Optima Community Complete (HMO D-SNP) By Optima Medicare



Optima Community Complete (HMO D-SNP) is a 2022 Medicare Advantage Special Needs Plan plan by Optima Medicare. This plan from Optima Medicare works with Medicare to give you significant coverage beyond original Medicare. If you decide to sign up you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Optima Medicare and not Original Medicare. All Medicare SNPs also provide Medicare additional Part-D drug coverage. Optima Community Complete (HMO D-SNP) H2563-004 is a Dual Eligible Special Needs Plan (D-SNP). A Dual Eligible SNP is for beneficiaries who are eligible for both Medicare and Medicaid. If you have Medicare and get help from Medicaid you can join any Medicare SNP you qualify for or switch plans at any time.



2022 Medicare Special Needs Plan Details

Plan Name:
Optima Community Complete (HMO D-SNP)
Plan ID:
H2563-004
Special Needs Type: Dual-Eligible
Provider: Optima Medicare
Plan Year:2022
Plan Type: Local HMO
Monthly Premium C+D: $35.10
Part C Premium: $0.00
Part D (Drug) Premium: $35.10
Part D Supplemental Premium $0.00
Total Part D Premium: $35.10
Drug Deductible: $480.00
Tiers with No Deductible: 0
Benchmark: below the regional benchmark
Type of Medicare Health Plan: Defined Standard Benefit
Drug Benefit Type: Basic
Gap Coverage: No Gap Coverage


The Optima Community Complete (HMO D-SNP) H2563-004 is available to residents in Virginia, and all Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. Optima Community Complete (HMO D-SNP) 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 need special care for a physician specialist, your primary care physician will make the arrangements and tell you where you can go in the network. You will need your PCPs okay, called a referral. Without getting a referral or services received from out-of-network providers are not typically covered by the 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 brand-name drugs and 25% on generic drugs unless your plan offers additional coverage. This Optima Medicare plan offer additional coverage through the gap.




Optima Community Complete (HMO D-SNP) Part-C Premium

Optima Medicare 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.



H2563-004 Part-D Deductible and Premium

Optima Community Complete (HMO D-SNP) has a monthly drug premium of $35.10 and a $480.00 drug deductible. This Optima Medicare plan offers a $35.10 Part D Basic Premium that is 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 Optima Medicare 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 $35.10 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.



Optima Medicare 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 Optima Medicare plan 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 Optima Community Complete (HMO D-SNP) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $8.80 for 75% low income subsidy $17.50 for 50% and $26.30 for 25%.



Full LIS Premium:$0.00
75% LIS Premium:$8.80
50% LIS Premium:$17.50
25% LIS Premium:$26.30


H2563-004 Formulary or Drug Coverage

Optima Community Complete (HMO D-SNP) 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 Optima Community Complete (HMO D-SNP) H2563-004 Formulary here.

Drug Tier Copay
Preferred
Pharmacy
Copay
Nonpreferred
Pharmacy
Tier 1 NA $0
Tier 2 NA $0
Tier 3 NA $0
Tier 4 NA $0
Tier 5 NA $0
*Initial Coverage Phase and 30 day supply







Reviews for Optima Community Complete (HMO D-SNP) H2563



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 Optima Community Complete (HMO D-SNP) Plans Performance

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


Health Plan Customer Service Rating for Optima Community Complete (HMO D-SNP)

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


Optima Community Complete (HMO D-SNP) 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


Coverage Area for Optima Community Complete (HMO D-SNP)

State: Medicare Plans in Virginia
County:

Accomack



Albemarle



Alexandria City



Alleghany



Amelia



Amherst



Appomattox



Arlington



Augusta



Bath



Bedford



Bland



Botetourt



Bristol City



Brunswick



Buchanan



Buckingham



Buena Vista City



Campbell



Caroline



Carroll



Charles City



Charlotte



Charlottesville City



Chesapeake City



Chesterfield



Clarke



Colonial Heights City



Covington City



Craig



Culpeper



Cumberland



Danville City



Dickenson



Dinwiddie



Emporia City



Essex



Fairfax



Fairfax City



Falls Church City



Fauquier



Floyd



Fluvanna



Franklin



Franklin City



Frederick



Fredericksburg City



Galax City



Giles



Gloucester



Goochland



Grayson



Greene



Greensville



Halifax



Hampton City



Hanover



Harrisonburg City



Henrico



Henry



Highland



Hopewell City



Isle of Wight



James City



King and Queen



King George



King William



Lancaster



Lee



Lexington City



Loudoun



Louisa



Lunenburg



Lynchburg City



Madison



Manassas City



Manassas Park City



Martinsville City



Mathews



Mecklenburg



Middlesex



Montgomery



Nelson



New Kent



Newport News City



Norfolk City



Northampton



Northumberland



Norton City



Nottoway



Orange



Page



Patrick



Petersburg City



Pittsylvania



Poquoson City



Portsmouth City



Powhatan



Prince Edward



Prince George



Prince William



Pulaski



Radford City



Rappahannock



Richmond



Richmond City



Roanoke



Roanoke City



Rockbridge



Rockingham



Russell



Salem City



Scott



Shenandoah



Smyth



Southampton



Spotsylvania



Stafford



Staunton City



Suffolk City



Surry



Sussex



Tazewell



Virginia Beach City



Warren



Washington



Waynesboro City



Westmoreland



Williamsburg City



Winchester City



Wise



Wythe



York





Source: CMS.

Plans as of September 1, 2021.

Notes: Data are subject to change. All contracts for 2022 have not been finalized. For 2022, enhanced alternative plans may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part Part D benefit.

Includes 2022 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.

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