Wellcare Patriot Giveback (HMO-POS)

2.5 out of 5 stars* for plan year 2023
$0.00 Monthly Premium

Wellcare Patriot Giveback (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc.

Plan ID: H1416-061-000

$0.00 Monthly Premium

Tennessee 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 Tennessee 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($1.00)
Out-of-pocket maximum$4,500.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$7,400.00
Primary care doctor visit
POS (Out-of-Network):

Doctor Office Visit:
Coinsurance for Medicare Covered Primary Care Office Visit 20%
Specialty doctor visit
POS (Out-of-Network):

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 20%
Inpatient hospital careIn-Network:

Acute Hospital Services:
$350.00 per day for days 1 to 5
$0.00 per day for days 6 to the end of your stay
Prior Authorization Required for Acute Hospital Services
Urgent care
Urgent Care:
Copayment for Urgent Care $35.00
Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $110.00
Maximum Plan Benefit of $50,000
Emergency room visit
Emergency Care:
Copayment for Emergency Care $110.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $110.00
Maximum Plan Benefit of $50,000
Ambulance transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $200.00

Air Ambulance:
Copayment for Air Ambulance Services $200.00

Please see Evidence of Coverage for Prior Authorization rules

Health Care Services and Medical Supplies

Wellcare Patriot Giveback (HMO-POS) covers a range of additional benefits. Learn more about Wellcare Patriot Giveback (HMO-POS) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage Details
Chiropractic services
POS (Out-of-Network):

Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 20%
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare-covered Diabetic Supplies 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
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
Diagnostic tests, lab and radiology services, and X-rays
POS (Out-of-Network):

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests
20%
Coinsurance for Medicare Covered Lab Services
20%
Coinsurance for Medicare Covered Diagnostic Radiological Services 20%
Coinsurance for Medicare Covered Therapeutic Radiological Services 20%
Coinsurance for Medicare Covered Outpatient X-Ray Services 20%
Home health care
POS (Out-of-Network):

Home Health Services:
Coinsurance for Medicare Covered Home Health 20%
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$325.00 per day for days 1 to 4
$0.00 per day for days 5 to 90
Prior Authorization Required for Psychiatric Hospital Services
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
Prior Authorization Required for Outpatient Mental Health Services
Outpatient services/surgery
POS (Out-of-Network):

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 20%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 20%
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 itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $175.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry services
POS (Out-of-Network):

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 20%
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$175.00 per day for days 21 to 50
$0.00 per day for days 51 to 100
Prior Authorization Required for Skilled Nursing Facility Services

Dental Benefits

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

Coverage Details
Dental careIn-Network:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 2 visits every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 2 visits every year
Copayment for Fluoride Treatment $0.00
  • Maximum 1 visit every year
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Referral Required for Preventive Dental

Comprehensive Dental:
Copayment for Medicare-covered Benefits $25.00
Copayment for Non-routine Services $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Diagnostic Services $0.00
  • Maximum 1 visit every year
Copayment for Restorative Services $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Endodontics $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Periodontics $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Extractions $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $2000.00 every year for Non-Medicare Covered Comprehensive
Prior Authorization Required for Comprehensive Dental

Vision Benefits

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

Coverage Details
Vision benefitsIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00 to $25.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year
Prior Authorization Required for Eye Exams
Referral Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Maximum Plan Allowance of $300.00 every year for all Non-Medicare covered eyewear
Prior Authorization Required for Eyewear
Referral Required for Eyewear

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
POS (Out-of-Network):

Medicare Covered Hearing Services:
Coinsurance for Medicare Covered Hearing Exams 20%

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 programsIn-Network:
$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

    When reviewing Tennessee 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 Tennessee 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

    Tennessee Counties Served

    Anderson Bedford Benton Bledsoe Blount Bradley Campbell Cannon Carroll Carter Cheatham Chester Claiborne Clay Cocke Coffee Crockett Cumberland Davidson Decatur Dekalb Dickson Dyer Fayette Fentress Franklin Gibson Giles Grainger Greene Grundy Hamblen Hamilton Hancock Hardeman Hardin Hawkins Haywood Henderson Henry Hickman Houston Humphreys Jackson Jefferson Johnson Knox Lake Lauderdale Lawrence Lewis Lincoln Loudon Macon Madison Marion Marshall Maury Mcminn Mcnairy Meigs Monroe Montgomery Moore Morgan Obion Overton Perry Pickett Polk Putnam Rhea Roane Robertson Rutherford Scott Sequatchie Sevier Shelby Smith Stewart Sullivan Sumner Tipton Trousdale Unicoi Union Van Buren Warren Washington Wayne Weakley White Williamson Wilson
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