Ascension Complete St. Vincent Access (PPO)
Ascension Complete St. Vincent Access (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Centene Corporation
Plan ID: H1774-002-000
Indiana Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about Indiana Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $2,900.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $7,400.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Coinsurance for Physician Specialist Office Visit 20% Prior Authorization Required for Doctor Specialty Visit |
| Inpatient hospital care | In-Network: Acute Hospital Services: $440.00 per day for days 1 to 4 $0.00 per day for days 5 to 90 Prior Authorization Required for Acute Hospital Services |
| Urgent care | Urgent Care: Copayment for Urgent Care $40.00 Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Urgent Coverage $125.00 Maximum Plan Benefit of $50,000 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $125.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $125.00 Maximum Plan Benefit of $50,000 |
| Ambulance transportation | Out-of-Network: Ambulance Services: Coinsurance for Medicare Covered Ambulance Services - Ground 20% Coinsurance for Medicare Covered Ambulance Services - Air 20% |
Health Care Services and Medical Supplies
Ascension Complete St. Vincent Access (PPO) covers a range of additional benefits. Learn more about Ascension Complete St. Vincent Access (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Coinsurance for Medicare-covered Chiropractic Services 20% Prior Authorization Required for Chiropractic Services |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0.00 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) |
| Durable medical equipment (DME) | Out-of-Network: Durable Medical Equipment: Coinsurance for Medicare Covered Durable Medical Equipment 20% |
| Diagnostic tests, lab and radiology services, and X-rays | Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $0.00 to $125.00 Coinsurance for Medicare Covered Diagnostic Procedures/Tests 20% Copayment for Medicare Covered Lab Services $0.00 to $125.00 Coinsurance for Medicare Covered Lab Services 20% Copayment for Medicare Covered Diagnostic Radiological Services $0.00 to $125.00 Coinsurance for Medicare Covered Diagnostic Radiological Services 20% Coinsurance for Medicare Covered Therapeutic Radiological Services 20% Coinsurance for Medicare Covered Outpatient X-Ray Services 20% |
| Home health care | Out-of-Network: Home Health Services: Copayment for Medicare Covered Home Health $0.00 |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: $575.00 per day for days 1 to 4 $0.00 per day for days 5 to 90 Prior Authorization Required for Psychiatric Hospital Services |
| Mental health outpatient care | Out-of-Network: Outpatient Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 20% Coinsurance for Medicare Covered Group Sessions 20% |
| Outpatient services/surgery | Out-of-Network: Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 20% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 20% |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare-covered Individual Sessions 20% Coinsurance for Medicare-covered Group Sessions 20% Prior Authorization Required for Outpatient Substance Abuse Services |
| Over-the-counter items | Out-of-Network: Over-The-Counter (OTC) Items: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $80.00 |
| Podiatry services | In-Network: Podiatry Services: Coinsurance for Medicare-Covered Podiatry Services 20% Coinsurance for Routine Foot Care 20% Prior Authorization Required for Podiatry Services |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $196.00 per day for days 21 to 40 $0.00 per day for days 41 to 100 Prior Authorization Required for Skilled Nursing Facility Services |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | Out-of-Network: Medicare Covered Dental Services: Coinsurance for Medicare Covered Comprehensive Dental 20% Non-Medicare Covered Dental Services: Coinsurance for Non-Medicare Covered Preventive Dental 70% Coinsurance for Non-Medicare Covered Comprehensive Dental 70% |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Vision benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 Coinsurance for Medicare Covered Benefits 20% Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Maximum Plan Allowance of $200.00 every year for all Non-Medicare covered eyewear for in and out of network services combined Prior Authorization Required for Eyewear |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing benefits | Out-of-Network: Medicare Covered Hearing Services: Coinsurance for Medicare Covered Hearing Exams 20% Non-Medicare Covered Hearing Services: Coinsurance for Non-Medicare Covered Hearing Exams 40% Coinsurance for Non-Medicare Covered Hearing Aids 40% |
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0.00 |
When reviewing Indiana Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Indiana that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Indiana Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.
