Plan H5496-014-0: Imperial Giveback (HMO) – 2025 Coverage Details for Riverside County, CA
This page provides coverage, cost, and availability details for Imperial Health Plan of California, Inc.’s H5496-014-0 Medicare Advantage plan for 2025.
See more Medicare Advantage Plans in Riverside County, California.
*CMS rated this Imperial Health Plan of California, Inc. plan (H5496-014-0) 3.5 (Above Average) out of 5 stars.
Imperial Giveback Basic Plan Details
- Plan ID
- H5496-014-0
- Plan Type
- HMO
- Plan Year
- 2025
- Premium
- $0.00/mo
Plus your Medicare Part B premium. - Health Plan Deductible
- $0.00
- Out-of-Pocket Maximum
- 9,350.00 /yr (in-network)
- Part B Reduction
- $0.00/mo
- Drug Plan Benefit
- Basic, $590.00 deductible
- Supplemental Benefits
- Vision, Hearing
- Availability
- Riverside County, CA
- Insured By
- Imperial Health Plan of California, Inc.
| Summary of Benefits |
|---|
Health Plan Out-of-Pocket Costs
This Imperial Health Plan of California, Inc. Part C plan has cost-sharing. These are costs you pay out-of-pocket when you use approved health services. The following table summarizes the most common in-network out-of-pocket costs in plan H5496-014-0.
NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.
Doctor's Office Visits
- Primary
- 20% Coinsurance
- Specialist
- 20% Coinsurance
Prior Authorization Required, Referral Required
Emergency, Urgent, and Inpatient Hospital Coverage
- Emergency room care
- 20% Coinsurance
- Urgent care
- 20% Coinsurance
- Ground ambulance
- 20% Coinsurance
- Inpatient hospital care
- Skilled Nursing Facility
Foot Care
- Foot Exams and Treatments (Medicare-covered)
- 20% Coinsurance
Prior Authorization Required, Referral Required - Routine Foot Care
- Not Covered
Chiropractic Care
- Medicare-covered chiropractic
- 20% Coinsurance
Prior Authorization Required, Referral Required - Routine chiropractic
- Not Covered
Mental Health Services
- Outpatient individual therapy
- 20% Coinsurance
- Outpatient group therapy
- 20% Coinsurance
- Inpatient psychiatric hospital care
Rehabilitation Services
- Physical therapy and speech and language therapy
- 20% Coinsurance
Prior Authorization Required, Referral Required - Occupational therapy
- 20% Coinsurance
Prior Authorization Required, Referral Required
Medical Equipment and Supplies
- Diabetes supplies
- 20% Coinsurance
Prior Authorization Required - Durable medical equipment
- 20% Coinsurance
Prior Authorization Required - Prosthetics
- 20% Coinsurance
Diagnostics, Lab Services, and Imaging
- Diagnostic radiology services
- 20% Coinsurance
Prior Authorization Required, Referral Required - Lab services
- 20% Coinsurance
Prior Authorization Required, Referral Required - Outpatient x-rays
- 20% Coinsurance
Prior Authorization Required, Referral Required - Diagnostic tests and procedures
- 20% Coinsurance
Prior Authorization Required, Referral Required
Medicare Part B Drugs
- Chemotherapy
- 20% Coinsurance
- Other Part B drugs (Medicare-covered)
- 20% Coinsurance
Dental Services
- Medicare Covered Preventive Dental
- Not Covered
- Oral exam
- $0
- Dental x-rays
- $0
- Cleaning
- $0
- Periodontics
- Not Covered
- Endodontics
- Not Covered
- Restorative Services
- Not Covered
- Maximum dental benefit
- $500.00 (Every year)
Hearing Aids and Services
- Fitting/evaluation
- Covered
Limits may apply - Hearing aids
- Covered
Limits may apply - Hearing exam
- Covered
Limits may apply
Vision Services
- Medicare-covered eye exam
- 20% Coinsurance
- Routine eye exam
- Covered
Limits may apply - Eyewear benefits
- None
Prescription Drug Costs & Benefits
Imperial Giveback includes a basic benefit Medicare Part D plan (PDP). Basic plans meet the minimum coverage standards set by the Centers for Medicare & Medicaid Services (CMS). These plans may have higher cost-sharing, deductibles, or limited drug coverage compared to enhanced plans, but they still provide essential prescription drug coverage at a lower premium.
As of 2023, approximately 75% of people on Medicare are enrolled in enhanced plans.
Prescription Drug Premium with Extra Help
Extra Help is a Social Security program that helps people with limited income and resources lower or cut Part D costs. The following table outlines premium assistance details with Extra Help.
| Low Income Premium Subsidy: | ${part_d_lips_amount} |
|---|---|
| Low Income Premium Subsidy CMS Pays: | $0.00 |
| Low Income Subsidy Premium: | $0.00 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Deductible
The Medicare Part D annual deductible with this plan is $590.00. You must pay this amount at the pharmacy before Imperial Health Plan of California, Inc. begins paying its share.
Prescription Drug Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Imperial Giveback has out-of-pocket costs you must pay when you pick up your prescriptions.
| Drug Tier | Retail | Mail Order |
|---|---|---|
| Cost data not available. | ||
| *The Part D deductible does not apply. | ||
CMS 5-Star Rating Marks
Each year the Centers for Medicare & Medicaid Services (CMS) rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories using a 5-star rating system. Here are the most recent CMS ratings for Imperial Giveback .
| CMS Measure | Star Rating |
|---|---|
| 2025 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | Not enough data available |
| 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 | Not enough data available |
| Drug Safety and Accuracy of Drug Pricing |
Additional Plan Options
The Medicare Part C program offers a myriad of HMO, PPO, and PFFS plan options, including these plans:
- Imperial Dynamic Plan (HMO)
- Imperial Traditional (HMO)
- Imperial Giveback (HMO)
- Imperial Courage Plan (HMO)
If you are enrolled in a Part C plan with prescription drug coverage, you cannot be enrolled in a stand-alone Medicare Part D plan, regardless of your chosen insurance company.
You cannot be enrolled in a Part C health plan and simultaneously hold Medicare Supplement Insurance (Medigap). Medicare Supplement plans are only compatible with Medicare Parts A and B.
Contact Us About Imperial Health Plan of California, Inc.
| Website: | Imperial Health Plan of California, Inc. Plan Page (opens in new tab) |
|---|---|
| Providers: | Imperial Health Plan of California, Inc. Providers Page (opens in new tab) |
| Formulary: | Imperial Health Plan of California, Inc. Formulary Page (opens in new tab) |
| Pharmacy: | Imperial Health Plan of California, Inc. Pharmacy Page (opens in new tab) |
| New Member Health Plan Help: | (800)838-5914 |
| New Member Health Plan TTY: | 711 |
| New Member Part D Help: | (800)838-5914 |
| New Member Part D TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Part C program on www.medicare.gov or call 1-800-MEDICARE.
Citations & References
- Imperial Health Plan of California, Inc., http://www.imperialhealthplan.com, Last Accessed March 1, 2025
- Medicare.gov, "Understanding Medicare Advantage Plans", Last Accessed January 21, 2024
- Medicare.gov, "Your Medicare coverage choices", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You Handbook", Last Accessed March 19, 2025
- Medicare.gov, "Your Medicare Coverage", Last Accessed March 19, 2025
- CMS.gov, Landscape Source Files, Last Accessed March 15, 2025
- CMS.gov, Medicare Part C & D Performance, Last Accessed March 15, 2025
- CMS.gov, Plan Benefits Package,Last Accessed March 15, 2025
Research Note: This content is based on independent analysis of CMS data by David Bynon, Medicare analyst and founder of MedicareWire.
For details on how this plan was analyzed and constructed using CMS data, see our Medicare Plan Research Methodology.
Disclaimer: MedicareWire does not endorse or rank Medicare plans. Plan information is provided for educational and research purposes only and may not reflect the most current data available from CMS or the plan provider.
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