Saint Alphonsus Health Plan Cash Back No Premium 2 (HMO) 2024 Benefit Details for Plan H6910-004-0 in Camas County, ID
Saint Alphonsus Health Plan Cash Back No Premium 2 is a 2024 Medicare Advantage HMO plan, {with_without_pdp} prescription drug coverage.
Delivery of healthcare services and costs are different than in Original Medicare, but this plan option, by Saint Alphonsus Health Plan, may offer extra benefits.
See more 2024 Medicare Advantage Plans available in Camas County, Idaho.
Plan Basics | |
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Plan ID: | H6910 004 0 |
Plan Type: | Local HMO |
Plan Year: | 2024 |
Premium: | $0.00/mo Plus your Medicare Part B premium. |
Health Plan Deductible: | $0.00 |
Out-of-Pocket Maximum: | $3,900/yr |
Part B Reduction: | $100.00/mo |
Drug Plan Benefit: | Not Included |
Rx Gap Coverage: | No |
Supplemental Benefits: | Vision, Hearing |
Availability: | Camas County, ID |
Insured By: | Saint Alphonsus Health Plan |
Summary of Benefits |
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Health Plan Cost Sharing
This Saint Alphonsus Health Plan Medicare Advantage plan has cost-sharing. These are costs you must pay out-of-pocket when you use approved health services.
NOTE: Most preventive services are covered 100% by the plan as a Part B benefit.
The following table summarizes the most common out-of-pocket costs you will incur if you join this plan unless you go out-of-network:
Healthcare Service | Member Cost |
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Doctor Visits (In-Network) | |
Primary: | $0 Copay |
Specialist: | $25 Copay |
Wellness programs (e.g., fitness, nursing hotline): | None |
Preventive care: | $0 Copay |
Foot Care (In-Network) | |
Foot exams and treatment (Medicare-covered): | $25 Copay |
Routine foot care: | Not Covered |
Chiropractic Care (In-Network) | |
Medicare-covered chiropractic care: | $20 Copay Authorization Required |
Routine chiropractic care: | Not Covered |
Emergency Care / Urgent Care | |
Emergency room care: | $90 Copay |
Urgent care: | $30 Copay |
Ground ambulance: | $225 Copay |
Inpatient hospital coverage: | $250.00 per day for days 1 through 4 $0.00 per day for days 5 and beyond |
Outpatient hospital coverage: | $225 Copay |
Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $203.00 per day for days 21 through 56 $0.00 per day for days 57 and beyond |
Optional supplemental benefits: | |
Mental Health Services (In-Network) | |
Outpatient individual therapy visit with a psychiatrist: | $20 Copay |
Outpatient group therapy visit with a psychiatrist: | $20 Copay |
Inpatient hospital - psychiatric: | $250.00 per day for days 1 through 4 $0.00 per day for days 5 and beyond |
Outpatient group therapy visit: | $20 Copay |
Outpatient individual therapy visit: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy visit: | $20 Copay |
Occupational therapy visit: | $20 Copay |
Medical Equipment / Supplies (In-Network) | |
Diabetes supplies: | $0 Copay Authorization Required |
Durable medical equipment (e.g., wheelchairs, oxygen): | 20% Coinsurance Authorization Required |
Prosthetics (e.g., braces, artificial limbs): | 20% Coinsurance |
Diagnostic Procedures / Lab Services / Imaging (In-Network) | |
Diagnostic radiology services (e.g., MRI): | $100 Copay Authorization Required |
Lab services: | $0 Copay Authorization Required |
Outpatient x-rays: | $10 Copay Authorization Required |
Diagnostic tests and procedures: | $10 Copay Authorization Required |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 20% Coinsurance |
Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our Saint Alphonsus Health Plan Cash Back No Premium 2 Summary of Benefits information.
Supplemental Benefits
The following is a summary of the supplemental benefits Saint Alphonsus Health Plan includes with this plan:
Supplemental Healthcare Service | Member Cost |
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Preventive Dental | |
Oral exam (In-Network) | Not Covered |
Fluoride treatment (In-Network) | Not Covered |
Dental x-ray(s) (In-Network) | Not Covered |
Cleaning (In-Network) | Not Covered |
Comprehensive Dental | |
Periodontics (In-Network) | Not Covered |
Non-routine services (In-Network) | Not Covered |
Diagnostic services (In-Network) | Not Covered |
Extractions (In-Network) | Not Covered |
Endodontics (In-Network) | Not Covered |
Restorative services (In-Network) | Not Covered |
Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Not Covered |
Hearing Aids | |
Fitting/evaluation (In-Network) | $0 Copay Limitations Apply |
Hearing aids (In-Network) | Covered Limits may apply |
Hearing exam (In-Network) | $0 Copay |
Vision | Maximum vision benefit: | $225.00 Every year |
Eyeglasses (frames and lenses) (In-Network) | $0 Copay |
Routine eye exam (In-Network) | $0 Copay |
Contact lenses (In-Network) | $0 Copay |
Additional Benefits
None specified.
Prescription Drug Plan Costs & Benefits
This plan does not include a Medicare Part D plan for prescriptions.
CMS Rating Marks for 2024
Each year Medicare rates health plans (Part C) and drug plans (Part D) in several major categories based on a 5-star rating system. These ratings are designed to help you understand the quality of care and service you can expect if you join this Saint Alphonsus Health Plan plan.
CMS Measure | Star Rating |
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2024 Overall 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 | Not enough data available |
Drug Plan Customer Service | |
Complaints and Changes in the Drug Plan | |
Member Experience with the Drug Plan | |
Drug Safety and Accuracy of Drug Pricing |
Additional Medicare Advantage Plan Options
The Medicare Advantage program offers a myriad of options, including these plans:
- Saint Alphonsus Health Plan No Premium
- Saint Alphonsus Health Plan Cash Back No Premium 1
- Saint Alphonsus Health Plan Cash Back No Premium 2
Contact Saint Alphonsus Health Plan
Plan Website: | http://saintalphonsus.org/medicare |
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Formulary Information: | http://www.medigold.com/tools-and-resources/drug-benefits/ |
Pharmacy Information: | Saint Alphonsus Health Plan Pharmacy Page |
Prospective Members: | (800)964-4525 |
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 Advantage program on www.medicare.gov.
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, GlobalHealth, Health Care Service Corporation, Cigna Healthcare, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Scott and White Health Plan now part of Baylor Scott & White Health, UnitedHealthcare(R), and Wellcare.
Citations & References
- Saint Alphonsus Health Plan, http://saintalphonsus.org/medicare, Last Accessed February 20, 2024
- Medicare.gov, "Understanding Medicare Advantage Plans", Last Accessed January 21, 2024
- Medicare.gov, "Compare Original Medicare & Medicare Advantage", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You in Different Formats", Last Accessed February 19, 2024
- Medicare.gov, "Is Your Test, Item, or Service Covered?", Last Accessed June 3, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
About This H6910-004-0 Plan Detail Page
The data on this Saint Alphonsus Health Plan Cash Back No Premium 2 plan detail page is derived from the 2024 Landscape Source Files, Plan Benefit Package, and Medicare Part C and Part D Performance Data published by CMS.
The author interprets these files, and their associated data dictionary, with great care, making every attempt to communicate the data submitted by Saint Alphonsus Health Plan to CMS as clearly and accurately as possible. Given the complexity of the data, the author recommends that all potential enrollees request an official Summary of Benefits from Saint Alphonsus Health Plan, at (800)964-4525, prior to enrollment.