Wellcare No Premium (HMO) 2024 Benefit Details for Plan H1215-002-0 in Lincoln County, NE
Wellcare No Premium is a HMO Medicare Advantage plan, {with_without_pdp} Part D prescription drug benefits, available in 2024.
This health plan, from Wellcare, includes all Original Medicare benefits, and may offer extra services, but out-of-pocket costs are different.
See more Lincoln County, Nebraska Medicare Advantage Plans.
Plan Basics | |
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Plan ID: | H1215 002 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: | $3,600/yr |
Part B Reduction: | $0.00/mo |
Drug Plan Benefit: | Enhanced, $0.00 deductible |
Rx Gap Coverage: | No |
Supplemental Benefits: | Dental, Vision, Hearing |
Availability: | Lincoln County, NE |
Insured By: | Wellcare |
Summary of Benefits |
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Health Plan Cost Sharing
This Wellcare 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 Authorization Required |
Wellness programs (e.g., fitness, nursing hotline): | None |
Preventive care: | $0 Copay |
Foot Care (In-Network) | |
Foot exams and treatment (Medicare-covered): | $25 Copay Authorization Required |
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: | $135 Copay |
Urgent care: | $35 Copay |
Ground ambulance: | $300 Copay |
Inpatient hospital coverage: | $375.00 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 $203.00 per day for days 21 through 40 $0.00 per day for days 41 and beyond |
Optional supplemental benefits: | |
Mental Health Services (In-Network) | |
Outpatient individual therapy visit with a psychiatrist: | $40 Copay |
Outpatient group therapy visit with a psychiatrist: | $40 Copay |
Inpatient hospital - psychiatric: | $370.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Outpatient group therapy visit: | $40 Copay |
Outpatient individual therapy visit: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy visit: | $25 Copay Authorization Required |
Occupational therapy visit: | $25 Copay Authorization Required |
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): | $250 Copay Authorization Required |
Lab services: | $50 Copay Authorization Required |
Outpatient x-rays: | $0 Copay Authorization Required |
Diagnostic tests and procedures: | $30 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 Wellcare No Premium Summary of Benefits information.
Supplemental Benefits
The following is a summary of the supplemental benefits Wellcare includes with this plan:
Supplemental Healthcare Service | Member Cost |
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Preventive Dental | Maximum dental benefit: | Non Specified |
Oral exam (In-Network) | Covered |
Fluoride treatment (In-Network) | Covered |
Dental x-ray(s) (In-Network) | Covered |
Cleaning (In-Network) | Covered |
Comprehensive Dental | |
Periodontics (In-Network) | Covered |
Non-routine services (In-Network) | Covered |
Diagnostic services (In-Network) | Covered |
Extractions (In-Network) | Covered |
Endodontics (In-Network) | Covered |
Restorative services (In-Network) | Covered |
Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Covered |
Hearing Aids | |
Fitting/evaluation (In-Network) | $0 Copay Authorization Required |
Hearing aids (In-Network) | Covered Limits may apply |
Hearing exam (In-Network) | $0 Copay Authorization Required |
Vision | Maximum vision benefit: | $200.00 Every year |
Eyeglasses (frames and lenses) (In-Network) | $0 Copay |
Routine eye exam (In-Network) | $0 Copay Authorization Required |
Contact lenses (In-Network) | $0 Copay |
Additional Benefits
None specified.
Prescription Drug Plan Costs & Benefits
Wellcare No Premium 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: | -$7.50 |
Supplemental Part D Premium: | $7.50 |
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 Wellcare begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Wellcare No Premium 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 | $0.00 copay |
2 (Generic) | $4.00 copay | $9.00 copay |
3 (Preferred Brand) | $42.00 copay | $47.00 copay |
4 (Non-Preferred Drug) | 50% | 50% |
5 (Specialty Tier) | 33% | 33% |
6 (Select Care Drugs) | $0.00 copay | $0.00 copay |
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 Wellcare No Premium.
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 | |
Member Experience with Health Plan | |
Complaints and Changes in Plans Performance | |
Health Plan Customer Service | Plan too new to be measured |
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:
Contact Wellcare
Plan Website: | http://www.wellcare.com/NE |
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Formulary Information: | http://www.wellcare.com/NE |
Pharmacy Information: | Wellcare Pharmacy Page |
Prospective Members: | (844)917-0175 |
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
- Wellcare, http://www.wellcare.com/NE, Last Accessed February 20, 2024
- Medicare.gov, "Medicare Advantage Plans cover all Medicare services", Last Accessed February 20, 2024
- Medicare.gov, "How Original Medicare Works", 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 H1215-002-0 Plan Detail Page
The data on this Wellcare No Premium 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 Wellcare 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 Wellcare, at (844)917-0175, prior to enrollment.