2022 SSM Health Plan Integrity (HMO-POS)

SSM Health Plan Integrity (HMO-POS) H8019-002 is a 2022 Medicare Advantage Plan or Part-C by WellFirst Health available to residents in Illinois and Missouri. This plan includes additional prescription drug (Part-D) coverage. The SSM Health Plan Integrity (HMO-POS) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $2,500 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $2,500 out-of-pocket. This can be a extremely nice safety net.

SSM Health Plan Integrity (HMO-POS) 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.

WellFirst Health works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for SSM Health Plan Integrity (HMO-POS) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from WellFirst 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 WellFirst 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 WellFirst Health Medicare Advantage Plan Costs

SSM Health Plan Integrity (HMO-POS) Part-C Premium

WellFirst 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.

H8019-002 Part-D Deductible and Premium

SSM Health Plan Integrity (HMO-POS) has a monthly drug premium of $0.00 and a $0.00 drug deductible. This WellFirst 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 WellFirst 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.

WellFirst 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 WellFirst Health plan does offer additional coverage through the gap.

H8019-002 Formulary or Drug Coverage

SSM Health Plan Integrity (HMO-POS) 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 SSM Health Plan Integrity (HMO-POS) H8019-002 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$0	$7
Tier 2	$5	$12
Tier 3	$40	$47
Tier 4	$90	$100
Tier 5	33%	33%
Tier 6	$0	$0

*Initial Coverage Phase and 30 day supply

2021 SSM Health Plan Integrity (HMO-POS) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	$0-45 copay
Endodontics	$595 copay
Extractions	$95 copay
Non-routine services	$45 copay
Periodontics	$45-95 copay
Prosthodontics, other oral/maxillofacial surgery, other services	$595 copay
Restorative services	$95 copay

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Deductible

$0

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Diagnostic Tests and Procedures

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

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Doctor Visits

Primary	$0 copay
Primary	$30 copay per visit (Out-of-Network)
Specialist	$35 copay per visit
Specialist	$60 copay per visit (Out-of-Network)

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Emergency care/Urgent Care

Emergency	$120 copay per visit (always covered)
Urgent care	$0-35 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$60 copay (Out-of-Network)
Foot exams and treatment	$35 copay
Routine foot care	$35 copay
Routine foot care	$60 copay (Out-of-Network)

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Ground Ambulance

40% coinsurance (Out-of-Network)
$250 copay

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Hearing

Fitting/evaluation	$0 copay
Hearing aids	$0 copay
Hearing exam	$60 copay (Out-of-Network)
Hearing exam	$0 copay

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Inpatient Hospital Coverage

$500 per day for days 1 through 7 $0 per day for days 8 through 90 (Out-of-Network)
$325 per day for days 1 through 7 $0 per day for days 8 through 90

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Medical Equipment/Supplies

Diabetes supplies	40% coinsurance per item (Out-of-Network)
Diabetes supplies	$0 copay per item
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	40% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	40% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item

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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

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Mental Health Services

Inpatient hospital - psychiatric	$500 per day for days 1 through 7 $0 per day for days 8 through 90 (Out-of-Network)
Inpatient hospital - psychiatric	$325 per day for days 1 through 7 $0 per day for days 8 through 90
Outpatient group therapy visit	$0 copay
Outpatient group therapy visit	$30 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$30 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$0 copay
Outpatient individual therapy visit	$0 copay
Outpatient individual therapy visit	$30 copay (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$0 copay
Outpatient individual therapy visit with a psychiatrist	$30 copay (Out-of-Network)

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MOOP

$5,000 In and Out-of-network $2,500 In-network

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Option

No

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Optional supplemental benefits

No

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Outpatient Hospital Coverage

20% coinsurance per visit (Out-of-Network)
$0-275 copay per visit

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Preventive Care

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

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Preventive Dental

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

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Rehabilitation Services

Occupational therapy visit	$35 copay
Occupational therapy visit	$60 copay (Out-of-Network)
Physical therapy and speech and language therapy visit	$35 copay
Physical therapy and speech and language therapy visit	$60 copay (Out-of-Network)

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Skilled Nursing Facility

$150 per day for days 1 through 100 (Out-of-Network)
$0 per day for days 1 through 20 $184 per day for days 21 through 100

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Transportation

$0 copay

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Vision

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

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Wellness Programs (e.g. fitness nursing hotline)

Covered

Ready to Enroll?

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

Coverage Area for SSM Health Plan Integrity (HMO-POS)

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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.