Molina Dual MI Coordinated Health (HMO D-SNP) - H5926-008-000

Doctor Office Visit:
Copayment for Primary Care Office Visit $0

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $0

Prior Authorization Required for Acute Hospital Services

Urgent Care:
Copayment for Urgent Care $0

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0
Maximum Plan Benefit of $10,000

Emergency Care:
Copayment for Emergency Care $0
Coinsurance for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $0
Copayment for Worldwide Emergency Transportation $0
Maximum Plan Benefit of $10,000

Ground Ambulance:
Copayment for Ground Ambulance Services $0

Prior authorization required for non-emergent ambulance only. 

Air Ambulance:
Copayment for Air Ambulance Services $0
Prior Authorization Required for Air Ambulance

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $0

Diabetic Supplies and Services:

Copayment for Medicare-covered Diabetic Supplies $0

Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0

Prior authorization may be required.

Prior authorization required for diabetic shoes and inserts.

Prior authorization is not required for preferred manufacturer.

Durable Medical Equipment:
Copayment for Medicare-covered Durable Medical Equipment $0
Prior Authorization Required for Durable Medical Equipment

Prior authorization may be required.

Prior authorization is not required for preferred manufacturers.

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0
Copayment for Medicare-covered Lab Services $0

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0
Copayment for Medicare-covered Therapeutic Radiological Services $0
Copayment for Medicare-covered X-Ray Services $0

Prior authorization may be required for some services.

No authorization is required for outpatient lab services and outpatient x-ray services.

Genetic lab testing requires prior authorization.

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $0
Prior Authorization Required for Psychiatric Hospital Services

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0

Prior authorization may be required. 

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services $0
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0
Prior Authorization Required for Ambulatory Surgical Center Services

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Prior Authorization Required for Outpatient Substance Abuse Services

Over-The-Counter (OTC) Items:

$167 combined allowance every month for OTC items.

Unused allowance does not carry over to the next month.

Please see the Flexible Extras section for a complete list of benefit and services that are included in the combined allowance. 

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $0
Prior Authorization Required for Podiatry Services

Skilled Nursing Facility Services:
Copayment for Skilled Nursing Facility Services per Stay $0
Prior Authorization Required for Skilled Nursing Facility Services

Medicare Covered Preventive Dental:
Copayment for Office Visit $0

Receive Periodic oral exams, extractions, preventive services, dentures and partials through  Medicaid dental coverage. An additional $4,000 allowance for comprehensive dental services every year above Medicaid coverage through a Molina Vlaue Added Service Benefit.

Eye Exams:
Copayment for Medicare Covered Benefits $0

Receive a routine eye exam and one pair of glasses every 2 years through Medicaid and an additional eye exam and a $250 allowance for eyewear (contacts, lenses, frames)through a Molina Value Added Benefit.

Hearing Exams:
Copayment for Medicare Covered Benefits $0

Receive 1 hearing aid through Medicaid once every 5 years and 36 batteries per hearing aid every 6 months. An additional 2 pre-selected hearing aids through Molina Value Added Benefit every 2 years.

$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:

• COVID-19 shots

• Flu shots

• Hepatitis B shots

• Pneumococcal shots

Tobacco use cessation
Yearly "Wellness" visit

• Summary of benefits
• Evidence of coverage
• Star ratings