2022 Capital Health Plan Preferred Advantage (HMO)


Capital Health Plan Preferred Advantage (HMO) H5938-006 is a 2022 Medicare Advantage Plan or Part-C by Capital Health Plan available to residents in Florida. This plan includes additional prescription drug (Part-D) coverage. The Capital Health Plan Preferred Advantage (HMO) has a monthly premium of $92.00 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.

Capital Health Plan Preferred Advantage (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.

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




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2022 Capital Health Plan Medicare Advantage Plan Costs

Name:
Capital Health Plan Preferred Advantage (HMO)
Plan ID:
H5938-006
Provider:Capital Health Plan
Year:2022
Type: Local HMO
Monthly Premium C+D: $92.00
Part C Premium:$23.60
MOOP: $3,400
Part D (Drug) Premium:$68.40
Part D Supplemental Premium$0.00
Total Part D Premium:$68.40
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
Similar Plan: H5938-008
New Plan: 2023 H5938-008




Capital Health Plan Preferred Advantage (HMO) Part-C Premium

Capital Health Plan charges a $23.60 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.



H5938-006 Part-D Deductible and Premium

Capital Health Plan Preferred Advantage (HMO) has a monthly drug premium of $68.40 and a $0.00 drug deductible. This Capital Health Plan plan offers a $68.40 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 Capital Health Plan 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 $68.40 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.



Capital Health Plan Gap Coverage

In 2022 once you and your plan provider have spent $4430 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 Capital Health Plan plan does offer additional coverage through the gap.



Premium Assistance

The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Capital Health Plan Preferred Advantage (HMO) medicare insurance offers a $34.10 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $42.70 for 75% low income subsidy $51.20 for 50% and $59.80 for 25%.



Full LIS Premium:$34.10
75% LIS Premium:$42.70
50% LIS Premium:$51.20
25% LIS Premium:$59.80


H5938-006 Formulary or Drug Coverage

Capital Health Plan Preferred Advantage (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. You can see complete 2022 Capital Health Plan Preferred Advantage (HMO) H5938-006 Formulary here.

Drug Tier Copay
Preferred
Pharmacy
Copay
Nonpreferred
Pharmacy
Tier 1 NA $3
Tier 2 NA $7
Tier 3 NA $45
Tier 4 NA $95
Tier 5 NA 33%
Tier 6 NA $0
*Initial Coverage Phase and 30 day supply





2021 Capital Health Plan Preferred Advantage (HMO) Summary of Benefits

*This will be updated with 2022 data when available.



Additional Benefits


No



Comprehensive Dental


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



Deductible


$0



Diagnostic Tests and Procedures


Diagnostic radiology services (e.g., MRI) $100 copay
Diagnostic tests and procedures $0 copay
Lab services $0 copay
Outpatient x-rays $0 copay



Doctor Visits


Primary $10 copay per visit
Specialist $25 copay per visit



Emergency care/Urgent Care


Emergency $120 copay per visit (always covered)
Urgent care $20 copay per visit (always covered)



Foot Care (podiatry services)


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



Ground Ambulance


$250 copay



Hearing


Fitting/evaluation Not covered
Hearing aids - inner ear Not covered
Hearing aids - outer ear Not covered
Hearing aids - over the ear Not covered
Hearing exam $25 copay



Inpatient Hospital Coverage


$300 per stay
$0 per day for days 91 and beyond



Medical Equipment/Supplies


Diabetes supplies 0-20% coinsurance per item
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 20% coinsurance
Other Part B drugs 20% coinsurance



Mental Health Services


Inpatient hospital - psychiatric $300 per stay
Outpatient group therapy visit $25 copay
Outpatient group therapy visit with a psychiatrist $25 copay
Outpatient individual therapy visit $25 copay
Outpatient individual therapy visit with a psychiatrist $25 copay



MOOP


$3,400 In-network



Option


No



Optional supplemental benefits


No



Outpatient Hospital Coverage


$200 copay per visit



Preventive Care


$0 copay



Preventive Dental


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



Rehabilitation Services


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



Skilled Nursing Facility


$20 per day for days 1 through 20
$75 per day for days 21 through 100



Transportation


Not covered



Vision


Contact lenses $0 copay
Eyeglass frames Not covered
Eyeglass lenses Not covered
Eyeglasses (frames and lenses) $0 copay
Other Not covered
Routine eye exam $10-25 copay
Upgrades Not covered



Wellness Programs (e.g. fitness nursing hotline)


Covered




CMS Star Ratings for Capital Health Plan Preferred Advantage (HMO) H5938



2021 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
Monitoring Physical Activity


Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Functional Status Assessment
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
Getting Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination


Member Complaints and Changes in Capital Health Plan Preferred Advantage (HMO) Plans Performance

Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement


Health Plan Customer Service Rating for Capital Health Plan Preferred Advantage (HMO)

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


Capital Health Plan Preferred Advantage (HMO) Drug Plan Customer Service Ratings

Total Rating
Call Center, TTY, Foreign Language


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



Ready to Enroll?

Click Here

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




Coverage Area for Capital Health Plan Preferred Advantage (HMO)

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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.

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Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.

Every year, Medicare evaluates plans based on a 5-star rating system.