2022 Vantage BASIC (HMO-POS)


Vantage BASIC (HMO-POS) H2722-002 is a 2022 Medicare Advantage Plan or Part-C by Vantage Health Plan available to residents in Arkansas. This plan includes additional prescription drug (Part-D) coverage. The Vantage BASIC (HMO-POS) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $5,900 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $5,900 out-of-pocket. This can be a extremely nice safety net.

Vantage BASIC (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.

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

Name:
Vantage BASIC (HMO-POS)
Plan ID:
H2722-002
Provider:Vantage Health Plan
Year:2022
Type: Local HMO
Monthly Premium C+D: $0
Part C Premium:$0.00
MOOP: $5,900
Part D (Drug) Premium:$0.00
Part D Supplemental Premium$0.00
Total Part D Premium:$0.00
Drug Deductible:$480.00
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: H2722-004




Vantage BASIC (HMO-POS) Part-C Premium

Vantage Health Plan 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.



H2722-002 Part-D Deductible and Premium

Vantage BASIC (HMO-POS) has a monthly drug premium of $0.00 and a $480.00 drug deductible. This Vantage Health Plan 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 Vantage 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 $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.



Vantage 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 Vantage Health Plan plan does offer additional coverage through the gap.



H2722-002 Formulary or Drug Coverage

Vantage BASIC (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 Vantage BASIC (HMO-POS) H2722-002 Formulary here.

Drug Tier Copay
Preferred
Pharmacy
Copay
Nonpreferred
Pharmacy
Tier 1 $0 $8
Tier 2 $16 $16
Tier 3 $47 $47
Tier 4 $100 $100
Tier 5 25% 25%
*Initial Coverage Phase and 30 day supply





2021 Vantage BASIC (HMO-POS) 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
Endodontics $0 copay (Out-of-Network)
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 (Out-of-Network)
Periodontics $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services $0 copay (Out-of-Network)
Restorative services $0 copay
Restorative services $0 copay (Out-of-Network)



Deductible


$500 Out-of-network



Diagnostic Tests and Procedures


Diagnostic radiology services (e.g., MRI) $100 copay
Diagnostic radiology services (e.g., MRI) 50% coinsurance (Out-of-Network)
Diagnostic tests and procedures 50% coinsurance (Out-of-Network)
Diagnostic tests and procedures 20% coinsurance
Lab services $0 copay
Lab services 50% coinsurance (Out-of-Network)
Outpatient x-rays 20% coinsurance
Outpatient x-rays 50% coinsurance (Out-of-Network)



Doctor Visits


Primary $0 copay or 0-20% coinsurance per visit
Primary 50% coinsurance per visit (Out-of-Network)
Specialist $35 copay or 0-20% coinsurance per visit
Specialist 50% coinsurance per visit (Out-of-Network)



Emergency care/Urgent Care


Emergency $90 copay per visit (always covered)
Urgent care $65 copay per visit (always covered)



Foot Care (podiatry services)


Foot exams and treatment $50 copay
Foot exams and treatment 50% coinsurance (Out-of-Network)
Routine foot care Not covered



Ground Ambulance


50% coinsurance (Out-of-Network)
$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 50% coinsurance (Out-of-Network)
Hearing exam 20% coinsurance



Inpatient Hospital Coverage


$318 per day for days 1 through 7
$0 per day for days 8 through 90
50% per stay (Out-of-Network)



Medical Equipment/Supplies


Diabetes supplies 0-20% coinsurance per item
Diabetes supplies 50% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen) 50% 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) 50% coinsurance per item (Out-of-Network)



Medicare Part B Drugs


Chemotherapy 50% coinsurance (Out-of-Network)
Chemotherapy 20% coinsurance
Other Part B drugs 20% coinsurance
Other Part B drugs 50% coinsurance (Out-of-Network)



Mental Health Services


Inpatient hospital - psychiatric $467 per day for days 1 through 4
$0 per day for days 5 through 90
Inpatient hospital - psychiatric 50% per stay (Out-of-Network)
Outpatient group therapy visit 50% coinsurance (Out-of-Network)
Outpatient group therapy visit 20% coinsurance
Outpatient group therapy visit with a psychiatrist 50% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist 20% coinsurance
Outpatient individual therapy visit 50% coinsurance (Out-of-Network)
Outpatient individual therapy visit 20% coinsurance
Outpatient individual therapy visit with a psychiatrist 20% coinsurance
Outpatient individual therapy visit with a psychiatrist 50% coinsurance (Out-of-Network)



MOOP


$5,900 In-network



Option


No



Optional supplemental benefits


No



Outpatient Hospital Coverage


50% coinsurance per visit (Out-of-Network)
$300 copay per visit



Preventive Care


$0 copay
50% coinsurance (Out-of-Network)



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 Not covered
Oral exam $0 copay
Oral exam $0 copay (Out-of-Network)



Rehabilitation Services


Occupational therapy visit 20% coinsurance
Occupational therapy visit 50% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit 50% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit 20% coinsurance



Skilled Nursing Facility


50% per stay (Out-of-Network)
$0 per day for days 1 through 20
$184 per day for days 21 through 100



Transportation


$0 copay



Vision


Contact lenses $0 copay (Out-of-Network)
Contact lenses $0 copay
Eyeglass frames $0 copay
Eyeglass frames $0 copay (Out-of-Network)
Eyeglass lenses $0 copay
Eyeglass lenses $0 copay (Out-of-Network)
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 50% coinsurance (Out-of-Network)
Upgrades $0 copay
Upgrades $0 copay (Out-of-Network)



Wellness Programs (e.g. fitness nursing hotline)


Covered





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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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