MercyCare Elite for Walworth, WI

MercyCare Elite
Summary Rating:This Medicare drug plan has an average rating of 0.0
Part C Premium:
$79.00
Part D Deductible:$0.00
ICL:$0.00
Mail Order:No
Gap Coverage:No Gap Coverage
LIS:No
Formulary Drugs:2883
Plan ID:H4123-004
Plan Year:2014
Residents of:WI Residents
Plan Type:Local HMO
Summary of Benefits:

Medicare Advantage Plan Summary & Benefits

MercyCare Elite, WI Medicare Advantage PlanMercyCare Elite (H4123-004), Health Maintenance Organization Advantage Plan, Walworth County, WI

MercyCare Elite is a Health Maintenance Organization (HMO) healthcare plan for seniors and other beneficiaries residing in Walworth County, WI. It includes all of the benefits of Original Medicare and may include prescription drug coverage and other extras. The primary benefit of an HMO is that the out-of-pocket costs are lower and more predictable than with other types of plans.

Please note: You must use plan providers to avoid incurring additional costs. You will be responsible for the costs of out of network care. Referrals may be required for all but primary care physician visits.

The health care benefit information provided here is an overview only and not a comprehensive description of available benefits. Additional information about the plan benefits is available from your agent.

Summary of Benefits

When this page was published the Summary of Benefits document for this 2014 health plan was not available. Please Ask an Agent for the Summary of Benefits documentation before choosing this plan.

Monthly Premium

The monthly premium for this health insurance plan in Walworth County is $79.00 plus your monthly Medicare Part B premium. Most Medicare beneficiaries pay the standard monthly Part B premium in addition to their MA or MAPD plan premium. However, some beneficiaries are required to pay slightly higher Part B and Medicare Part D premiums because of their income (over $85,000 per year for singles or $170,000 for married couples), or due to late enrollment penalties.

Part D Prescription Drug Plan Information

This plan includes prescription drug coverage. The formulary (00014449) has a total of 2,883 prescription medications.

If you have Part D assistance, your premium will be adjusted based on your percentage.

Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
  — Drugs per Tier:1733460470220
  — Cost-Sharing in ICP:$0.00$40.00$75.0033% 

The Medicare Part D deductible with this health plan is $0.00. That means you have first dollar coverage.

Maximum Out of Pocket (MOOP) Benefit

The new healthcare law allows for a maximum limit of $6,700 on your out of pocket medical costs for 2014 Medicare Advantage plans. This amount is commonly called the plan MOOP (Maximum Out of Pocket). A plan's MOOP does not include your prescription drugs or the monthly premiums you pay for your health plan. Although the mandatory MOOP limit is $6,700, the Affordable Care Act law allows for a “Voluntary MOOP” that can be as low as $3,400. The MOOP on this plan is $2,950 .

Doctor Visits

Most Medicare health plans require you to make a co-payment (aka, copay) when you visit your primary care physician or a doctor. Here's how this plan works:

  • Pre-authorization rules apply.
  • $0 co-payment for each visit to your primary care physician.
  • $30 co-payment for each visit to a specialist covered by Medicare.

Urgent Care Doctor Visits

Urgent care is the delivery of ambulatory medical care outside of a hospital emergency department on a walk-in basis without a scheduled appointment. Here's how Urgent Care works with this plan:

  • $25 co-payment for urgent care treatment covered by Medicare.
  • When you are to the hospital within 1-day for the same medical condition you pay $0 for the urgent care treatment.

Emergency Care

Emergency care is medical attention for patients with acute illnesses or injuries which require immediate medical attention. Here's how Emergency Care works with this plan:

  • $65 co-payment for emergency room treatments covered by Medicare.
  • Not covered outside the U.S. and its territories except under limited circumstances. Contact plan for details.
  • When you are to the hospital within 1-day for the same medical condition you pay $0 for the emergency room treatment.

Ambulance Service

Most health plans do not cover transportation to and from medical services. The exception, of course, is when you have an emergency or when non-ambulatory. Here's how this plan covers ambulance service:

  • Pre-authorization rules apply.
  • $150 co-payment for ambulance benefits covered by Medicare.

Inpatient Treatment (Hospital Stays)

A patient who is admitted to a hospital or clinic for treatment that requires at least one overnight stay is an inpatient. Most health plans have a tiered cost structure for inpatient treatment. Here's how this plan covers hospital stays:

  • Plan covers 364 days each benefit period.
  • For hospital stay covered by Medicares:
  • Days 1 - 7: $175 co-payment per day.
  • .
  • Days 8 - 90: $0 co-payment per day.
.
  • Plan covers 60 lifetime reserve days. $0 co-payment per lifetime reserve day.
  • $0 co-payment for additional non-Medicare-covered hospital days.
  • Except in the case of an emergency your physician must let the plan know when you are to be admitted into the hospital.
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    This page was last updated on: 10/28/2013

    More Information

    About The Insurer MercyCare Health Plans

    The summary (overall) rating for this plan is 0.0 out of 5 based on reviews from 0 user ratings from the previous year. For more information about the review process, visit http://cms.gov.