Molina Medicare Complete Care Select (HMO D-SNP) - H5823-010-000

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

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0 or $30

Acute Hospital Services:

$325 per day for days 1 to 6

$0 per day for days 7 to 90

Prior Authorization Required for Acute Hospital Services

Urgent Care:
Copayment for Urgent Care $0 or $30

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

Emergency Care:
Copayment for Emergency Care $0 or $100
Copayment 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:
Coinsurance for Ground Ambulance Services 0% or 20%
Prior authorization required for non-emergent ambulance only. 

Air Ambulance:
Coinsurance for Air Ambulance Services 0% or 20%
Prior Authorization Required for Air Ambulance

Chiropractic Services:

Copayment for Medicare-covered Chiropractic Services $0 or $15

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 0% or 20%
Prior Authorization Required for Durable Medical Equipment

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare-covered Diagnostic Procedures/Tests 0% to 20%
Coinsurance for Medicare-covered Lab Services 0% to 20%

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 0% to 20%
Coinsurance for Medicare-covered Therapeutic Radiological Services 0% to 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 $0 or $45

Copayment for Medicare-covered Group Sessions $0 or $45

Prior authorization may be required. 

Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 0% or 20%
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $0 or $325
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0 or $50
Prior Authorization Required for Ambulatory Surgical Center Services

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0 or $30
Copayment for Medicare-covered Group Sessions $0 or $30
Prior Authorization Required for Outpatient Substance Abuse Services

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0

Combined Group Name: Transportation/OTC Combined Benefit Allowance Amount: $39.00 Every Month

Combined Benefit Groups: Transportation Services - Plan Approved Health-related Location;Over-the-Counter (OTC) Items;OTC Hearing Aids;

Mode of Delivery: Catalogue Purchase, Debit Card;

Transportation services may be accessed through debit card. OTC items may be purchased through debit card or catalogue purchase. OTC hearing aids may be purchased through catalogue purchase. Unused allowance does not carry over to the next month.

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $0 or $30
Prior Authorization Required for Podiatry Services

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$200 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services

Medicare Covered Preventive Dental:

Copayment for Office Visit $0

Non-Medicare Covered Preventive Dental:

Copayment for Non-medicare preventive $0

Copayment for Oral exams $0

• Maximum 2 visits (Please see Evidence of Coverage for details)

Copayment for Dental x-rays $0

• Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Prophylaxis $0

• Maximum 2 visits every year

Copayment for Fluoride treatment $0

• Maximum 2 visits every year

Non-Medicare Covered Comprehensive Dental:

Copayment for Non-medicare comprehensive $0

Copayment for Restorative services $0

• Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Endodontics $0

• Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Periodontics $0

• Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Prosthodontics, removable $0

• Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Maxillofacial surgery $0

• Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Adjunctive general services $0

• Maximum 1 visit (Please see Evidence of Coverage for details)

Maximum plan benefit coverage amount: $500.00 Every Year

Eye Exams:

Copayment for Medicare Covered Benefits $0

Copayment for Routine Eye Exams $0

• Maximum 1 Routine Eye Exams every year

Eyewear:

Coinsurance for Medicare-Covered Benefits 0% or 20%

Copayment for Contact Lenses $0

Copayment for Eyeglasses (lenses and frames) $0

Copayment for Eyeglass Lenses $0

Copayment for Eyeglass Frames $0

Copayment for Upgrades $0

$200.00 maximum eyewear allowance every year for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, upgrades

Hearing Exams:

Copayment for Medicare Covered Benefits $0 or $30

Copayment for Routine Hearing Exams $0

• Maximum 1 visit every year

Copayment for Fitting/Evaluation for Hearing Aid $0

• Maximum 1 visit every year

Hearing Aids:

Copayment for Hearing Aids $0

• Maximum 2 Hearing Aids every two 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

• Standard retail $0.00
• Standard mail order $0.00

• Standard retail $0.00
• Standard mail order $0.00

• Standard retail $0.00
• Standard mail order $0.00

• Standard retail $0.00
• Standard mail order $0.00

• Standard retail $0.00
• Standard mail order $0.00

• Standard retail $0.00
• Standard mail order $0.00

• Standard retail $0.00
• Standard mail order $0.00

• Standard retail $0.00
• Standard mail order $0.00

• Standard retail $0.00
• Standard mail order $0.00

• Summary of benefits
• Evidence of coverage
• Star ratings