2019 Medicare Advantage Plan Services for
Clover Health Value (HMO)
Clover Health Value (HMO) H8010-003 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 Value (HMO) has a monthly premium of $37.20 and has an in-network Maximum Out-of-Pocket limit of $6,400 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $6,400 out of pocket. This can be a extremely nice safety net.
Clover Health Value (HMO) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered by the plan.
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 Value (HMO) 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.
2019 Clover Health Medicare Advantage Plan Details
Clover Health Value (HMO)
|Monthly Premium C+D:||$37.20|
|Part C Premium:||$0.00|
|Part D (Drug) Premium:||$37.20|
|Part D Supplemental Premium||$0.00|
|Total Part D Premium:||$37.20|
|Tiers with No Deductible:||1|
|Initial Coverage Limit:||$3820|
|Benchmark:||not below the regional benchmark|
|Type of Medicare Health:||Enhanced Alternative|
|Drug Benefit Type:||Enhanced|
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 Value (HMO) has a monthly drug premium of $37.20 and a $415.00 drug deductible. This Clover Health plan offers a $37.20 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 $37.20. 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.
Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Clover Health Value (HMO) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $9.30 for 75% low income subsidy $18.60 for 50% and $27.90 for 25%.
|Full LIS Premium:||$0.00|
|75% LIS Premium:||$9.30|
|50% LIS Premium:||$18.60|
|25% LIS Premium:||$27.90|
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.
Health plan deductible
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||$0-150|
|Lab services||$0 copay|
|Diagnostic radiology services (e.g., MRI)||$30-150|
|Oral exam||$0 copay|
|Fluoride treatment||$0 copay|
|Dental x-ray(s)||$0 copay|
|Prosthodontics, other oral/maxillofacial surgery, other services||$20|
|Routine eye exam||$0 copay|
|Contact lenses||$0 copay|
|Eyeglasses (frames and lenses)||$0 copay|
|Eyeglass frames||$0 copay|
|Eyeglass lenses||$0 copay|
Mental health services
|Inpatient hospital - psychiatric||$170 per day for days 1 through 6
$0 per day for days 7 through 90
|Outpatient group therapy visit with a psychiatrist||$5|
|Outpatient individual therapy visit with a psychiatrist||$5|
|Outpatient group therapy visit||$5|
|Outpatient individual therapy visit||$5|
Skilled Nursing Facility
|$0 per day for days 1 through 20
$172 per day for days 21 through 100
|Occupational therapy visit||$5|
|Physical therapy and speech and language therapy visit||$5|
Other health plan deductibles?
Foot care (podiatry services)
|Foot exams and treatment||$5|
|Routine foot care||Not covered|
|Durable medical equipment (e.g., wheelchairs, oxygen)||20% per item|
|Prosthetics (e.g., braces, artificial limbs)||20% per item|
|Diabetes supplies||$0 copay|
Wellness programs (e.g., fitness, nursing hotline)
Medicare Part B drugs
|Other Part B drugs||20%|
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
Optional supplemental benefits
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
Inpatient hospital coverage
|$170 per day for days 1 through 6
$0 per day for days 7 through 90
Outpatient hospital coverage
|$175 per visit|
|Specialist||$5 per visit|
Coverage Area for Clover Health Value (HMO)
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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.