2019 Clover Health Choice (PPO) H5141-004 By Clover Health

2019 Medicare Advantage Plan Services for
Clover Health Choice (PPO)


Clover Health Choice (PPO) H5141-004 is a 2019 Medicare Advantage or Medicare Part-C plan by Clover Health available to residents in New Jersey. This plan includes additional Medicare prescription drug (Part-D) coverage. The Clover Health Choice (PPO) has a monthly premium of $- and has an in-network Maximum Out-of-Pocket limit of $6,700 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $6,700 out of pocket. This can be a extremely nice safety net.

Clover Health Choice (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.

Clover Health works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Clover Health Choice (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Clover Health and not Original Medicare. With Medicare Advantage Plans you are always covered for urgently needed and emergency care. Plus you receive all of the benefits of Original Medicare from Clover Health except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.



COMPARE AND SAVE ON MEDICARE INSURANCE




2019 Clover Health Medicare Advantage Plan Details

Name:
Clover Health Choice (PPO)
ID:
H5141-004
Provider:Clover Health
Year:2019
Type: Local PPO
Monthly Premium C+D: $-
Part C Premium:$0.00
MOOP: $6,700
Part D (Drug) Premium:$0.00
Part D Supplemental Premium$0.00
Total Part D Premium:$0.00
Drug Deductible:$150.00
Tiers with No Deductible:1
Gap Coverage:No
Initial Coverage Limit:$3820
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced






Part-C Premium

Clover Health plan charges a $0.00 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.



Part-D Deductible and Premium

Clover Health Choice (PPO) has a monthly drug premium of $0.00 and a $150.00 drug deductible. This Clover Health plan offers a $0.00 Part D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Clover Health above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $0.00. The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.



Premium Assistance

Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Clover Health Choice (PPO) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $0.00 for 75% low income subsidy $0.00 for 50% and $0.00 for 25%.



Full LIS Premium:$0.00
75% LIS Premium:$0.00
50% LIS Premium:$0.00
25% LIS Premium:$0.00


Gap Coverage

In 2019 once you and your plan provider have spent $3820 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for brand-name drugs and 37% on generic drugs unless your plan offers additional coverage. This Clover Health plan does not offer additional coverage through the gap.





Plan Services




Health plan deductible


$0



Emergency care/Urgent care


Emergency $90 per visit (always covered)
Urgent care $40 per visit (always covered)



Diagnostic procedures/lab services/imaging


Diagnostic tests and procedures In-Network $0-150
Diagnostic tests and procedures Out-of-Network $0-150
Lab services In-Network $10
Lab services Out-of-Network $0-150
Diagnostic radiology services (e.g., MRI) In-Network $35-150
Diagnostic radiology services (e.g., MRI) Out-of-Network $35-150
Outpatient x-rays In-Network $30
Outpatient x-rays Out-of-Network $35-150



Hearing


Hearing exam In-Network $25
Hearing exam Out-of-Network $25
Fitting/evaluation Not covered
Hearing aids In-Network $699-999
Hearing aids Out-of-Network $0-999



Preventive dental


Oral exam In-Network $0 copay
Oral exam Out-of-Network $0 copay
Cleaning In-Network $0 copay
Cleaning Out-of-Network $0 copay
Fluoride treatment Not covered
Dental x-ray(s) In-Network $0 copay
Dental x-ray(s) Out-of-Network $0 copay



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



Mental health services


Inpatient hospital - psychiatric In-Network $275 per day for days 1 through 6
$0 per day for days 7 through 90
Inpatient hospital - psychiatric Out-of-Network $275 per day for days 1 through 6
$0 per day for days 7 through 90
Outpatient group therapy visit with a psychiatrist In-Network $25
Outpatient group therapy visit with a psychiatrist Out-of-Network $25
Outpatient individual therapy visit with a psychiatrist In-Network $25
Outpatient individual therapy visit with a psychiatrist Out-of-Network $25
Outpatient group therapy visit In-Network $25
Outpatient group therapy visit Out-of-Network $25
Outpatient individual therapy visit In-Network $25
Outpatient individual therapy visit Out-of-Network $25



Skilled Nursing Facility


In-Network $0 per day for days 1 through 20
$172 per day for days 21 through 100
Out-of-Network $0 per day for days 1 through 20
$172 per day for days 21 through 100



Rehabilitation services


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



Ground ambulance


In-Network $250
Out-of-Network $250



Other health plan deductibles?


In-Network No



Transportation


Not covered



Foot care (podiatry services)


Foot exams and treatment In-Network $25
Foot exams and treatment Out-of-Network $25
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 20% per item
Prosthetics (e.g., braces, artificial limbs) In-Network 20% per item
Prosthetics (e.g., braces, artificial limbs) Out-of-Network 20% per item
Diabetes supplies In-Network $0 copay
Diabetes supplies Out-of-Network $0 copay



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


Covered



Medicare Part B drugs


Chemotherapy In-Network 20%
Chemotherapy Out-of-Network 20%
Other Part B drugs In-Network 20%
Other Part B drugs Out-of-Network 20%



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


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



Optional supplemental benefits


No



Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?


In-Network No



Inpatient hospital coverage


In-Network $290 per day for days 1 through 6
$0 per day for days 7 through 90
Out-of-Network $290 per day for days 1 through 6
$0 per day for days 7 through 90



Outpatient hospital coverage


In-Network $325 per visit
Out-of-Network $90-325 per visit



Doctor visits


Primary In-Network $0 copay
Primary Out-of-Network $0 copay
Specialist In-Network $25 per visit
Specialist Out-of-Network $25 per visit



Preventive care


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




Ratings for Clover Health Choice (PPO) H5141

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


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
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Plan All-Cause Readmissions
Statin Therapy


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 Clover Health Choice (PPO) Plans Performance

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


Health Plan Customer Service Rating for Clover Health Choice (PPO)

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


Clover Health Choice (PPO) Drug Plan Customer Service ratings

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


Ratings For Member Complaints and Changes in the Drug Plans Performance

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


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
Statin with Diabetes


Coverage Area for Clover Health Choice (PPO)

(Click county to compare all available Advantage plans)



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Source: CMS.
Data as of September 2, 2018.
Star Rating as of October 10, 2018.
For More Information on Ratings Please See the CMS Tech Notes.
Notes: Data are subject to change as contracts are finalized. For 2019, 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 2019 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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