Molina Medicare Choice Care (HMO) - H2715-003-000

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

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $40

Acute Hospital Services:
$295 per day for days 1 to 6
$0 per day for days 7 to 90
Prior Authorization Required for Acute Hospital Services

Ground Ambulance:
Coinsurance for Ground Ambulance Services 20%

Prior authorization required for non-emergent ambulance only.

Air Ambulance:
Coinsurance for Air Ambulance Services 20%
Prior Authorization Required for Air Ambulance

Chiropractic Services:
Coinsurance for Medicare-covered Chiropractic Services 20%

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:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior authorization may be required. Prior authorization is not required for preferred manufacturers.

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare-covered Diagnostic Procedures/Tests 0% to 20%
Copayment for Medicare-covered Lab Services $0
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
Minimum coinsurance applies to diagnostic procedures and tests received at a freestanding location. Maximum coinsurance applies to diagnostic procedures and tests received at a hospital.

Outpatient Diag/Therapeutic Rad Services:
Coinsurance for Medicare-covered Diagnostic Radiological Services 20%
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
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 $45
Copayment for Medicare-covered Group Sessions $45

Prior authorization may be required.

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $500
Prior Authorization Required for Outpatient Hospital Services
Minimum amount for diagnostic colonoscopies in an outpatient setting. Maximum amount for all other services.

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $295
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 to $250
Prior Authorization Required for Ambulatory Surgical Center Services
Minimum amount for diagnostic colonoscopies in an ASC setting. Maximum amount for all other services.

Intensive Outpatient Program Services: $70.00 copay Prior Authorization Required

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $40
Copayment for Medicare-covered Group Sessions $40
Prior Authorization Required for Outpatient Substance Abuse Services

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

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$145 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services

Medicare Covered Preventive Dental:
Copayment for Office Visit $40

Eye Exams:
Copayment for Medicare Covered Benefits $40

Hearing Exams:
Copayment for Medicare Covered Benefits $10

$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