Medica Prime Solution Standard (COST) Plan Details for Koochiching County, MN
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*CMS rated this Medica plan (H2450-044-0) 4 (Good) out of 5 stars.
Medica Prime Solution Standard (Cost) is a Medicare Advantage plan with prescription benefits. Eligibility and enrollment periods apply. Online enrollment available.
See more Medicare Advantage Plans in Koochiching County, Minnesota.
Medica Prime Solution Standard Basic Details
| Plan Basics | |
|---|---|
| Plan ID: | H2450-044-0 |
| Plan Type: | Cost |
| Plan Year: | 2025 |
| Premium: | $0.00/mo Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | 5,000.00 /yr (in-network) |
| Part B Reduction: | $0.00/mo |
| Drug Plan Benefit: | Not Included |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | Koochiching County, MN |
| Insured By: | Medica |
| Summary of Benefits |
|---|
Medica Out-of-Pocket Costs
This Medica 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 H2450-044-0.
NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.
Doctor's Office Visits
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | $15 Copay |
| Specialist: | $60 Copay |
Emergency, Urgent, and Inpatient Hospital Coverage
| Service | Enrollee Cost |
|---|---|
| Emergency room care: | $125 Copay |
| Urgent care: | $55 Copay |
| Ground ambulance: | $350 Copay |
| Inpatient hospital care: | $325.00 per day for days 1 through 4 $0.00 per day for days 5 and beyond |
| Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $214.00 per day for days 21 and beyond |
Foot Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Foot Exams and Treatments (Medicare-covered): | $60 Copay |
| Routine Foot Care: | Not Covered |
Chiropractic Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Medicare-covered chiropractic: | $20 Copay |
| Routine chiropractic: | Not Covered |
Mental Health Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | $60 Copay |
| Outpatient group therapy: | $60 Copay |
| Inpatient psychiatric hospital care: | $325.00 per day for days 1 through 4 $0.00 per day for days 5 and beyond |
Rehabilitation Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Physical therapy and speech and language therapy: | $60 Copay |
| Occupational therapy: | $45 Copay |
Medical Equipment and Supplies
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | 20% Coinsurance |
| Durable medical equipment: | 30% Coinsurance |
| Prosthetics: | 30% Coinsurance |
Diagnostics, Lab Services, and Imaging
| Service | Enrollee Cost (in-network) |
|---|---|
| Diagnostic radiology services: | $155 Copay |
| Lab services: | Not Covered |
| Outpatient x-rays: | $60 Copay |
| Diagnostic tests and procedures: | $60 Copay |
Medicare Part B Drugs
| Service | Enrollee Cost (in-network) |
|---|---|
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered): | 20% Coinsurance |
Dental Services
| Service | Member Cost (in-network) |
|---|---|
| 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: | $400.00 (Every year) |
Hearing Aids and Services
| Service | Member Cost (in-network) |
|---|---|
| Fitting/evaluation | Covered Limits may apply |
| Hearing aids | Not Covered |
| Hearing exam | Not Covered |
Vision Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare-covered eye exam | $ to $60 Copay |
| Routine eye exam | Covered Limits may apply |
| Eyewear benefits | None |
Feel free to download our Medica Prime Solution Standard Summary of Benefits information.
Prescription Drug Costs & Benefits
This plan does not include a Medicare Part D plan for prescriptions.
CMS 5-Star Rating Marks
The following table shows the quality ratings for this Medica plan. Each year 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 ratings for Medica Prime Solution Standard .
| CMS Measure | Star Rating |
|---|---|
| 2025 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 | |
| Drug Plan Customer Service | Not enough data available |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| 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:
- Medica Prime Solution Core w/Rx (Cost)
- Medica Prime Solution Premier w/Rx (Cost)
- Medica Prime Solution Thrift (Cost)
- Medica Prime Solution Basic w/Rx 2 (Cost)
- Medica Prime Solution Basic w/Rx (Cost)
- Medica Prime Solution Core (Cost)
- Medica Prime Solution Enhanced (Cost)
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 Medica
| Website: | Medica Plan Page |
|---|---|
| Providers: | Medica Providers Page |
| New Member Health Plan Help: | (800)906-5432 |
| New Member Health Plan TTY: | 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
- Medica, http://medica.com, Last Accessed February 20, 2024
- Medicare.gov, "Your health plan options", Last Accessed February 20, 2024
- Medicare.gov, "How Original Medicare Works", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You Handbook", 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
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.