2022 Personal Choice 65 Medical Only (PPO)


Personal Choice 65 Medical Only (PPO) H3909-007 is a 2022 Medicare Advantage Plan or Part-C by Independence Blue Cross available to residents in Pennsylvania. This plan does not provide additional prescription drug (Part-D) coverage. The Personal Choice 65 Medical Only (PPO) has a monthly premium of $179.00 and has an in-network maximum out-of-pocket limit of $5,000 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $5,000 out-of-pocket. This can be a extremely nice safety net.

Personal Choice 65 Medical Only (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.

Independence Blue Cross works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Personal Choice 65 Medical Only (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Independence Blue Cross 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 Independence Blue Cross except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.




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2022 Independence Blue Cross Medicare Advantage Plan Costs

Name:
Personal Choice 65 Medical Only (PPO)
Plan ID:
H3909-007
Provider:Independence Blue Cross
Year:2022
Type: Local PPO *
Monthly Premium C+D: $179.00
Part C Premium:
MOOP: $5,000
Similar Plan: H3909-009
New Plan: 2023 H3909-009




2021 Personal Choice 65 Medical Only (PPO) Summary of Benefits

*This will be updated with 2022 data when available.



Additional Benefits


No



Comprehensive Dental


Diagnostic services Not covered
Endodontics 80% coinsurance (Out-of-Network)
Endodontics 20% coinsurance
Extractions 80% coinsurance (Out-of-Network)
Extractions 20% coinsurance
Non-routine services Not covered
Periodontics 20% coinsurance
Periodontics 80% coinsurance (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services 40% coinsurance
Prosthodontics, other oral/maxillofacial surgery, other services 80% coinsurance (Out-of-Network)
Restorative services 80% coinsurance (Out-of-Network)
Restorative services 20% coinsurance



Deductible


$0



Diagnostic Tests and Procedures


Diagnostic radiology services (e.g., MRI) 30% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI) $0-175 copay
Diagnostic tests and procedures 30% coinsurance (Out-of-Network)
Diagnostic tests and procedures $0 copay
Lab services $0 copay
Lab services 30% coinsurance (Out-of-Network)
Outpatient x-rays $40 copay
Outpatient x-rays 30% coinsurance (Out-of-Network)



Doctor Visits


Primary 30% coinsurance per visit (Out-of-Network)
Primary $5 copay per visit
Specialist 30% coinsurance per visit (Out-of-Network)
Specialist $35 copay per visit



Emergency care/Urgent Care


Emergency $90 copay per visit (always covered)
Urgent care $5-40 copay per visit (always covered)



Foot Care (podiatry services)


Foot exams and treatment $20 copay
Foot exams and treatment 30% coinsurance (Out-of-Network)
Routine foot care 30% coinsurance (Out-of-Network)
Routine foot care $20 copay



Ground Ambulance


$175 copay
$175 copay (Out-of-Network)



Hearing


Fitting/evaluation $0 copay
Fitting/evaluation $10 copay (Out-of-Network)
Hearing aids $499-799 copay (Out-of-Network)
Hearing aids $499-799 copay
Hearing exam $35 copay
Hearing exam 30% coinsurance (Out-of-Network)



Inpatient Hospital Coverage


30% per stay (Out-of-Network)
$240 per day for days 1 through 6
$0 per day for days 7 through 90



Medical Equipment/Supplies


Diabetes supplies 30% 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) 30% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs) 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) 30% coinsurance per item (Out-of-Network)



Medicare Part B Drugs


Chemotherapy 30% coinsurance (Out-of-Network)
Chemotherapy 20% coinsurance
Other Part B drugs 20% coinsurance
Other Part B drugs 30% coinsurance (Out-of-Network)



Mental Health Services


Inpatient hospital - psychiatric 30% per stay (Out-of-Network)
Inpatient hospital - psychiatric $240 per day for days 1 through 6
$0 per day for days 7 through 90
Outpatient group therapy visit $40 copay
Outpatient group therapy visit 30% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist 30% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist $40 copay
Outpatient individual therapy visit $40 copay
Outpatient individual therapy visit 30% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist $40 copay
Outpatient individual therapy visit with a psychiatrist 30% coinsurance (Out-of-Network)



MOOP


$10,000 In and Out-of-network
$5,000 In-network



Option


Yes, contact plan for further details



Optional supplemental benefits


No



Outpatient Hospital Coverage


$300 copay per visit
30% coinsurance per visit (Out-of-Network)



Preventive Care


$0 copay
30% coinsurance (Out-of-Network)



Preventive Dental


Cleaning 80% coinsurance (Out-of-Network)
Cleaning $0 copay
Dental x-ray(s) 80% coinsurance (Out-of-Network)
Dental x-ray(s) $0 copay
Fluoride treatment Not covered
Oral exam 80% coinsurance (Out-of-Network)
Oral exam $0 copay



Rehabilitation Services


Occupational therapy visit $20 copay
Occupational therapy visit 30% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit 30% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit $20 copay



Skilled Nursing Facility


$0 per day for days 1 through 20
$184 per day for days 21 through 100
30% per stay (Out-of-Network)



Transportation


Not covered



Vision


Contact lenses $0 copay
Contact lenses 80% coinsurance (Out-of-Network)
Eyeglass frames Not covered
Eyeglass lenses Not covered
Eyeglasses (frames and lenses) $0 copay
Eyeglasses (frames and lenses) 80% coinsurance (Out-of-Network)
Other Not covered
Routine eye exam 80% coinsurance (Out-of-Network)
Routine eye exam $10 copay
Upgrades Not covered



Wellness Programs (e.g. fitness nursing hotline)


Covered




CMS Star Ratings for Personal Choice 65 Medical Only (PPO) H3909



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 Personal Choice 65 Medical Only (PPO) Plans Performance

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


Health Plan Customer Service Rating for Personal Choice 65 Medical Only (PPO)

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


Personal Choice 65 Medical Only (PPO) 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 Personal Choice 65 Medical Only (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.

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