2022 Wellcare Patriot Giveback Open (PPO)


Wellcare Patriot Giveback Open (PPO) H5965-003 is a 2022 Medicare Advantage Plan or Part-C by Wellcare available to residents in Washington. This plan does not provide additional prescription drug (Part-D) coverage. The Wellcare Patriot Giveback Open (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $4,000 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $4,000 out-of-pocket. This can be a extremely nice safety net.

Wellcare Patriot Giveback Open (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.

Wellcare works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Wellcare Patriot Giveback Open (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Wellcare 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 Wellcare except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.




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2022 Wellcare Medicare Advantage Plan Costs

Name:
Wellcare Patriot Giveback Open (PPO)
Plan ID:
H5965-003
Provider:Wellcare
Year:2022
Type: Local PPO *
Monthly Premium C+D: $0
Part C Premium:
MOOP: $4,000
Similar Plan: H5965-001
New Plan: 2023 H5965-001




2021 Wellcare Patriot Giveback Open (PPO) Summary of Benefits

*This will be updated with 2022 data when available.



Additional Benefits


No



Comprehensive Dental


Diagnostic services Not covered
Endodontics Not covered
Extractions $0 copay
Extractions 50% coinsurance (Out-of-Network)
Non-routine services 50% coinsurance (Out-of-Network)
Non-routine services $0 copay
Periodontics 50% coinsurance (Out-of-Network)
Periodontics $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services 50% coinsurance (Out-of-Network)
Restorative services 50% coinsurance (Out-of-Network)
Restorative services $0 copay



Deductible


$0



Diagnostic Tests and Procedures


Diagnostic radiology services (e.g., MRI) $0-250 copay
Diagnostic radiology services (e.g., MRI) 40% coinsurance (Out-of-Network)
Diagnostic tests and procedures $0-50 copay
Diagnostic tests and procedures 40% coinsurance (Out-of-Network)
Lab services 40% coinsurance (Out-of-Network)
Lab services $0 copay
Outpatient x-rays $0 copay
Outpatient x-rays 40% coinsurance (Out-of-Network)



Doctor Visits


Primary 40% coinsurance per visit (Out-of-Network)
Primary $20 copay per visit
Specialist $50 copay per visit
Specialist 40% 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 $50 copay
Foot exams and treatment 40% coinsurance (Out-of-Network)
Routine foot care $25 copay
Routine foot care 40% coinsurance (Out-of-Network)



Ground Ambulance


$250 copay (Out-of-Network)
$250 copay



Hearing


Fitting/evaluation 40% coinsurance (Out-of-Network)
Fitting/evaluation $0 copay
Hearing aids 40% coinsurance (Out-of-Network)
Hearing aids $0 copay
Hearing exam 40% coinsurance (Out-of-Network)
Hearing exam $50 copay



Inpatient Hospital Coverage


20% per day for days 1 through 90 (Out-of-Network)
$500 per day for days 1 through 3
$0 per day for days 4 through 90



Medical Equipment/Supplies


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



Medicare Part B Drugs


Chemotherapy 40% coinsurance (Out-of-Network)
Chemotherapy 20% coinsurance
Other Part B drugs 40% coinsurance (Out-of-Network)
Other Part B drugs 20% coinsurance



Mental Health Services


Inpatient hospital - psychiatric $550 per day for days 1 through 3
$0 per day for days 4 through 90
Inpatient hospital - psychiatric 40% per day for days 1 through 90 (Out-of-Network)
Outpatient group therapy visit $40 copay
Outpatient group therapy visit 40% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist 40% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist $40 copay
Outpatient individual therapy visit $40 copay
Outpatient individual therapy visit 40% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist $40 copay
Outpatient individual therapy visit with a psychiatrist 40% coinsurance (Out-of-Network)



MOOP


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



Option


No



Optional supplemental benefits


No



Outpatient Hospital Coverage


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



Preventive Care


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



Preventive Dental


Cleaning 50% coinsurance (Out-of-Network)
Cleaning $0 copay
Dental x-ray(s) 50% coinsurance (Out-of-Network)
Dental x-ray(s) $0 copay
Fluoride treatment 50% coinsurance (Out-of-Network)
Fluoride treatment $0 copay
Oral exam 50% coinsurance (Out-of-Network)
Oral exam $0 copay



Rehabilitation Services


Occupational therapy visit 40% coinsurance (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% coinsurance (Out-of-Network)



Skilled Nursing Facility


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



Transportation


Not covered



Vision


Contact lenses 40% coinsurance (Out-of-Network)
Contact lenses $0 copay
Eyeglass frames $0 copay
Eyeglass frames 40% coinsurance (Out-of-Network)
Eyeglass lenses $0 copay
Eyeglass lenses 40% coinsurance (Out-of-Network)
Eyeglasses (frames and lenses) $0 copay
Eyeglasses (frames and lenses) 40% coinsurance (Out-of-Network)
Other Not covered
Routine eye exam $0 copay
Routine eye exam 40% coinsurance (Out-of-Network)
Upgrades $0 copay
Upgrades 40% coinsurance (Out-of-Network)



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 Wellcare Patriot Giveback Open (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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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.

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