Select counties in NJ.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Wellcare Patriot No Premium (HMO) is offered in the following locations.
Plan Overview
Wellcare Patriot No Premium (HMO) offers the following coverage and cost-sharing.
| Insurer: | Wellcare |
| Health Plan Deductible: | $0.00 |
| MOOP: | $7,550 In-network |
| Drugs Covered: | No |
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Premium Breakdown
Wellcare Patriot No Premium (HMO) 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 |
|---|---|---|---|
| $174.70 | $0.00 | $0.00 | $174.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Wellcare Patriot No Premium (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $7,550 In-network |
| No |
| In-network | No |
| $0-150 copay per visit (Authorization is required.) (Referral is not required.) |
| Primary | $5 copay per visit (Not applicable.) (Not applicable.) |
| Specialist | $40 copay per visit (Authorization is required.) (Referral is not required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $100 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $35 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $0-20 copay (Authorization is required.) (Referral is not required.) |
| Lab services | $0-50 copay (Authorization is required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | $0-150 copay (Authorization is required.) (Referral is not required.) |
| Outpatient x-rays | $25 copay (Authorization is required.) (Referral is not required.) |
| Hearing exam | $40 copay (Authorization is required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Hearing aids | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Fluoride treatment | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Non-routine services | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Diagnostic services | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Restorative services | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Endodontics | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Periodontics | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Extractions | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Upgrades | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Occupational therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
| $250 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| Foot exams and treatment | $40 copay (Authorization is required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | $0 copay per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
| $400 per day for days 1 through 4 $0 per day for days 5 through 90 (Authorization is required.) (Referral is not required.) |
| Inpatient hospital – psychiatric | $300 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | $25 copay (Authorization is required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $25 copay (Authorization is required.) (Referral is not required.) |
| Outpatient group therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
| Outpatient individual therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
| $0 per day for days 1 through 20 $203 per day for days 21 through 60 $0 per day for days 61 through 100 (Authorization is required.) (Referral is not required.) |
Ready to sign up for Wellcare Patriot No Premium (HMO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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