Wellcare Patriot Giveback Open (PPO) H7169-004 is a 2023 Medicare Advantage Plan or Part-C by Wellcare available to residents in Ohio. This plan does not provide additional prescription drug (Part-D) coverage. Wellcare Wellcare Patriot Giveback Open (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $6,700 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $6,700 out-of-pocket. This can be an extremely nice safety net.

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 2023 Medicare Advantage Plan 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 if you sign up for Medicare Advantage in Ohio.

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2023 Wellcare Medicare Advantage Plan Overview

What type of plan is Wellcare Patriot Giveback Open (PPO)

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.

How much does Wellcare Patriot Giveback Open (PPO) cost?

Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Wellcare charges a $0 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.

MOOP

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Wellcare Patriot Giveback Open (PPO) by Wellcare MOOP is $6,700. Once you spend $6,700 you will pay nothing for Part A or Part B covered services. Copayments and coinsurance for Medicare approved services apply toward your out-of-pocket limit. Remember Original Medicare (Parts A and B) doesn’t have a MOOP.

2023 Summary of Benefits

The benefit information provided is a summary of what Wellcare Patriot Giveback Open (PPO) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Wellcare helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

Wellness programs (e.g., fitness, nursing hotline)	Covered

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Contact lenses

Vision	Not covered

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Eyeglass frames

Vision	Not covered

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Eyeglass lenses

Vision	Not covered

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Eyeglasses (frames and lenses)

Vision	Not covered

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Other

Vision	Not covered

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Routine eye exam

Vision	Not covered

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Upgrades

Vision	Not covered

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Transportation	Not covered
In-Network Skilled Nursing Facility	$0 per day for days 1 through 20 $196 per day for days 21 through 60 $0 per day for days 61 through 100
Out-of-Network Skilled Nursing Facility	$0 per day for days 1 through 20 $196 per day for days 21 through 100

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Occupational therapy visit

Out-of-Network Rehabilitation services	$30 copay
In-Network Rehabilitation services	$30 copay

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Physical therapy and speech and language therapy visit

In-Network Rehabilitation services	$30 copay
Out-of-Network Rehabilitation services	$30 copay

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Cleaning

Out-of-Network Preventive dental	50% coinsurance
In-Network Preventive dental	$0 copay

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Dental x-ray(s)

Out-of-Network Preventive dental	50% coinsurance
In-Network Preventive dental	$0 copay

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Fluoride treatment

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	50% coinsurance

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Oral exam

Out-of-Network Preventive dental	50% coinsurance
In-Network Preventive dental	$0 copay

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In-Network Preventive care	$0 copay
Out-of-Network Preventive care	$0 copay
In-Network Outpatient hospital coverage	$275 copay per visit
Out-of-Network Outpatient hospital coverage	$275 copay per visit
In-Network Other health plan deductibles?	No
Optional supplemental benefits	No

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Inpatient hospital - psychiatric

Out-of-Network Mental health services	$300 per day for days 1 through 6 $0 per day for days 7 through 90
In-Network Mental health services	$300 per day for days 1 through 6 $0 per day for days 7 through 90

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Outpatient group therapy visit

In-Network Mental health services	$40 copay
Out-of-Network Mental health services	$40 copay

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Outpatient group therapy visit with a psychiatrist

In-Network Mental health services	$40 copay
Out-of-Network Mental health services	$40 copay

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Outpatient individual therapy visit

In-Network Mental health services	$40 copay
Out-of-Network Mental health services	$40 copay

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Outpatient individual therapy visit with a psychiatrist

Out-of-Network Mental health services	$40 copay
In-Network Mental health services	$40 copay

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Chemotherapy

In-Network Medicare Part B drugs	20% coinsurance
Out-of-Network Medicare Part B drugs	20% coinsurance

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Other Part B drugs

In-Network Medicare Part B drugs	20% coinsurance
Out-of-Network Medicare Part B drugs	20% coinsurance

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Diabetes supplies

In-Network Medical equipment/supplies	$0 copay per item
Out-of-Network Medical equipment/supplies	$0 copay or 20% coinsurance per item

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Durable medical equipment (e.g., wheelchairs, oxygen)

In-Network Medical equipment/supplies	20% coinsurance per item
Out-of-Network Medical equipment/supplies	20% coinsurance per item

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Prosthetics (e.g., braces, artificial limbs)

In-Network Medical equipment/supplies	20% coinsurance per item
Out-of-Network Medical equipment/supplies	20% coinsurance per item

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Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$10,000 In and Out-of-network $6,700 In-network
Out-of-Network Inpatient hospital coverage	$325 per day for days 1 through 6 $0 per day for days 7 through 90
In-Network Inpatient hospital coverage	$325 per day for days 1 through 6 $0 per day for days 7 through 90

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Fitting/evaluation

Hearing	Not covered

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Hearing aids - inner ear

Hearing	Not covered

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Hearing aids - outer ear

Hearing	Not covered

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Hearing aids - over the ear

Hearing	Not covered

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Hearing exam

In-Network Hearing	$30 copay
Out-of-Network Hearing	$30 copay

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Health plan deductible	$0
Out-of-Network Ground ambulance	$250 copay
In-Network Ground ambulance	$250 copay

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Foot exams and treatment

In-Network Foot care (podiatry services)	$30 copay
Out-of-Network Foot care (podiatry services)	$30 copay

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Routine foot care

Foot care (podiatry services)	Not covered

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Emergency

Emergency care/Urgent care	$95 copay per visit (always covered)

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Urgent care

Emergency care/Urgent care	$50 copay per visit (always covered)

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Primary

In-Network Doctor visits	$0 copay
Out-of-Network Doctor visits	$0 copay

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Specialist

In-Network Doctor visits	$30 copay per visit
Out-of-Network Doctor visits	$30 copay per visit

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Diagnostic radiology services (e.g., MRI)

In-Network Diagnostic procedures/lab services/imaging	$0-275 copay
Out-of-Network Diagnostic procedures/lab services/imaging	$0-275 copay

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Diagnostic tests and procedures

In-Network Diagnostic procedures/lab services/imaging	$0-100 copay
Out-of-Network Diagnostic procedures/lab services/imaging	$0-275 copay

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Lab services

In-Network Diagnostic procedures/lab services/imaging	$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging	$0 copay

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Outpatient x-rays

Out-of-Network Diagnostic procedures/lab services/imaging	$0 copay
In-Network Diagnostic procedures/lab services/imaging	$0 copay

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Diagnostic services

Out-of-Network Comprehensive dental	50% coinsurance
In-Network Comprehensive dental	$0 copay

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Endodontics

Comprehensive dental	Not covered

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Extractions

Comprehensive dental	Not covered

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Non-routine services

Out-of-Network Comprehensive dental	50% coinsurance
In-Network Comprehensive dental	$0 copay

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Periodontics

Comprehensive dental	Not covered

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Prosthodontics, other oral/maxillofacial surgery, other services

Comprehensive dental	Not covered

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Restorative services

Comprehensive dental	Not covered

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In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?	No

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1-855-778-4180
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Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Advantage Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Wellcare Patriot Giveback Open (PPO) requires you to live in that plan’s service area. The service area is listed below:

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Source:CMS. Data as of Oct 1, 2022.

Last updated on December 03, 2022

Notes: Data are subject to change as contracts are finalized. For 2023, 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 2023 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.