2020 EON GOLD (PPO C-SNP) EA-H9589

EON GOLD (PPO C-SNP) By Clear Spring Health



EON GOLD (PPO C-SNP) is a 2020 Medicare Advantage Special Needs Plan plan by Clear Spring Health. This plan from Clear Spring Health works with Medicare to give you significant coverage beyond original Medicare. If you decide to sign up you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Clear Spring Health and not Original Medicare. All Medicare SNPs also provide Medicare additional Part-D drug coverage. EON GOLD (PPO C-SNP) EA-H9589 is a Chronic Condition SNP (C-SNP). A Chronic Condition SNP is for beneficiaries with the following severe or disabling chronic conditions: . If you have Medicare and you develop certain severe or disabling conditions you can join a Medicare SNP designed to serve people with those conditions at any time.



2020 Medicare Special Needs Plan Details

Plan Name:
EON GOLD (PPO C-SNP)
Plan ID:
EA-H9589
Special Needs Type: Chronic or Disabling Condition
Provider: Clear Spring Health
Plan Year:2020
Plan Type: Local PPO
Monthly Premium C+D: $15.00


The EON GOLD (PPO C-SNP) EA-H9589 is available to residents in Georgia, and all Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. EON GOLD (PPO C-SNP) 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.



Part-C Premium

Clear Spring 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

The EON GOLD (PPO C-SNP) plan has a monthly drug premium of $15.00 and a $250.00 drug deductible. This Clear Spring Health plan offers a $15.00 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 Clear Spring 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 $15.00. 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 EON GOLD (PPO C-SNP) medicare insurance plan offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $3.70 for 75% low income subsidy $7.50 for 50% and $11.20 for 25%.



Part C Premium: $0.00
Part D (Drug) Premium: $15.00
Part D Supplemental Premium $0.00
Total Part D Premium: $15.00
Drug Deductible: $250.00
Tiers with No Deductible: 1
Benchmark: not below the regional benchmark
Type of Medicare Health Plan: Enhanced Alternative
Drug Benefit Type: Enhanced
Full LIS Premium: $0.00
75% LIS Premium: $3.70
50% LIS Premium: $7.50
25% LIS Premium: $11.20
Gap Coverage: No


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 brand-name drugs and 25% on generic drugs unless your plan offers additional coverage. This Clear Spring Health plan does not offer additional coverage through the gap.




Clear Spring Health 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 EON GOLD (PPO C-SNP) H9589-001 Formulary here.

Drug Tier Copay
Preferred
Copay
Nonpreferred
1 NA $0
2 NA $15
3 NA $47
4 NA $100
5 NA 28%
6 NA $9
*Initial Coverage Phase and 30 day supply

See the 2020 Clear Spring Health Formulary



2019 Plan Services

(*2020 Plan services will be added when available)




Health plan deductible


$500 annual deductible



Emergency care/Urgent care


Emergency $80 per visit (always covered)
Urgent care $50 per visit (always covered)



Diagnostic procedures/lab services/imaging


Diagnostic tests and procedures Out-of-Network 40%
Diagnostic tests and procedures In-Network 20%
Lab services Out-of-Network 40%
Lab services In-Network $5
Diagnostic radiology services (e.g., MRI) Out-of-Network 40%
Diagnostic radiology services (e.g., MRI) In-Network 20%
Outpatient x-rays Out-of-Network 40%
Outpatient x-rays In-Network $25



Hearing


Hearing exam Out-of-Network 40%
Hearing exam In-Network $25
Fitting/evaluation Out-of-Network 50%
Fitting/evaluation In-Network $0 copay
Hearing aids Out-of-Network 50%
Hearing aids In-Network $0 copay



Preventive dental


Oral exam Out-of-Network 50%
Oral exam In-Network $0 copay
Cleaning Out-of-Network 50%
Cleaning In-Network $0 copay
Fluoride treatment Not covered
Dental x-ray(s) Out-of-Network 50%
Dental x-ray(s) In-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 Out-of-Network 50%
Routine eye exam In-Network $0 copay
Other Not covered
Contact lenses Out-of-Network 50%
Contact lenses In-Network $0 copay
Eyeglasses (frames and lenses) Out-of-Network 50%
Eyeglasses (frames and lenses) In-Network $0 copay
Eyeglass frames Not covered
Eyeglass lenses Not covered
Upgrades Not covered



Mental health services


Inpatient hospital - psychiatric Out-of-Network 40% per stay
Inpatient hospital - psychiatric In-Network $300 per day for days 1 through 5
$0 per day for days 6 through 90
Outpatient group therapy visit with a psychiatrist Out-of-Network 40%
Outpatient group therapy visit with a psychiatrist In-Network $40
Outpatient individual therapy visit with a psychiatrist Out-of-Network 40%
Outpatient individual therapy visit with a psychiatrist In-Network $40
Outpatient group therapy visit Out-of-Network 40%
Outpatient group therapy visit In-Network $40
Outpatient individual therapy visit Out-of-Network 40%
Outpatient individual therapy visit In-Network $40



Skilled Nursing Facility


Out-of-Network 40% per stay
In-Network $0 per day for days 1 through 20
$167 per day for days 21 through 100



Rehabilitation services


Occupational therapy visit Out-of-Network 40%
Occupational therapy visit In-Network $40
Physical therapy and speech and language therapy visit Out-of-Network 40%
Physical therapy and speech and language therapy visit In-Network $40



Ground ambulance


Out-of-Network $225
In-Network $225



Other health plan deductibles?


In-Network No



Transportation


Not covered



Foot care (podiatry services)


Foot exams and treatment Out-of-Network 40%
Foot exams and treatment In-Network $0 copay
Routine foot care Out-of-Network 40%
Routine foot care In-Network $0 copay



Medical equipment/supplies


Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-Network 40% per item
Durable medical equipment (e.g., wheelchairs, oxygen) In-Network 20% per item
Prosthetics (e.g., braces, artificial limbs) Out-of-Network 40% per item
Prosthetics (e.g., braces, artificial limbs) In-Network 20% per item
Diabetes supplies Out-of-Network 40% per item
Diabetes supplies In-Network $0 copay



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


Covered



Medicare Part B drugs


Chemotherapy Out-of-Network 40%
Chemotherapy In-Network 20%
Other Part B drugs Out-of-Network 40%
Other Part B drugs In-Network 20%



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


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



Optional supplemental benefits


No



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


In-Network No



Inpatient hospital coverage


Out-of-Network 40% per stay
In-Network $300 per day for days 1 through 5
$0 per day for days 6 through 90



Outpatient hospital coverage


Out-of-Network 40% per visit
In-Network $225 per visit



Doctor visits


Primary Out-of-Network 40% per visit
Primary In-Network $15 per visit
Specialist Out-of-Network 40% per visit
Specialist In-Network $50 per visit



Preventive care


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





Coverage Area for EON GOLD (PPO C-SNP)



Source: CMS.

Plans as of September 4, 2019.

Star Rating as of October 11, 2019.

Plan Services are 2019 information as reference. 2020 information will be added when released.

Notes: Data are subject to change. All contracts for 2020 have not been finalized. For 2020, enhanced alternative plans may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part Part D benefit.

Includes 2020 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.

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