CCA Medicare Value (PPO) 2024 Benefit Details for Plan H9876-002-0 in Kent County, RI
CCA Medicare Value is a 2024 Medicare Advantage PPO plan, {with_without_pdp} prescription drug coverage.
Delivery of healthcare services and costs are different than in Original Medicare, but this plan option, by CCA Health Rhode Island, may offer extra benefits.
See more 2024 Medicare Advantage Plans available in Kent County, Rhode Island.
Plan Basics | |
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Plan ID: | H9876 002 0 |
Plan Type: | Local PPO |
Plan Year: | 2024 |
Premium: | $29.00/mo Plus your Medicare Part B premium. |
Health Plan Deductible: | $0.00 |
Out-of-Pocket Maximum: | $4,500/yr |
Part B Reduction: | $0.00/mo |
Drug Plan Benefit: | Enhanced, $545.00 deductible |
Rx Gap Coverage: | Yes |
Supplemental Benefits: | Vision, Hearing |
Availability: | Kent County, RI |
Insured By: | CCA Health Rhode Island |
Summary of Benefits |
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Health Plan Cost Sharing
This CCA Health Rhode Island 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 |
Specialist: | $30 Copay |
Wellness programs (e.g., fitness, nursing hotline): | None |
Preventive care: | $0 |
Foot Care (In-Network) | |
Foot exams and treatment (Medicare-covered): | $30 Copay Authorization Required |
Routine foot care: | $30 Copay Authorization Required |
Chiropractic Care (In-Network) | |
Medicare-covered chiropractic care: | $20 Copay |
Routine chiropractic care: | Not Covered |
Emergency Care / Urgent Care | |
Emergency room care: | $90 Copay |
Urgent care: | $30 Copay |
Ground ambulance: | $250 Copay |
Inpatient hospital coverage: | $200.00 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 $180.00 per day for days 21 through 45 $0.00 per day for days 46 and beyond |
Optional supplemental benefits: | |
Mental Health Services (In-Network) | |
Outpatient individual therapy visit with a psychiatrist: | $0 |
Outpatient group therapy visit with a psychiatrist: | $0 |
Inpatient hospital - psychiatric: | $300.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Outpatient group therapy visit: | $0 |
Outpatient individual therapy visit: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy visit: | $15 Copay Authorization Required |
Occupational therapy visit: | $15 Copay Authorization Required |
Medical Equipment / Supplies (In-Network) | |
Diabetes supplies: | $0 |
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): | $150 Copay Authorization Required |
Lab services: | $0 |
Outpatient x-rays: | $0 |
Diagnostic tests and procedures: | $0 |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 20% Coinsurance |
Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our CCA Medicare Value Summary of Benefits information.
Supplemental Benefits
The following is a summary of the supplemental benefits CCA Health Rhode Island 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: | $400.00 Every year |
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
CCA Medicare Value 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: | $29.00 |
Supplemental Part D Premium: | $0.00 |
Total Part D Premium: | $29.00 |
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 $545.00. This is the amount you must pay at the pharmacy before CCA Health Rhode Island begins paying its share.
NOTE: The deductible does not apply to one or more drug tiers in this plan (see "Prescription Drug Plan Out-of-Pocket Costs" below).
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, CCA Medicare Value 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) | N/A | $0.00 copay (deductible does not apply) |
2 (Generic) | N/A | $0.00 copay |
3 (Preferred Brand) | N/A | $47.00 copay |
4 (Non-Preferred Brand) | N/A | $100.00 copay |
5 (Specialty Tier) | N/A | 25% |
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 CCA Health Rhode Island plan.
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 | Plan too new to be measured |
Additional Medicare Advantage Plan Options
The Medicare Advantage program offers a myriad of options, including these plans:
Contact CCA Health Rhode Island
Plan Website: | http://ccahealthri.org/become-a-member |
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Formulary Information: | https://www.commonwealthcarealliance.org/members/pharmacy-program |
Pharmacy Information: | CCA Health Rhode Island Pharmacy Page |
Prospective Members: | (866)275-1222 |
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
- CCA Health Rhode Island, http://ccahealthri.org/become-a-member, 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 in Different Formats", Last Accessed February 19, 2024
- Medicare.gov, "Your Medicare Coverage", Last Accessed April 11, 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 H9876-002-0 Plan Detail Page
The data on this CCA Medicare Value 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 CCA Health Rhode Island 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 CCA Health Rhode Island, at (866)275-1222, prior to enrollment.