2020 Imperial Traditional (HMO) (HMO) H5496-007 By Imperial Health Plan of California, Inc..

2020 Medicare Advantage Plan Services for
Imperial Traditional (HMO) (HMO)


Imperial Traditional (HMO) (HMO) H5496-007 is a 2020 Medicare Advantage Plan or Medicare Part-C plan by Imperial Health Plan of California, Inc. available to residents in California. This plan includes additional Medicare prescription drug (Part-D) coverage. The Imperial Traditional (HMO) (HMO) has a monthly premium of $- and has an in-network Maximum Out-of-Pocket limit of $4,000 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $4,000 out of pocket. This can be a extremely nice safety net.

Imperial Traditional (HMO) (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.

Imperial Health Plan of California, Inc. works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Imperial Traditional (HMO) (HMO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Imperial Health Plan of California, Inc. 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 Imperial Health Plan of California, Inc. except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.





2020 Imperial Health Plan of California, Inc. Medicare Advantage Plan Details

Name:
Imperial Traditional (HMO) (HMO)
ID:
H5496-007
Provider:Imperial Health Plan of California, Inc.
Year:2020
Type: Local HMO
Monthly Premium C+D: $-
Part C Premium:$0.00
MOOP: $4,000
Part D (Drug) Premium:$0.00
Part D Supplemental Premium$0.00
Total Part D Premium:$0.00
Drug Deductible:$0.00
Tiers with No Deductible:0
Gap Coverage:Yes
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced




Part-C Premium

Imperial Health Plan of California, Inc. 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

Imperial Traditional (HMO) (HMO) has a monthly drug premium of $0.00 and a $0.00 drug deductible. This Imperial Health Plan of California, Inc. 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 Imperial Health Plan of California, Inc. 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 Imperial Traditional (HMO) (HMO) 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 2020 once you and your plan provider have spent $4020 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 prescription drugs unless your plan offers additional coverage. This Imperial Health Plan of California, Inc. plan does offer additional coverage through the gap.



Imperial Health Plan of California, Inc. Drug Coverage and Formulary

A formulary is divided into tiers or levels of coverage based on the type or usage of your medication or benefit categories, according to drug costs. Each tier will have a defined out-of-pocket cost that you must pay before receiving the drug. You can see complete 2020 Imperial Traditional (HMO) (HMO) H5496-007 Formulary here.

Drug Tier Copay
Preferred
Copay
Nonpreferred
1 NA $0
2 NA $5
3 NA $45
4 NA $90
5 NA 33%
*Initial Coverage Phase and 30 day supply

See the 2020 Imperial Health Plan of California, Inc. Formulary





2019 Plan Services

(*2020 Plan services will be added when available)




Health plan deductible


$0



Emergency care/Urgent care


Emergency $90 per visit (always covered)
Urgent care $0 copay



Diagnostic procedures/lab services/imaging


Diagnostic tests and procedures $0 copay
Lab services $0 copay
Diagnostic radiology services (e.g., MRI) $0 copay
Outpatient x-rays $0 copay



Hearing


Hearing exam 20%
Fitting/evaluation 20%
Hearing aids 20%



Preventive dental


Office visit 10%
Oral exam Covered under office visit
Cleaning Covered under office visit
Fluoride treatment Covered under office visit
Dental x-ray(s) Covered under office visit



Comprehensive dental


Non-routine services Not covered
Diagnostic services Not covered
Restorative services 10%
Endodontics Not covered
Periodontics Not covered
Extractions Not covered
Prosthodontics, other oral/maxillofacial surgery, other services 10%



Vision


Routine eye exam $15
Other Not covered
Contact lenses $15
Eyeglasses (frames and lenses) $15
Eyeglass frames Not covered
Eyeglass lenses Not covered
Upgrades Not covered



Mental health services


Inpatient hospital - psychiatric $200 per day for days 1 through 7
$0 per day for days 8 through 90
Outpatient group therapy visit with a psychiatrist $0 copay
Outpatient individual therapy visit with a psychiatrist $0 copay
Outpatient group therapy visit 20%
Outpatient individual therapy visit 20%



Skilled Nursing Facility


$0 per day for days 1 through 20
$164.50 per day for days 21 through 100



Rehabilitation services


Occupational therapy visit $10
Physical therapy and speech and language therapy visit 20%



Ground ambulance


$85



Other health plan deductibles?


In-Network No



Transportation


$0 copay



Foot care (podiatry services)


Foot exams and treatment $0 copay
Routine foot care $0 copay



Medical equipment/supplies


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)


Covered



Medicare Part B drugs


Chemotherapy $0 copay
Other Part B drugs $0 copay



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


$4,000 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


$100 per day for days 1 through 5
$0 per day for days 6 through 90



Outpatient hospital coverage


$0 copay



Doctor visits


Primary $0 copay
Specialist $0 copay



Preventive care


$0 copay




Coverage Area for Imperial Traditional (HMO) (HMO)

(Click county to compare all available Advantage plans)



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Source: CMS.
Data as of September 4, 2019.
Star Rating as of October 10, 2019.
Plan Services are 2019 information as reference. 2020 information will be added when released.
Notes: Data are subject to change as contracts are finalized. For 2020, 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 2020 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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