Blue Medicare Advantage HMO (HMO) 2024 Benefit Details for Plan H8095-001-0 in Jackson County, IA
Blue Medicare Advantage HMO is a 2024 HMO Medicare Advantage plan {with_without_pdp} prescription drug plan benefits (Part D).
This Wellmark Advantage Health Plan option offers the same basic benefits as Original Medicare, but out-of-pocket costs are different. It may also include additional, valuable benefits not covered by Part A or Part B.
See more Medicare Advantage Plans in Jackson County, Iowa.
Plan Basics | |
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Plan ID: | H8095 001 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: | $3,450/yr |
Part B Reduction: | $0.00/mo |
Drug Plan Benefit: | Enhanced, $0.00 deductible |
Rx Gap Coverage: | No |
Supplemental Benefits: | Vision, Hearing |
Availability: | Jackson County, IA |
Insured By: | Wellmark Advantage Health Plan |
Summary of Benefits |
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Health Plan Cost Sharing
This Wellmark Advantage 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: | $35 Copay |
Wellness programs (e.g., fitness, nursing hotline): | None |
Preventive care: | $0 Copay |
Foot Care (In-Network) | |
Foot exams and treatment (Medicare-covered): | $45 Copay |
Routine foot care: | Not Covered |
Chiropractic Care (In-Network) | |
Medicare-covered chiropractic care: | $20 Copay |
Routine chiropractic care: | Not Covered |
Emergency Care / Urgent Care | |
Emergency room care: | $120 Copay |
Urgent care: | $45 Copay |
Ground ambulance: | $300 Copay |
Inpatient hospital coverage: | $360.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Outpatient hospital coverage: | $200 Copay Authorization Required |
Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $184.00 per day for days 21 through 55 $0.00 per day for days 56 and beyond |
Optional supplemental benefits: | |
Mental Health Services (In-Network) | |
Outpatient individual therapy visit with a psychiatrist: | $35 Copay |
Outpatient group therapy visit with a psychiatrist: | $35 Copay |
Inpatient hospital - psychiatric: | $360.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Outpatient group therapy visit: | $35 Copay |
Outpatient individual therapy visit: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy visit: | $35 Copay |
Occupational therapy visit: | $35 Copay |
Medical Equipment / Supplies (In-Network) | |
Diabetes supplies: | 20% Coinsurance |
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: | $5 Copay Authorization Required |
Outpatient x-rays: | $20 Copay Authorization Required |
Diagnostic tests and procedures: | $100 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 Blue Medicare Advantage HMO Summary of Benefits information.
Supplemental Benefits
The following is a summary of the supplemental benefits Wellmark Advantage 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) | Covered Limits may apply |
Hearing aids (In-Network) | Covered Limits may apply |
Hearing exam (In-Network) | Covered Limits may apply |
Vision | Maximum vision benefit: | Non Specified |
Eyeglasses (frames and lenses) (In-Network) | Covered Limits may apply |
Routine eye exam (In-Network) | Covered Limits may apply |
Contact lenses (In-Network) | Covered Limits may apply |
Additional Benefits
None specified.
Prescription Drug Plan Costs & Benefits
Blue Medicare Advantage HMO includes an enhanced benefit Medicare Part D plan (PDP). Enhanced plans have a higher actuarial value than basic plans. Actuarial value simply refers to the percentage of cost that's covered by the plan.
Prescription Drug Plan Premium
Although the prescription drug plan (Part D) premium is bundled with the total plan cost, some plans have supplemental costs and/or offer low-income subsidy (LIS) assistance. LIS, also known as 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 the prescription drug plan premium details of this plan.
Basic Part D Premium: | -$1.30 |
Supplemental Part D Premium: | $1.30 |
Total Part D Premium: | $0.00 |
Part D Premium with Full LIS Assistance: | $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 Plan Deductible
The Medicare Part D annual deductible with this plan is $0.00. This is the amount you must pay at the pharmacy before Wellmark Advantage Health Plan begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Blue Medicare Advantage HMO has out-of-pocket costs that you must pay when you pick up your prescriptions.
Drug Tier | Preferred | Standard |
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1 (Preferred Generic) | $0.00 copay | $10.00 copay |
2 (Generic) | $10.00 copay | $20.00 copay |
3 (Preferred Brand) | $47.00 copay | $47.00 copay |
4 (Non-Preferred Drug) | $100.00 copay | $100.00 copay |
5 (Specialty Tier) | 33% | 33% |
2024 CMS 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 based on a 5-star rating system. Here are the most recent CMS ratings for Blue Medicare Advantage HMO.
CMS Measure | Star Rating |
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2024 Overall Rating | |
Staying Healthy: Screenings, Tests, Vaccines | Plan too new to be measured |
Managing Chronic (Long Term) Conditions | Plan too new to be measured |
Member Experience with Health Plan | Plan too new to be measured |
Complaints and Changes in Plans Performance | Plan too new to be measured |
Health Plan Customer Service | Plan too new to be measured |
Drug Plan Customer Service | |
Complaints and Changes in the Drug Plan | Plan too new to be measured |
Member Experience with the Drug Plan | Plan too new to be measured |
Drug Safety and Accuracy of Drug Pricing |
Additional Medicare Advantage Plan Options
The Medicare Advantage program offers a myriad of options, including these plans:
Contact Wellmark Advantage Health Plan
Plan Website: | http://www.Wellmarkadvantagehealthplan.com |
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Formulary Information: | http://www.Wellmark.com/Finder-Medicare |
Pharmacy Information: | Wellmark Advantage Health Plan Pharmacy Page |
Prospective Members: | (800)213-3771 |
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
- Wellmark Advantage Health Plan, http://www.Wellmarkadvantagehealthplan.com, Last Accessed February 20, 2024
- 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", Last Accessed February 19, 2024
- Medicare.gov, "What Medicare Covers", Last Accessed February 7, 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 H8095-001-0 Plan Detail Page
The data on this Blue Medicare Advantage HMO 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 Wellmark Advantage 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 Wellmark Advantage Health Plan, at (800)213-3771, prior to enrollment.