Basic MA

Disclaimers:

  • PrimeTime Health Plan is an HMO-POS plan with a Medicare contract. Enrollment in PrimeTime Health Plan depends on contract renewal.
  • This information is not a complete description of benefits. Contact the plan for more information.
  • Limitations, co-payments, and restrictions may apply.
  • Benefits, premium and/or co-payments/co-insurance may change on January 1 of each year.
  • You must continue to pay your Medicare Part B premium.
  • The provider network may change at any time. You will receive notice when necessary.

2017 PrimeTime Health Plan Basic-MA Only (HMO-POS)

With PrimeTime Health Plan Basic-MA Only (HMO-POS) there are no deductibles to pay. Instead, your cost-sharing consists of co-payments or co-insurances for the services that you receive.

Eligibility Requirements:
You are eligible for membership in our plan as long as:

  • You live in our service area
    (Carroll, Columbiana, Harrison, Holmes, Mahoning, Medina, Portage, Stark, Summit, Trumbull, Tuscarawas, and Wayne Counties)
  • --and-- you have both Medicare Part A and Medicare Part B
    (When you enroll in a Medicare Advantage Plan, you continue to pay your Medicare Part B premium.)
  • --and--you do not have End-Stage Renal Disease (ESRD), with limited exceptions, such as if you develop ESRD when you are already a member of a plan that we offer, or you were a member of a different plan that was terminated.
PrimeTime Health Plan Basic-MA Only (HMO-POS)
Plan Premium $0 per month
Primary Care Physician $35 copay for each Medicare-covered primary care doctor visit
Specialist $45 copay for each Medicare-covered specialist visit
Urgent Care (Inside United States) $45 copay for Medicare-covered urgently-needed-care visits
Urgent Care (Outside United States) $65 copay for Medcare-covered urgently-needed-care visits
Emergency Care (Worldwide coverage) $65 copay for Medicare-covered emergency room visits
Inpatient Hospital Care $300 copay per day, days 1 – 6; then $0 copay per day for Medicare-covered hospital stays
Outpatient Surgery (Ambulatory/Outpatient Surgery) 20% of the cost for each Medicare-covered surgical visit; member’s share of co-insurance for facility charges is limited to $500 annually
Home Health Care $20 copay for each Medicare-covered home health visit
Ambulance Services $200 copay for Medicare-covered ambulance benefits
Durable Medical Equipment 20% of the cost for Medicare-covered durable medical equipment
Diabetes Supplies 20% of the cost for Medicare-covered diabetic supplies
General Diagnostic Tests and Radiology Services (not including x-rays) $45 copay for Medicare-covered general diagnostic tests and radiology services (not including x-rays)
Complex Diagnostic Tests and Radiology Services (ex. MRI/CT/PET/Thallium Scans) $185 copay for Medicare-covered complex diagnostic tests and radiology services (not including x-rays)
Lab $5 copay for Medicare-covered comprehensive metabolic panel once a year; $45 copay for all other Medicare-covered lab services
X-Ray $45 per copay for Medicare-covered X-rays
Radiation Therapy 20% of the cost for Medicare-covered therapeutic radiology services
Part B Prescription and Chemotherapy Drugs 20% of the cost for Medicare-covered Part B prescription and chemotherapy drugs
Preventive Services $0 copay for all preventive services covered under Original Medicare at zero cost sharing.
Silver&Fit Exercise & Healthy Aging Program Offers members access to participating fitness facilities and instructor led classes. Alternatively, members have the option to receive up to 2 Home Fitness Kits per year. Members may also choose to receive health information, track their fitness activity, participate in health challenges, and earn rewards.
Routine Vision Up to $25 coverage annually for glasses (frames and lenses) or contacts; No coverage for routine vision exam
Routine Dental Not covered
Out of Pocket Maximum (per calendar year) $3,400
For coverage details and additional co-payments/co-insurance please see the Summary of Benefits. Conditions and limitations may apply.

You must receive your care from a network provider.

In most cases, care you receive from an out-of-network provider (a provider who is not part of plan’s network) will not be covered. There are four exceptions:

  • The plan covers emergency or urgently needed services that you get from an out-of-network provider.
  • If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider with our prior approval. In this situation with our approval, you will pay the same as you would pay if you got the care from a network provider.
  • The plan covers kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.
  • Our plan offers a Point of Service (POS) option for services associated with routine eyewear. For lenses and frames or contacts (except after cataract surgery), you may use a qualified provider of your choice.
Last updated: 10/01/2016