2021 Amerivantage Classic (HMO) H3240-022 By Amerigroup Community Care.

Summary of Benefits for
2021 Amerivantage Classic (HMO)


Amerivantage Classic (HMO) H3240-022 is a 2021 Medicare Advantage Plan or Medicare Part-C plan by Amerigroup Community Care available to residents in New Jersey. This plan includes additional Medicare prescription drug (Part-D) coverage. The Amerivantage Classic (HMO) has a monthly premium of $0 and has an in-network Maximum Out-of-Pocket limit of $6,950 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $6,950 out of pocket. This can be a extremely nice safety net.

Amerivantage Classic (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.

Amerigroup Community Care works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Amerivantage Classic (HMO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Amerigroup Community Care 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 Amerigroup Community Care 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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2021 Amerigroup Community Care Medicare Advantage Plan Costs

Name:
Amerivantage Classic (HMO)
Plan ID:
H3240-022
Provider:Amerigroup Community Care
Year:2021
Type: Local HMO
Monthly Premium C+D: $0
Part C Premium: $0
MOOP: $6,950
Part D (Drug) Premium: $0
Part D Supplemental Premium $0
Total Part D Premium: $0
Drug Deductible: $200.0
Tiers with No Deductible:1
Gap Coverage:Yes
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced
Similar Plan: H3240-021




Amerivantage Classic (HMO) Part-C Premium

Amerigroup Community Care plan charges a $0 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.



H3240-022 Part-D Deductible and Premium

Amerivantage Classic (HMO) has a monthly drug premium of $0 and a $200.0 drug deductible. This Amerigroup Community Care plan offers a $0 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 this Premium covers any enhanced plan benefits offered by Amerigroup Community Care 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 . 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.



Amerigroup Community Care Gap Coverage

In 2021 once you and your plan provider have spent $4130 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 Amerigroup Community Care plan does offer additional coverage through the gap.



H3240-022 Formulary or Drug Coverage

Amerivantage Classic (HMO) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.

Drug Tier Copay
Preferred
Pharmacy
Copay
Nonpreferred
Pharmacy
Tier 1 $4 $9
Tier 2 $10 $15
Tier 3 $42 $47
Tier 4 $95 $100
Tier 5 29% 29%
Tier 6 $0 $0
*Initial Coverage Phase and 30 day supply







2021 Amerivantage Classic (HMO) Summary of Benefits




Additional Benefits


No



Comprehensive Dental


Diagnostic services $0 copay
Endodontics $0 copay
Extractions $0 copay
Non-routine services $0 copay
Periodontics $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services $0 copay
Restorative services $0 copay



Deductible


$0



Diagnostic Tests and Procedures


Diagnostic radiology services (e.g., MRI) 20% coinsurance
Diagnostic tests and procedures $0-90 copay
Lab services $0 copay
Outpatient x-rays $20-30 copay



Doctor Visits


Primary $5 copay per visit
Specialist $25 copay per visit



Emergency care/Urgent Care


Emergency $90 copay per visit (always covered)
Urgent care $65 copay per visit (always covered)



Foot Care (podiatry services)


Foot exams and treatment $25 copay
Routine foot care Not covered



Ground Ambulance


$300 copay



Hearing


Fitting/evaluation $0 copay
Hearing aids $0 copay
Hearing exam $25 copay



Inpatient Hospital Coverage


$350 per day for days 1 through 5
$0 per day for days 6 through 90



Medical Equipment/Supplies


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



Medicare Part B Drugs


Chemotherapy 20% coinsurance
Other Part B drugs 20% coinsurance



Mental Health Services


Inpatient hospital - psychiatric $330 per day for days 1 through 5
$0 per day for days 6 through 90
Outpatient group therapy visit $40 copay
Outpatient group therapy visit with a psychiatrist $40 copay
Outpatient individual therapy visit $40 copay
Outpatient individual therapy visit with a psychiatrist $40 copay



MOOP


$6,950 In-network



Option


No



Optional supplemental benefits


No



Outpatient Hospital Coverage


$0-295 copay per visit



Preventive Care


$0 copay



Preventive Dental


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



Rehabilitation Services


Occupational therapy visit $35 copay
Physical therapy and speech and language therapy visit $25 copay



Skilled Nursing Facility


$0 per day for days 1 through 20
$184 per day for days 21 through 100



Transportation


Not covered



Vision


Contact lenses $0 copay
Eyeglass frames $0 copay
Eyeglass lenses $0 copay
Eyeglasses (frames and lenses) $0 copay
Other Not covered
Routine eye exam $0 copay
Upgrades Not covered



Wellness Programs (e.g. fitness nursing hotline)


Covered




Reviews for Amerivantage Classic (HMO) H3240



2019 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
Rheumatoid Arthritis
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Statin Therapy


Member Experience with Health Plan

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


Member Complaints and Changes in Amerivantage Classic (HMO) Plans Performance

Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement
Timely Decisions About Appeals


Health Plan Customer Service Rating for Amerivantage Classic (HMO)

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


Amerivantage Classic (HMO) 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



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Coverage Area for Amerivantage Classic (HMO)

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Source: CMS.
Data as of September 9, 2020.
Notes: Data are subject to change as contracts are finalized. For 2021, 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 2021 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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