2018 Presbyterian MediCare PPO Plan 1 (PPO) H3206-003 By Presbyterian Insurance Company, Inc.

2018 Medicare Advantage Presbyterian MediCare PPO Plan 1 (PPO)

Presbyterian MediCare PPO Plan 1 (PPO) H3206-003 is a 2018 Medicare Advantage or Medicare Part-C plan by Presbyterian Insurance Company, Inc. available to residents in New Mexico. This plan does not provide additional Medicare prescription drug (Part-D) coverage. The Presbyterian MediCare PPO Plan 1 (PPO) has a monthly premium of $95.00 and has a in-network Maximum Out-of-Pocket limit of $6,700 (MOOP). This means that if you get sick or need a high cost procedure your co-pays are capped once you pay out of pocket $6,700 this can be a very nice safety net.

Presbyterian MediCare PPO Plan 1 (PPO) is a Local PPO *. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Presbyterian Insurance Company, Inc. works with Medicare to give you significant coverage beyond Part A and Part B benefits. If you decide to sign up for Presbyterian MediCare PPO Plan 1 (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Presbyterian Insurance Company, Inc. and not Original Medicare. With Medicare Advantage your always covered for urgently needed and emergency care and you receive all of the benefits of Original Medicare from Presbyterian Insurance Company, Inc. except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.



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2018 Presbyterian Insurance Company, Inc. Medicare Advantage Plan Details

Name:
Presbyterian MediCare PPO Plan 1 (PPO)
ID:
H3206-003
Provider:Presbyterian Insurance Company, Inc.
Year:2018
Type: Local PPO *
Monthly Premium C+D: $95.00
MOOP: $6,700




Plan Services






Health plan deductible


$0



Diagnostic procedures/lab services/imaging


Diagnostic tests and procedures In-Network $0 copay
Diagnostic tests and procedures Out-of-Network 20%
Lab services In-Network $0 copay
Lab services Out-of-Network 20%
Diagnostic radiology services (e.g., MRI) In-Network $300
Diagnostic radiology services (e.g., MRI) Out-of-Network 20%
Outpatient x-rays In-Network $0 copay
Outpatient x-rays Out-of-Network 20%



Hearing


Hearing exam In-Network $50
Hearing exam Out-of-Network $60
Fitting/evaluation Not covered
Hearing aids - inner ear Not covered
Hearing aids - outer ear Not covered
Hearing aids - over the ear Not covered



Preventive dental


Oral exam Not covered
Cleaning Not covered
Fluoride treatment Not covered
Dental x-ray(s) Not covered



Comprehensive dental


Non-routine services Not covered
Diagnostic services Not covered
Restorative services Not covered
Endodontics Not covered
Periodontics Not covered
Extractions Not covered
Prosthodontics, other oral/maxillofacial surgery, other services Not covered



Vision


Routine eye exam In-Network $0-50
Routine eye exam Out-of-Network $60
Other Not covered
Contact lenses Not covered
Eyeglasses (frames and lenses) Not covered
Eyeglass frames Not covered
Eyeglass lenses Not covered
Upgrades Not covered



Mental health services


In-Network $320 for days 1 through 5
$0 for days 6 through 90
Out-of-Network $500 for days 1 through 5
$0 for days 6 through 90
Outpatient group therapy visit with a psychiatrist In-Network $40
Outpatient group therapy visit with a psychiatrist Out-of-Network 50%
Outpatient individual therapy visit with a psychiatrist In-Network $40
Outpatient individual therapy visit with a psychiatrist Out-of-Network 50%
Outpatient group therapy visit In-Network $40
Outpatient group therapy visit Out-of-Network 50%
Outpatient individual therapy visit In-Network $40
Outpatient individual therapy visit Out-of-Network 50%



Skilled Nursing Facility


In-Network $0 for days 1 through 20
$95 for days 21 through 100
Out-of-Network $0 for days 1 through 20
$150 for days 21 through 100



Rehabilitation services


Occupational therapy visit In-Network $25
Occupational therapy visit Out-of-Network $35
Physical therapy and speech and language therapy visit In-Network $25
Physical therapy and speech and language therapy visit Out-of-Network $35



Ambulance


In-Network $200
Out-of-Network $200



Transportation


Not covered



Other health plan deductibles?


In-Network No



Foot care (podiatry services)


Foot exams and treatment In-Network $0 copay
Foot exams and treatment Out-of-Network $60
Routine foot care Not covered



Medical equipment/supplies


Durable medical equipment (e.g., wheelchairs, oxygen) In-Network 20% per item
Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-Network 25% per item
Prosthetics (e.g., braces, artificial limbs) In-Network 20% per item
Prosthetics (e.g., braces, artificial limbs) Out-of-Network 25% per item
Diabetes supplies In-Network $0-10 per item
Diabetes supplies Out-of-Network 25% per item



Wellness programs (e.g., fitness, nursing hotline)


Covered



Medicare Part B drugs


Chemotherapy In-Network 0-15%
Chemotherapy Out-of-Network 20%
Other Part B drugs In-Network $10 or 0-15%
Other Part B drugs Out-of-Network 20%



Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)


$10,000 In and Out-of-network
$6,700 In-network



Optional supplemental benefits


No



Inpatient hospital coverage


In-Network $320 for days 1 through 5
$0 for days 6 through 90
Out-of-Network $500 for days 1 through 5
$0 for days 6 through 90



Outpatient hospital coverage


In-Network $80-320 per visit
Out-of-Network 20% per visit



Doctor visits


Primary In-Network $15 per visit
Primary Out-of-Network $35 per visit
Specialist In-Network $50 per visit
Specialist Out-of-Network $60 per visit



Preventive care


In-Network $0 copay
Out-of-Network $35



Emergency care/Urgent care


Emergency $80 per visit (always covered)
Urgent care $15-65 per visit (always covered)






Ratings for Presbyterian MediCare PPO Plan 1 (PPO) H3206

2018 Overall Rating
Part C Summary Rating
Part D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing


Member Experience with Health Plan

Total Experience Rating
Getting Needed Care
Timely Care and Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination


Member Complaints and Changes in Presbyterian MediCare PPO Plan 1 (PPO) Plans Performance

Total Rating
Members Leaving the Plan
Complaints about Health Plan
Beneficiary Access
Health Plan Quality Improvement


Health Plan Customer Service Rating for Presbyterian MediCare PPO Plan 1 (PPO)

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language


Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Improving Physical
Improving Mental Health
Monitoring Physical Activity
Adult BMI Assessment


Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Functional Status Assessment
Pain Screening
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Controlling Blood Pressure
Rheumatoid Arthritis
Improving Bladder Control
Reducing Risk of Falling
Plan - Cause Readmissions


Member Experience with the Drug Plan

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs


Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR


Ratings For Member Complaints and Changes in the Drug Plans Performance

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Beneficiary Access
Drug Plan Quality Improvement


Presbyterian MediCare PPO Plan 1 (PPO) Drug Plan Customer Service ratings

Total Rating
Appeals Auto Forward
Appeals Upheld
Call Center, TTY, Foreign Language


Coverage Area for Presbyterian MediCare PPO Plan 1 (PPO)

(Click county to compare all available plans)



Source: CMS.

Data as of September 5, 2017

Star Rating as of September 6, 2017.

For More Information on Ratings Please See the CMS Tech Notes Here.

Notes: Data are subject to change as contracts are finalized. For 2018, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit

Includes 2018 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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