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This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2016 Health Alliance Medicare PPO Basic (PPO) in Saline, Illinois

Medicare Advantage Plan Benefit Details in Plain Text
The following Medicare Advantage plan benefits apply to the Health Alliance Medicare PPO Basic (PPO) (H1417 - 011) in Saline, Illinois .

This plan is administered by .  To switch to a different Medicare Advantage plan or to change your location, click here.
Click here to see the Health Alliance Medicare PPO Basic (PPO) health benefit details in chart format or email and view benefits chart

Plan Premium
The Health Alliance Medicare PPO Basic (PPO) has a monthly premium of $9.00. That is $108.00 for 12 months. There are a few factors that can increase or decrease this premium. If you qualify for full or partial extra help, your premium will be lower. If you have a premium penalty, your premium will be higher. Please remember that the $9.00 montly premium is in addition to your Medicare Part B premium. If you have a premium penalty, your premium will be higher. Or if you have a higher income you would be subject to the Income Related Adjustment Amount (IRMAA).

This Medicare Advantage Plan without Prescription Drug Coverage is a Local PPO * plan.

Plan Membership and Plan Ratings
The Health Alliance Medicare PPO Basic (PPO) (H1417 - 011) currently has 61 members. There are less than 10 members enrolled in this plan in Saline, Illinois, and less than 10 members in Illinois.

The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 4 stars. The detail CMS plan carrier ratings are as follows:
Please be aware that this plan does NOT include Prescription Drug Coverage!
The Health Alliance Medicare PPO Basic (PPO) offers many Health Coverage Benefits. The following section will describe these benefits in detail.

** Cost **
Monthly premium, deductible, and limits on how much you pay for covered services
$9.00 per month. In addition you must keep paying your Medicare Part B premium.
This plan does not have a deductible.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $5 800 for services you receive from in-network providers.
  • $10 000 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums.
Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply.
** Doctor and Hospital Choice **
Acupuncture
Not covered
** Extra Benefits **
Inpatient mental health care
For inpatient mental health care see the "Mental Health Care" section.
Outpatient prescription drugs
For Part B drugs such as chemotherapy drugs1:
  • In-network:  20% of the cost
  • Out-of-network:  20% of the cost
Other Part B drugs1:
  • In-network:  20% of the cost
  • Out-of-network:  20% of the cost
Our plan does not cover Part D prescription drug.
** Important Information **
Monthly premium, deductible, and limits on how much you pay for covered services
$9.00 per month. In addition you must keep paying your Medicare Part B premium.
This plan does not have a deductible.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $5 800 for services you receive from in-network providers.
  • $10 000 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums.
Our plan has a coverage limit every year for certain benefits from any provider. Contact us for services that apply.
** Outpatient Care and Services **
Acupuncture
Not covered
Ambulance
  • In-network:  $100 copay
  • Out-of-network:  $100 copay
Chiropractic care
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):
  • In-network:  $20 copay
  • Out-of-network:  $50 copay
Dental services
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):
  • In-network:  $25 copay
  • Out-of-network:  $50 copay
Preventive dental services:
  • Cleaning:
    • In-network:  You pay nothing
    • Out-of-network:  You pay nothing
  • Dental x-ray(s):
    • In-network:  You pay nothing
    • Out-of-network:  You pay nothing
  • Fluoride treatment:
    • In-network:  You pay nothing
    • Out-of-network:  You pay nothing
  • Oral exam:
    • In-network:  You pay nothing
    • Out-of-network:  You pay nothing
    Diabetes supplies and services
    Diabetes monitoring supplies:
    • In-network:  0-20% of the cost depending on the supply
    • Out-of-network:  20% of the cost
    Diabetes self-management training:
    • In-network:  You pay nothing
    • Out-of-network:  $50 copay
    Therapeutic shoes or inserts:
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Diagnostic tests, lab and radiology services, and x-rays (Costs for these services may be different if received in an outpatient surgery setting)
    Diagnostic radiology services (such as MRIs CT scans):
    • In-network:  $40 copay
    • Out-of-network:  $50 copay
    Diagnostic tests and procedures:
    • In-network:  $40 copay
    • Out-of-network:  $50 copay
    Lab services:
    • In-network:  $40 copay
    • Out-of-network:  $50 copay
    Outpatient x-rays:
    • In-network:  $40 copay
    • Out-of-network:  $50 copay
    Therapeutic radiology services (such as radiation treatment for cancer):
    • In-network:  $40 copay
    • Out-of-network:  $50 copay
    Doctor's office visits
    Primary care physician visit:
    • In-network:  $20 copay
    • Out-of-network:  $50 copay
    Specialist visit:
    • In-network:  $50 copay
    • Out-of-network:  $50 copay
    Durable medical equipment (wheelchairs, oxygen, etc.)
    • In-network:  20% of the cost
    • Out-of-network:  20% of the cost
    Emergency care
    $75 copay
    If you are immediately admitted to the hospital you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section for other costs.
    Foot care (podiatry services)
    Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
    • In-network:  $50 copay
    • Out-of-network:  $50 copay
    Hearing services
    Exam to diagnose and treat hearing and balance issues:
    • In-network:  $50 copay
    • Out-of-network:  $50 copay
    Routine hearing exam:
    • In-network:  You pay nothing
    • Out-of-network:  You pay nothing
    Hearing aid fitting/evaluation:
    • In-network:  You pay nothing
    • Out-of-network:  You pay nothing
    Hearing aid:
    • In-network:  You pay nothing
    • Out-of-network:  You pay nothing
    Home health care
    • In-network:  You pay nothing
    • Out-of-network:  $50 copay
    Mental health care
    Inpatient visit:
    Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.
    Our plan covers 90 days for an inpatient hospital stay.
    Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days.
    • In-network:  
      • $350 copay per day for days 1 through 4
      • You pay nothing per day for days 5 through 90
        • Out-of-network:  
          • $400 copay per day for days 1 through 4
            • Outpatient group therapy visit:
            • In-network:  $40 copay
            • Out-of-network:  $50 copay
            Outpatient individual therapy visit:
            • In-network:  $40 copay
            • Out-of-network:  $50 copay
            Outpatient rehabilitation
            Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):
            • In-network:  You pay nothing
            • Out-of-network:  $50 copay
            Occupational therapy visit:
            • In-network:  $20 copay
            • Out-of-network:  $50 copay
            Physical therapy and speech and language therapy visit:
            • In-network:  $20 copay
            • Out-of-network:  $50 copay
            Outpatient substance abuse
            Group therapy visit:
            • In-network:  $50 copay
            • Out-of-network:  $50 copay
            Individual therapy visit:
            • In-network:  $50 copay
            • Out-of-network:  $50 copay
            Outpatient surgery
            Ambulatory surgical center:
            • In-network:  20% of the cost
            • Out-of-network:  20% of the cost
            Outpatient hospital:
            • In-network:  20% of the cost
            • Out-of-network:  20% of the cost
            Over-the-counter items
            Not Covered
            Prosthetic devices (braces, artificial limbs, etc.)
            Prosthetic devices:
            • In-network:  20% of the cost
            • Out-of-network:  20% of the cost
            Related medical supplies:
            • In-network:  20% of the cost
            • Out-of-network:  20% of the cost
            Renal dialysis
            • In-network:  You pay nothing
            • Out-of-network:  You pay nothing
            Transportation
            Not covered
            Urgently needed services
            $65 copay
            Vision services
            Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):
            • In-network:  $25 copay
            • Out-of-network:  $50 copay
            Routine eye exam:
            • In-network:  You pay nothing
            • Out-of-network:  You pay nothing
            Contact lenses:
            • In-network:  You pay nothing
            • Out-of-network:  You pay nothing
            Eyeglasses (frames and lenses):
            • In-network:  You pay nothing
            • Out-of-network:  You pay nothing
            Eyeglass frames:
            • In-network:  You pay nothing
            • Out-of-network:  You pay nothing
            Eyeglass lenses:
            • In-network:  You pay nothing
            • Out-of-network:  You pay nothing
            Eyeglasses or contact lenses after cataract surgery:
            • In-network:  You pay nothing
            • Out-of-network:  You pay nothing
            ** Hospice **
            Hospice
            You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.
            ** Preventive Care **
            Preventive care
            • In-network:  You pay nothing
            • Out-of-network:  $50 copay
            Our plan covers many preventive services including:
            • Abdominal aortic aneurysm screening
            • Alcohol misuse counseling
            • Bone mass measurement
            • Breast cancer screening (mammogram)
            • Cardiovascular disease (behavioral therapy)
            • Cardiovascular screenings
            • Cervical and vaginal cancer screening
            • Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
            • Depression screening
            • Diabetes screenings
            • HIV screening
            • Medical nutrition therapy services
            • Obesity screening and counseling
            • Prostate cancer screenings (PSA)
            • Sexually transmitted infections screening and counseling
            • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
            • Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
            • "Welcome to Medicare" preventive visit (one-time)
            • Yearly "Wellness" visit
            Any additional preventive services approved by Medicare during the contract year will be covered.
            ** Inpatient Care **
            Inpatient hospital care
            Our plan covers an unlimited number of days for an inpatient hospital stay.
            • In-network:  
              • $390 copay per day for days 1 through 4
              • You pay nothing per day for days 5 through 90
              • You pay nothing per day for days 91 and beyond
                • Out-of-network:  
                  • $450 copay per day for days 1 through 4
                    • Inpatient mental health care
                    For inpatient mental health care see the "Mental Health Care" section.
                    Skilled Nursing Facility (SNF)
                    Our plan covers up to 100 days in a SNF.
                    • In-network:  
                      • You pay nothing per day for days 1 through 20
                      • $150 copay per day for days 21 through 100
                        • Out-of-network:  
                          • $100 copay per day for days 1 through 20
                          • $200 copay per day for days 21 through 100
                            • Outpatient prescription drugs
                            For Part B drugs such as chemotherapy drugs1:
                            • In-network:  20% of the cost
                            • Out-of-network:  20% of the cost
                            Other Part B drugs1:
                            • In-network:  20% of the cost
                            • Out-of-network:  20% of the cost
                            Our plan does not cover Part D prescription drug.
                            ** Outpatient Care **
                            Diabetes supplies and services
                            Diabetes monitoring supplies:
                            • In-network:  0-20% of the cost depending on the supply
                            • Out-of-network:  20% of the cost
                            Diabetes self-management training:
                            • In-network:  You pay nothing
                            • Out-of-network:  $50 copay
                            Therapeutic shoes or inserts:
                            • In-network:  20% of the cost
                            • Out-of-network:  20% of the cost
                            Foot care (podiatry services)
                            Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
                            • In-network:  $50 copay
                            • Out-of-network:  $50 copay
                            Hearing services
                            Exam to diagnose and treat hearing and balance issues:
                            • In-network:  $50 copay
                            • Out-of-network:  $50 copay
                            Routine hearing exam:
                            • In-network:  You pay nothing
                            • Out-of-network:  You pay nothing
                            Hearing aid fitting/evaluation:
                            • In-network:  You pay nothing
                            • Out-of-network:  You pay nothing
                            Hearing aid:
                            • In-network:  You pay nothing
                            • Out-of-network:  You pay nothing
                            ** Outpatient Medical Services and Supplies **
                            Outpatient substance abuse
                            Group therapy visit:
                            • In-network:  $50 copay
                            • Out-of-network:  $50 copay
                            Individual therapy visit:
                            • In-network:  $50 copay
                            • Out-of-network:  $50 copay
                            Prosthetic devices (braces, artificial limbs, etc.)
                            Prosthetic devices:
                            • In-network:  20% of the cost
                            • Out-of-network:  20% of the cost
                            Related medical supplies:
                            • In-network:  20% of the cost
                            • Out-of-network:  20% of the cost
                            ** Additional Benefits **
                            Inpatient mental health care
                            For inpatient mental health care see the "Mental Health Care" section.




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                            .