Wellcare Giveback (HMO)
Wellcare Giveback (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc.
Plan ID: H0174-013-001
Texas 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 Texas 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 | $300.00 |
| Out-of-pocket maximum | $6,700.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $7,050.00 |
| Primary care doctor visit | $0 copay |
| Specialty doctor visit | $50 |
| Inpatient hospital care | $325 copay per day for days 1-6 and a $0 copay per day for days 7-90 |
| Urgent care | $30 |
| Emergency room visit | $90 |
| Ambulance transportation | $245 |
Health Care Services and Medical Supplies
Wellcare Giveback (HMO) covers a range of additional benefits. Learn more about Wellcare Giveback (HMO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | Medicare Covered Chiropractic Services: $20 per visit |
| Diabetes supplies, training, nutrition therapy and monitoring | Diabetes Supplies: $0 / Diabetes Self-Management Training: $0 / Diabetic Therapeutic Shoes or Inserts: 20% |
| Durable medical equipment (DME) | 20% |
| Diagnostic tests, lab and radiology services, and X-rays | X-Ray Services: $0 / Lab Services: $0. $0 for COVID-related testing. For other services, please refer to the Evidence of Coverage for more information. |
| Home health care | $0 copay |
| Mental health inpatient care | $300 copay per day for days 1-6 and a $0 copay per day for days 7-90 |
| Mental health outpatient care | $25 for individual or group |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $300.00 to $350.00 Prior Authorization Required for Outpatient Hospital Services Referral Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $90.00 to $350.00 Prior Authorization Required for Outpatient Observation Services Referral Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $250.00 Prior Authorization Required for Ambulatory Surgical Center Services Referral Required for Ambulatory Surgical Center Services |
| Outpatient substance abuse care | $25 for individual or group |
| Podiatry services | Medicare Covered Podiatry Services: $50 |
| Skilled Nursing Facility (SNF) care | $0 copay per day for days 1-20 and a $165 copay per day for days 21-100 |
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 | The dental benefits on this plan include coverage of preventive and comprehensive services up to $1000, including but not limited to cleanings, x-ray(s), oral exams, fluoride treatments, fillings, dentures or a bridge or a crown and a root canal with a $0 member co-pay. |
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 | The vision benefits on this plan cover routine eye exams and up to $100 for unlimited contacts, glasses, lenses, and/or frames per year |
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 | The hearing benefits on this plan include, but are not limited to, an annual exam, hearing aid fitting and evaluation, and up to $1,500 a year towards hearing aids A maximum of one hearing aid per ear will apply |
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 | Most services offered at $0 cost share, please refer to your Evidence of Coverage for more information. |
Prescription Drug Costs and Coverage
The Wellcare Giveback (HMO) offers prescription drug coverage, with an annual drug deductible of $300.00 (excludes Tiers 1, 2 and 6)
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual drug deductible | $300.00 (excludes Tiers 1, 2 and 6) |
| Tier 1 | |
| Tier 2 | |
| Tier 6 | |
| Annual drug deductible | $300.00 (excludes Tiers 1, 2 and 6) |
| Tier 1 | |
| Tier 2 | |
| Tier 6 | |
| Annual drug deductible | $300.00 (excludes Tiers 1, 2 and 6) |
| Tier 1 | |
| Tier 2 | |
| Tier 6 | |
When reviewing Texas 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 Texas 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 |
Texas Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.
