2021 Imperial Traditional (HMO) H5496-007 By Imperial Health Plan of California, Inc.

Summary of Benefits for
2021 Imperial Traditional (HMO)


Imperial Traditional (HMO) H5496-007 is a 2021 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) has a monthly premium of $0 and has an in-network Maximum Out-of-Pocket limit of $2,999 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $2,999 out of pocket. This can be a extremely nice safety net.

Imperial Traditional (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) 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.




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2021 Imperial Health Plan of California, Inc Medicare Advantage Plan Costs

Name:
Imperial Traditional (HMO)
Plan ID:
H5496-007
Provider:Imperial Health Plan of California, Inc
Year:2021
Type: Local HMO
Monthly Premium C+D: $0
Part C Premium: $0
MOOP: $2,999
Part D (Drug) Premium: $0
Part D Supplemental Premium $0
Total Part D Premium: $0
Drug Deductible: $0
Tiers with No Deductible:0
Gap Coverage:Yes
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced
Similar Plan: H5496-009




Imperial Traditional (HMO) Part-C Premium

Imperial Health Plan of California, Inc 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.



H5496-007 Part-D Deductible and Premium

Imperial Traditional (HMO) has a monthly drug premium of $0 and a $0 drug deductible. This Imperial Health Plan of California, Inc 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 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 . 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.



Imperial Health Plan of California, Inc 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 Imperial Health Plan of California, Inc plan does offer additional coverage through the gap.



H5496-007 Formulary or Drug Coverage

Imperial Traditional (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 NA $0
Tier 2 NA $5
Tier 3 NA $45
Tier 4 NA $90
Tier 5 NA 33%
*Initial Coverage Phase and 30 day supply







2021 Imperial Traditional (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) $0 copay
Diagnostic tests and procedures $0 copay
Lab services $0 copay
Outpatient x-rays $0 copay



Doctor Visits


Primary $0 copay
Specialist $0 copay



Emergency care/Urgent Care


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



Foot Care (podiatry services)


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



Ground Ambulance


$125 copay



Hearing


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



Inpatient Hospital Coverage


$100 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) 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) 20% coinsurance per item



Medicare Part B Drugs


Chemotherapy $0 copay
Other Part B drugs $0 copay



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 20% coinsurance
Outpatient group therapy visit with a psychiatrist $0 copay
Outpatient individual therapy visit 20% coinsurance
Outpatient individual therapy visit with a psychiatrist $0 copay



MOOP


$2,999 In-network



Option


No



Optional supplemental benefits


No



Outpatient Hospital Coverage


$0 copay



Preventive Care


$0 copay



Preventive Dental


Cleaning $0 copay
Dental x-ray(s) $0 copay
Fluoride treatment $0 copay
Oral exam $0 copay



Rehabilitation Services


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



Skilled Nursing Facility


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



Transportation


$0 copay



Vision


Contact lenses $10 copay
Eyeglass frames Not covered
Eyeglass lenses Not covered
Eyeglasses (frames and lenses) $10 copay
Other Not covered
Routine eye exam $15 copay
Upgrades Not covered



Wellness Programs (e.g. fitness nursing hotline)


Covered





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Sun 9am-6pm EST




Coverage Area for Imperial Traditional (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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