2022 Basic (HMO)

Basic (HMO) H5774-003 is a 2022 Medicare Advantage Plan or Part-C by Triple S Advantage available to residents in Puerto Rico. This plan does not provide additional prescription drug (Part-D) coverage. The Basic (HMO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $3,400 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $3,400 out-of-pocket. This can be a extremely nice safety net.

Basic (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.

Triple S Advantage works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Basic (HMO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Triple S Advantage and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Triple S Advantage except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

2022 Triple S Advantage Medicare Advantage Plan Costs

2021 Basic (HMO) Summary of Benefits

*This will be updated with 2022 data when available.

---

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)	$0-50 copay
Diagnostic tests and procedures	0-10% coinsurance
Lab services	0-10% coinsurance
Outpatient x-rays	$0 copay

---

Doctor Visits

Primary	$0 copay
Specialist	$0-5 copay per visit

---

Emergency care/Urgent Care

Emergency	$50 copay per visit (always covered)
Urgent care	$0 copay

---

Foot Care (podiatry services)

Foot exams and treatment	$0-5 copay
Routine foot care	$0-5 copay

---

Ground Ambulance

$0 copay

---

Hearing

Fitting/evaluation	$5-15 copay
Hearing aids	$0 copay
Hearing exam	$10-20 copay

---

Inpatient Hospital Coverage

Tier 1 $0 copay per stay Tier 2 $50 per stay

---

Medical Equipment/Supplies

Diabetes supplies	$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)	0-10% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	0-10% coinsurance per item

---

Medicare Part B Drugs

Chemotherapy	10% coinsurance
Other Part B drugs	0-20% coinsurance

---

Mental Health Services

Inpatient hospital - psychiatric	$0 copay
Outpatient group therapy visit	$5 copay
Outpatient group therapy visit with a psychiatrist	$5 copay
Outpatient individual therapy visit	$5 copay
Outpatient individual therapy visit with a psychiatrist	$5 copay

---

MOOP

$3,400 In-network

---

Option

No

---

Optional supplemental benefits

No

---

Outpatient Hospital Coverage

$25 copay per visit

---

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	$5 copay
Physical therapy and speech and language therapy visit	$0 copay

---

Skilled Nursing Facility

$0 copay

---

Transportation

$0 copay

---

Vision

Contact lenses	$0 copay
Eyeglass frames	$0 copay
Eyeglass lenses	$0 copay
Eyeglasses (frames and lenses)	$0 copay
Other	$0 copay
Routine eye exam	$0 copay
Upgrades	$0 copay

---

Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for Basic (HMO) H5774

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in Basic (HMO) Plans Performance

Health Plan Customer Service Rating for Basic (HMO)

Basic (HMO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Basic (HMO)

(Click county to compare all available Advantage plans)

Go to top

Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, 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 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.