2022 Clear Spring Health Essential (PPO)


Clear Spring Health Essential (PPO) H2020-003 is a 2022 Medicare Advantage Plan or Part-C by Clear Spring Health available to residents in North Carolina. This plan includes additional prescription drug (Part-D) coverage. The Clear Spring Health Essential (PPO) has a monthly premium of $39.00 and has an in-network maximum out-of-pocket limit of $4,500 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $4,500 out-of-pocket. This can be a extremely nice safety net.

Clear Spring Health Essential (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 Essential (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.




Ready to Enroll?

Click Here

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




2022 Clear Spring Health Medicare Advantage Plan Costs

Name:
Clear Spring Health Essential (PPO)
Plan ID:
H2020-003
Provider:Clear Spring Health
Year:2022
Type: Local PPO
Monthly Premium C+D: $39.00
Part C Premium:$0.00
MOOP: $4,500
Part D (Drug) Premium:$39.00
Part D Supplemental Premium$0.00
Total Part D Premium:$39.00
Drug Deductible:$100.00
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: H2020-005
New Plan: 2023 H2020-005




Clear Spring Health Essential (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.



H2020-003 Part-D Deductible and Premium

Clear Spring Health Essential (PPO) has a monthly drug premium of $39.00 and a $100.00 drug deductible. This Clear Spring Health plan offers a $39.00 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 $39.00 . 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 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 Clear Spring Health Essential (PPO) medicare insurance offers a $3.20 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $12.10 for 75% low income subsidy $21.10 for 50% and $30.00 for 25%.



Full LIS Premium:$3.20
75% LIS Premium:$12.10
50% LIS Premium:$21.10
25% LIS Premium:$30.00


H2020-003 Formulary or Drug Coverage

Clear Spring Health Essential (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 Essential (PPO) H2020-003 Formulary here.

Drug Tier Copay
Preferred
Pharmacy
Copay
Nonpreferred
Pharmacy
Tier 1 $0 $7
Tier 2 $5 $12
Tier 3 $42 $47
Tier 4 $95 $100
Tier 5 31% 31%
*Initial Coverage Phase and 30 day supply





2021 Clear Spring Health Essential (PPO) Summary of Benefits

*This will be updated with 2022 data when available.



Additional Benefits


No



Comprehensive Dental


Diagnostic services $0 copay
Diagnostic services $0 copay (Out-of-Network)
Endodontics $0 copay (Out-of-Network)
Endodontics $0 copay
Extractions $0 copay (Out-of-Network)
Extractions $0 copay
Non-routine services $0 copay (Out-of-Network)
Non-routine services $0 copay
Periodontics $0 copay
Periodontics $0 copay (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services $0 copay (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services $0 copay
Restorative services $0 copay (Out-of-Network)
Restorative services $0 copay



Deductible


$0



Diagnostic Tests and Procedures


Diagnostic radiology services (e.g., MRI) $20-175 copay
Diagnostic radiology services (e.g., MRI) 45% coinsurance (Out-of-Network)
Diagnostic tests and procedures $10 copay
Diagnostic tests and procedures 45% coinsurance (Out-of-Network)
Lab services $10 copay
Lab services 45% coinsurance (Out-of-Network)
Outpatient x-rays $30 copay
Outpatient x-rays 45% coinsurance (Out-of-Network)



Doctor Visits


Primary $0 copay
Primary 45% coinsurance per visit (Out-of-Network)
Specialist $40 copay per visit
Specialist 45% coinsurance per visit (Out-of-Network)



Emergency care/Urgent Care


Emergency $90 copay per visit (always covered)
Urgent care $30 copay per visit (always covered)



Foot Care (podiatry services)


Foot exams and treatment 45% coinsurance (Out-of-Network)
Foot exams and treatment $40 copay
Routine foot care Not covered



Ground Ambulance


$300 copay
$300 copay (Out-of-Network)



Hearing


Fitting/evaluation 45% coinsurance (Out-of-Network)
Fitting/evaluation $0 copay
Hearing aids $400 copay
Hearing aids 45% coinsurance (Out-of-Network)
Hearing exam 45% coinsurance (Out-of-Network)
Hearing exam $45 copay



Inpatient Hospital Coverage


45% per day for days 1 through 5
45% per day for days 6 through 90 (Out-of-Network)
$350 per day for days 1 through 5
$0 per day for days 6 through 90



Medical Equipment/Supplies


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



Medicare Part B Drugs


Chemotherapy 20% coinsurance
Chemotherapy 45% coinsurance (Out-of-Network)
Other Part B drugs 45% coinsurance (Out-of-Network)
Other Part B drugs 20% coinsurance



Mental Health Services


Inpatient hospital - psychiatric $375 per day for days 1 through 4
$0 per day for days 5 through 90
Inpatient hospital - psychiatric 45% per day for days 1 through 6
45% per day for days 7 through 90 (Out-of-Network)
Outpatient group therapy visit $40 copay
Outpatient group therapy visit 45% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist 45% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist $40 copay
Outpatient individual therapy visit 45% coinsurance (Out-of-Network)
Outpatient individual therapy visit $40 copay
Outpatient individual therapy visit with a psychiatrist 45% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist $40 copay



MOOP


$10,000 In and Out-of-network
$4,500 In-network



Option


No



Optional supplemental benefits


No



Outpatient Hospital Coverage


45% coinsurance per visit (Out-of-Network)
$40-295 copay per visit



Preventive Care


45% coinsurance (Out-of-Network)
$0 copay



Preventive Dental


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



Rehabilitation Services


Occupational therapy visit $40 copay
Occupational therapy visit 45% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit 45% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit $40 copay



Skilled Nursing Facility


45% per day for days 1 through 20
45% per day for days 21 through 100 (Out-of-Network)
$0 per day for days 1 through 20
$178 per day for days 21 through 100



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) $0 copay (Out-of-Network)
Other Not covered
Routine eye exam $0 copay
Routine eye exam 45% coinsurance (Out-of-Network)
Upgrades Not covered



Wellness Programs (e.g. fitness nursing hotline)


Covered





Ready to Enroll?

Click Here

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




Coverage Area for Clear Spring Health Essential (PPO)

(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.

      Site Search:

MedicareHelp.org is a privately-owned Non-governmental agency. The government website can be found at HealthCare.gov.

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.