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Clear Spring Health Choice Plan (PPO) - H9589-003-000

Not enough data available* for plan year 2024

$0.00

Monthly Premium

Clear Spring Health Choice Plan (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Clear Spring Health

Plan ID: H9589-003-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$0.00

Monthly Premium

Georgia 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 Georgia 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

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$250.00
Out-of-pocket maximum$6,700.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$8,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0.00 to $45.00. $0.00 Copay for Endocrinologist Specialist and $45 for all other Specialist Visits.

Out-of-Network:

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $50.00
Inpatient hospital careIn-Network:

Acute Hospital Services:
$295.00 per day for days 1 to 7
$0.00 per day for days 8 to 90
Prior Authorization Required for Acute Hospital Services
Urgent care
Urgent Care:
Copayment for Urgent Care $35.00

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $120.00
Maximum Plan Benefit of $50,000
Emergency room visit
Emergency Care:
Copayment for Emergency Care $90.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 1 days

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $120.00
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

Clear Spring Health Choice Plan (PPO) covers a range of additional benefits. Learn more about Clear Spring Health Choice Plan (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $15.00
Prior Authorization Required for Chiropractic Services
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0.00
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00
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)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
This Plan has preferred Vendors/Manufacturers - Please see Evidence of Coverage
Diagnostic tests, lab and radiology services, and X-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20%
Copayment for Medicare-covered Lab Services $0.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $100.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0.00 to $100.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Home health care
Out-of-Network:

Home Health Services:
Coinsurance for Medicare Covered Home Health 20%
Mental health inpatient care
Out-of-Network:
$395.00 per day for days 1 to 7
$0.00 per day for days 8 to 90
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $250.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services $250.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $200.00
Prior Authorization Required for Ambulatory Surgical Center Services
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
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 $85.00
Podiatry services
Out-of-Network:

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 45%
Skilled Nursing Facility (SNF) care
Out-of-Network:
$195.00 per day for days 1 to 35
$0.00 per day for days 36 to 100

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Dental careIn-Network:

Comprehensive Dental:
Copayment for Medicare-covered Benefits $50.00
Copayment for Diagnostic Services $0.00
Copayment for Restorative Services $0.00
Copayment for Endodontics $0.00
Copayment for Periodontics $0.00
Copayment for Extractions $0.00
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00
Maximum Plan Benefit of $2000.00 every year for in and out of network services combined for Non-Medicare Covered Comprehensive

Out-of-Network:

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 20%
Non-Medicare Covered Dental Services:
Copayment for Non-Medicare Covered Preventive Dental Not Covered
Copayment for Non-Medicare Covered Comprehensive Dental Not Covered

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage

CoverageDetails
Vision careIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $50.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Copayment for Eyeglasses (lenses and frames) $0.00
  • Maximum 1 Pair every year
Maximum Plan Benefit of $200.00 every year for all Non-Medicare covered eyewear for in and out of network services combined

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing careIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $50.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 1 visit every year

Hearing Aids:
Copayment for Hearing Aids $0.00
  • Maximum 2 Hearing Aids every year
Maximum Plan Benefit of $500.00 every year per ear for in and out of network services combined
Hearing aids must be purchased through NationsHearing in order to access the benefit.

Out-of-Network:

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 20%
Non-Medicare Covered Hearing Services:
Copayment for Non-Medicare Covered Hearing Exams Not Covered
Copayment for Non-Medicare Covered Hearing Aids Not Covered

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.

CoverageDetails
Preventive services and health/wellness education programs
Out-of-Network:

Medicare-covered Zero Dollar Preventive Services:
Coinsurance for Medicare Covered Medicare-covered Preventive Services 45%

Prescription Drug Costs and Coverage

The Clear Spring Health Choice Plan (PPO) offers prescription drug coverage, with an annual drug deductible of $250.00 (excludes Tiers 1 and 2)

Coverage & Cost
Coverage
Cost
Annual drug deductible$250.00 (excludes Tiers 1 and 2)
Tier 1
  • Preferred retail $0.00
  • Standard retail $5.00
  • Preferred mail order $0.00
  • Standard mail order $5.00
Tier 2
  • Preferred retail $0.00
  • Standard retail $17.00
  • Preferred mail order $0.00
  • Standard mail order $17.00
Annual drug deductible$250.00 (excludes Tiers 1 and 2)
Tier 1
  • Preferred retail $0.00
  • Standard retail $10.00
  • Preferred mail order $0.00
  • Standard mail order $10.00
Tier 2
  • Preferred retail $0.00
  • Standard retail $34.00
  • Preferred mail order $0.00
  • Standard mail order $34.00
Annual drug deductible$250.00 (excludes Tiers 1 and 2)
Tier 1
  • Preferred retail $0.00
  • Standard retail $5.00
  • Preferred mail order $0.00
  • Standard mail order $5.00
Tier 2
  • Preferred retail $0.00
  • Standard retail $42.50
  • Preferred mail order $0.00
  • Standard mail order $42.50

When reviewing Georgia 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 Georgia 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

Georgia Counties Served

We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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