2022 Clear Spring Health Choice Plan (PPO)


Clear Spring Health Choice Plan (PPO) H9589-003 is a 2022 Medicare Advantage Plan or Part-C by Clear Spring Health available to residents in Georgia. This plan includes additional prescription drug (Part-D) coverage. The Clear Spring Health Choice Plan (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $7,550 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $7,550 out-of-pocket. This can be a extremely nice safety net.

Clear Spring Health Choice Plan (PPO) 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.

Clear Spring Health works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Clear Spring Health Choice Plan (PPO) 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. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Clear Spring Health except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.




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2022 Clear Spring Health Medicare Advantage Plan Costs

Name:
Clear Spring Health Choice Plan (PPO)
Plan ID:
H9589-003
Provider:Clear Spring Health
Year:2022
Type: Local PPO
Monthly Premium C+D: $0
Part C Premium:$0.00
MOOP: $7,550
Part D (Drug) Premium:$0.00
Part D Supplemental Premium$0.00
Total Part D Premium:$0.00
Drug Deductible:$250.00
Tiers with No Deductible:1
Gap Coverage:No
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced
Similar Plan: H9589-003




Clear Spring Health Choice Plan (PPO) Part-C Premium

Clear Spring Health 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.



H9589-003 Part-D Deductible and Premium

Clear Spring Health Choice Plan (PPO) has a monthly drug premium of $0.00 and a $250.00 drug deductible. This Clear Spring Health plan offers a $0.00 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 $0.00 . 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.



Clear Spring Health 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 Clear Spring Health plan does not offer additional coverage through the gap.



H9589-003 Formulary or Drug Coverage

Clear Spring Health Choice Plan (PPO) 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 Clear Spring Health Choice Plan (PPO) H9589-003 Formulary here.

Drug Tier Copay
Preferred
Pharmacy
Copay
Nonpreferred
Pharmacy
Tier 1 $0 $5
Tier 2 $12 $17
Tier 3 $42 $47
Tier 4 $95 $100
Tier 5 28% 28%
*Initial Coverage Phase and 30 day supply





2021 Clear Spring Health Choice Plan (PPO) Summary of Benefits

*This will be updated with 2022 data when available.



Additional Benefits


No



Comprehensive Dental


Diagnostic services $0 copay
Diagnostic services 20% coinsurance (Out-of-Network)
Endodontics Not covered
Extractions Not covered
Non-routine services Not covered
Periodontics Not covered
Prosthodontics, other oral/maxillofacial surgery, other services 20% coinsurance (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services $0 copay
Restorative services 20% coinsurance (Out-of-Network)
Restorative services $0 copay



Deductible


$0



Diagnostic Tests and Procedures


Diagnostic radiology services (e.g., MRI) $0-100 copay or 20% coinsurance
Diagnostic radiology services (e.g., MRI) 20% coinsurance (Out-of-Network)
Diagnostic tests and procedures 20% coinsurance
Diagnostic tests and procedures 20% coinsurance (Out-of-Network)
Lab services $10 copay (Out-of-Network)
Lab services $10 copay
Outpatient x-rays 40% coinsurance (Out-of-Network)
Outpatient x-rays $0-100 copay



Doctor Visits


Primary $0 copay
Primary $20 copay per visit (Out-of-Network)
Specialist $0-45 copay per visit
Specialist $45 copay per visit (Out-of-Network)



Emergency care/Urgent Care


Emergency $90 copay per visit (always covered)
Urgent care $35 copay per visit (always covered)



Foot Care (podiatry services)


Foot exams and treatment $45 copay
Foot exams and treatment $45 copay (Out-of-Network)
Routine foot care $45 copay (Out-of-Network)
Routine foot care $45 copay



Ground Ambulance


$275 copay
20% coinsurance (Out-of-Network)



Hearing


Fitting/evaluation 50% coinsurance (Out-of-Network)
Fitting/evaluation $0 copay
Hearing aids 50% coinsurance (Out-of-Network)
Hearing aids $0 copay
Hearing exam 20% coinsurance (Out-of-Network)
Hearing exam $45 copay



Inpatient Hospital Coverage


$295 per day for days 1 through 5
$0 per day for days 6 through 90
$395 per day for days 1 through 4
$0 per day for days 5 through 90 (Out-of-Network)



Medical Equipment/Supplies


Diabetes supplies $0 copay
Diabetes supplies 20% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen) 45% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen) 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) 20% coinsurance per item (Out-of-Network)



Medicare Part B Drugs


Chemotherapy 20% coinsurance
Chemotherapy 20% coinsurance (Out-of-Network)
Other Part B drugs 20% coinsurance (Out-of-Network)
Other Part B drugs 20% coinsurance



Mental Health Services


Inpatient hospital - psychiatric $395 per day for days 1 through 4
$0 per day for days 5 through 90
Inpatient hospital - psychiatric $395 per day for days 1 through 4
$0 per day for days 5 through 90 (Out-of-Network)
Outpatient group therapy visit $30 copay
Outpatient group therapy visit $40 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist $30 copay
Outpatient group therapy visit with a psychiatrist $40 copay (Out-of-Network)
Outpatient individual therapy visit $40 copay (Out-of-Network)
Outpatient individual therapy visit $40 copay
Outpatient individual therapy visit with a psychiatrist $40 copay
Outpatient individual therapy visit with a psychiatrist $40 copay (Out-of-Network)



MOOP


$7,550 In and Out-of-network
$7,550 In-network
$7,550 Out-of-network



Option


No



Optional supplemental benefits


No



Outpatient Hospital Coverage


$250 copay per visit
20% coinsurance per visit (Out-of-Network)



Preventive Care


$0 copay
$0 copay (Out-of-Network)



Preventive Dental


Cleaning $0 copay
Cleaning 50% coinsurance (Out-of-Network)
Dental x-ray(s) $0 copay
Dental x-ray(s) 50% coinsurance (Out-of-Network)
Fluoride treatment Not covered
Oral exam 50% coinsurance (Out-of-Network)
Oral exam $0 copay



Rehabilitation Services


Occupational therapy visit $40 copay (Out-of-Network)
Occupational therapy visit $40 copay
Physical therapy and speech and language therapy visit $40 copay
Physical therapy and speech and language therapy visit $40 copay (Out-of-Network)



Skilled Nursing Facility


$0 per day for days 1 through 20
$160 per day for days 21 through 62
$0 per day for days 63 through 100
$195 per day for days 1 through 35
$0 per day for days 36 through 100 (Out-of-Network)



Transportation


Not covered



Vision


Contact lenses Not covered
Eyeglass frames Not covered
Eyeglass lenses Not covered
Eyeglasses (frames and lenses) $0 copay
Eyeglasses (frames and lenses) 50% coinsurance (Out-of-Network)
Other Not covered
Routine eye exam 50% coinsurance (Out-of-Network)
Routine eye exam $0 copay
Upgrades Not covered



Wellness Programs (e.g. fitness nursing hotline)


Covered





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Coverage Area for Clear Spring Health Choice Plan (PPO)

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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.

*Licensed Agent Disclaimer: We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY users should call 1-877-486-2048) 24 hours a day/7 days a week to get information on all of your options.

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