Amerivantage Full Dual Coordination (HMO D-SNP) H5828-001-000 2023 Plan Details and Costs (2024)

Basic Costs and Coverage

Coverage	Details
Monthly plan premium	$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible	$0.00
Out-of-pocket maximum	$8,300.00
Initial drug coverage limit	$0.00
Catastrophic drug coverage limit	$7,400.00
Primary care doctor visit	In-Network: $0.00 copay
Specialty doctor visit	In-Network: $0.00 copay
Inpatient hospital care	In-Network: $0.00 copay per stay
Urgent care	Urgent Care: $0.00 copay
Emergency room visit	Emergency Care: $0.00 copay Worldwide Coverage: This plan covers urgent care and emergency services when traveling outside of the United States for less than six months. This benefit is limited to $100,000.00 per year.
Ambulance transportation	Ground Ambulance: $0.00 copay Per Trip Air Ambulance: $0.00 copay

Health Care Services and Medical Supplies

Amerivantage Full Dual Coordination (HMO D-SNP) covers a range of additional benefits. Learn more about Amerivantage Full Dual Coordination (HMO D-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage	Details
Chiropractic services	In-Network: Medicare Covered Chiropractic Services: $0.00 copay Routine Chiropractic Services: $0.00 copay 48 visits each year
Diabetes supplies, training, nutrition therapy and monitoring	In-Network: Diabetic Supplies: $0.00 copay
Durable medical equipment (DME)	In-Network: $0.00 copay
Diagnostic tests, lab and radiology services, and X-rays	In-Network: Lab Services: $0.00 copay X-Rays: $0.00 copay Therapeutic Radiological Services: $0.00 copay Outpatient Diagnostic Procedures/Tests: $0.00 copay Diagnostic Radiological Services: $0.00 copay
Home health care	In-Network: $0.00 copay
Mental health inpatient care	In-Network: $0.00 copay per stay
Mental health outpatient care	In-Network: Individual and Group Sessions: $0.00 copay
Outpatient services/surgery	In-Network: Outpatient Hospital - Surgery: $0.00 copay Observation Services: $0.00 copay Ambulatory Surgical Center: $0.00 copay
Outpatient substance abuse care	In-Network: Individual and Group Sessions: $0.00 copay
Over-the-counter items	You can receive a $215.00 monthly spending allowance to buy eligible over-the-counter (OTC) products and healthy groceries at participating stores near you. OTC products and select healthy groceries are also available online.
Podiatry services	In-Network: Medicare Covered Podiatry Services: $0.00 copay Routine Foot Care: $0.00 copay Unlimited routine foot care visits each year.
Skilled Nursing Facility (SNF) care	In-Network: $0.00 copay per stay

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Dental care	In-Network: Preventive Dental Services: $0.00 copay This plan covers: 2 oral exam(s), 2 cleaning(s), 1 dental X-ray(s), 1 fluoride treatment(s) every year. Medicare Covered Dental: $0.00 copay Comprehensive Dental Services: $0.00 copay This plan covers up to a $5,000.00 allowance for covered comprehensive dental services every year.

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Vision benefits	In-Network: Medicare Covered Eye Exam: $0.00 copay Routine Eye Exam: $0.00 copay This plan covers 1 routine eye exam(s) every year. Medicare Covered Eye Wear: $0.00 copay Routine Eye Wear: $0.00 copay This plan covers up to $425.00 for eyeglasses or contact lenses every year.

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Hearing benefits	In-Network: Medicare Covered Hearing Exam: $0.00 copay Routine Hearing Exam: $0.00 copay for routine hearing exam(s). $0.00 copay for hearing aids up to the maximum plan benefit amount. This plan covers 1 routine hearing exam(s) and hearing aid fitting/evaluation(s) every year. $3,000.00 maximum plan benefit coverage amount applies to prescribed hearing aids covered by the plan every year.

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Preventive services and health/wellness education programs	In-Network: $0.00 copay for Medicare Covered Preventive Services

When reviewing Tennessee Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

You may be able to find plans in your part of Tennessee that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents

Summary of benefits
Evidence of coverage
Star ratings

Tennessee Counties Served

Anderson Bedford Benton Bledsoe Blount Bradley Campbell Cannon Carroll Carter Cheatham Chester Claiborne Clay co*cke Coffee Crockett Cumberland Davidson Decatur Dekalb Dickson Dyer Fayette Fentress Franklin Gibson Giles Grainger Greene Grundy Hamblen Hamilton Hanco*ck Hardeman Hardin Hawkins Haywood Henderson Henry Hickman Houston Humphreys Jackson Jefferson Johnson Knox Lake Lauderdale Lawrence Lewis Lincoln Loudon Macon Madison Marion Marshall Maury Mcminn Mcnairy Meigs Monroe Montgomery Moore Morgan Obion Overton Perry Pickett Polk Putnam Rhea Roane Robertson Rutherford Scott Sequatchie Sevier Shelby Smith Stewart Sullivan Sumner Tipton Trousdale Unicoi Union Van Buren Warren Washington Wayne Weakley White Williamson Wilson

We represent carriers such as Humana, UnitedHealthcare^®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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