Memorial Hermann Advantage (HMO) Harris County, Texas Medicare Advantage Plan
Memorial Hermann Advantage, by Memorial Hermann Health Plan, is a 2023 Medicare Advantage HMO plan for Medicare beneficiaries living in Harris County, Texas. Delivery of healthcare services and costs are different than in Original Medicare, but the plan may offer additional benefits.
Key Takeaways
- Memorial Hermann Advantage is a Medicare Advantage Health Maintenance Organization (HMO) plan.
- It must provide all of the same hospital and medical benefits as Medicare Part A and Part B, however, costs may be different.
- It has additional benefits not included in Medicare Part A and Part B, including prescription drug coverage.
- If you join this Memorial Hermann Health Plan Medicare Advantage plan it will replace your Medicare Part A and Part B coverage. Except in the event of an emergency, you must use the Memorial Hermann Health Plan provider network in Harris County, Texas.
- The plan's monthly premium is $0.00, which does not include your monthly Medicare Part B premium.
- This plan does not offer a Medicare Part B premium reduction (no giveback benefit).
- The health plan does not have a deductible.
- The plan's out-of-pocket costs are different than Original Medicare (See: "Health Plan Costs & Benefits" below), but the plan includes an out-of-pocket maximum of $3,400 per year (in-network).
- Memorial Hermann Advantage includes a Part D prescription drug plan for prescription medication coverage. There is no annual deductible. Cost sharing begins with your first prescription.
- This plan's Part D Initial Coverage Limit is $4,430 (standard).
- It offers the following supplemental benefits: Dental, Hearing (limitations apply, see below).
| Plan Basics | |
|---|---|
| Plan ID: | H7115-001-0 |
| Plan Type: | Local HMO |
| Plan Year: | 2023 |
| Premium: | $0.00/mo Plus your Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | $3,400/yr |
| Part B Reduction: | $0.00/mo |
| Drug Plan Benefit: | Enhanced, $0.00 deductible |
| Rx Gap Coverage: | Yes |
| Supplemental Benefits: | Dental, Hearing |
| Availability: | Harris County, TX |
| Insured By: | Memorial Hermann Health Plan |
WARNING: It is not uncommon for a private health plan, like Memorial Hermann Advantage, to have higher hospitalization costs than Original MedicareOriginal Medicare is private fee-for-service health insurance for people on Medicare. It has two parts. Part A is hospital coverage. Part B is medical coverage.. For this reason, it is important to carefully consider your personal needs before you enroll. Our free Summary of Benefits PDF download will help you compare this plan.
Health Plan Costs & Benefits
PremiumsA premium is an amount that an insurance policyholder must pay for coverage. Premiums are typically paid on a monthly basis. In the federal Medicare program, there are four different types of premiums. , deductiblesA deductible is an amount a beneficiary must pay for their health care expenses before the health insurance policy begins to pay its share., and copays vary widely from plan to plan. It is very important to compare costs and apply them to your personal financial and healthcare needs.
Monthly Premium
Memorial Hermann Advantage's total monthly premium in Harris County is $0.00. This includes your prescription coverage, as well. Plus, you must continue to pay your monthly Medicare Part B premiumThe Medicare Part B premium is the monthly charge paid by beneficiaries for their outpatient medical care, services, and supplies. A beneficiary's premium may be uplifted by an IRMAA surcharge if their income is above....
Some Medicare Advantage plansMedicare Advantage (MA), also known as Medicare Part C, are health plans from private insurance companies that are available to people eligible for Original Medicare (Medicare Part A and Medicare Part B). include a monthly Part B premium reduction, also known as the Medicare give back. This plan's Part B premium reduction is $0.00. The monthly premium does not include the plan's supplemental premium for add-on benefits (if available).
Annual Deductible
Memorial Hermann Advantage's annual health plan deductible is $0.00. This does not include the deductible for the prescription drug plan (if any), which is detailed below.
Maximum Out-of-Pocket Limit
The Maximum Out-of-Pocket (MOOP) with this Memorial Hermann Health Plan plan is $3,400. Unlike Original Medicare, Medicare Advantage plans must set an annual Maximum Out-of-Pocket (MOOP) limit on inpatient and outpatient healthcare services. Once you reach this amount of spending on your copaymentsA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service., all of your Medicare Part AMedicare Part A is hospital coverage for Medicare beneficiaries. It covers inpatient care in hospitals and skilled nursing facilities. It also covers limited home healthcare services and hospice care. and Part B services will be covered at no additional charge for the remainder of the year. MOOP does not include monthly premiums, prescriptions, or other extra benefits.
Health Plan Out-of-Pocket Costs
The following table is a summary of the most common out-of-pocket costsOut-of-Pocket Costs for Medicare are the remaining costs that are not covered by the beneficiary's health insurance plan. These costs can come from the beneficiary's monthly premiums, deductibles, coinsurance, and copayments. you will incur if you join this Memorial Hermann Health Plan plan:
| Healthcare Service | Member Cost |
|---|---|
| Health plan deductible | $0 |
| Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | $3,400 In-networkDoctors, hospitals, pharmacies, and other healthcare providers that agree to health plan members' services and supplies at a set price are in-network providers. With some health plans, your care is only covered if you get... |
| Doctor Visits | |
| Specialist | $25 copay per visit |
| Wellness programs (e.g., fitness, nursing hotline) | Covered |
| Preventive care | $0 copay |
| Mental Health Services | |
| Inpatient hospital - psychiatric | $350 per stay (authorization required) |
| Outpatient group therapy visit | $0 copay |
| Outpatient group therapy visit with a psychiatrist | $25 copay |
| Outpatient individual therapy visit with a psychiatrist | $25 copay |
| Rehabilitation Services | |
| Occupational therapy visit | $20 copay |
| Medical Equipment / Supplies | |
| Durable medical equipmentDurable medical equipment (DME) is equipment that is designed to last and can be used repeatedly. It is suitable for home use and includes wheelchairs, oxygen equipment, and hospital beds. (e.g., wheelchairs, oxygen) | 20% coinsuranceCoinsurance is a percentage of the total you are required to pay for a medical service. per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (authorization required) |
| Diagnostic Procedures / Lab Services / Imaging | |
| Lab services | $0 copay |
| Diagnostic tests and procedures | $25 copay |
| Diagnostic radiology services (e.g., MRI) | $150 copay (authorization required) |
| Medicare Part BMedicare Part B is medical coverage for people with Original Medicare benefits. It covers doctor visits, preventative care, tests, durable medical equipment, and supplies. Medicare Part B pays 80 percent of most medically necessary healthcare services. Drugs | |
| Other Part B drugs | 20% coinsurance (authorization required) |
| Foot Care (podiatry Services) | |
| Routine foot care | Not covered |
| Hearing | |
| Fitting/evaluation | $0 copay |
| Hearing aids | $0 copay (limits may apply) |
| Preventive Dental | |
| Dental x-ray(s) | 0-20% coinsurance (limits may apply) |
| Fluoride treatment | 0-20% coinsurance (limits may apply) |
| Cleaning | 0-20% coinsurance (limits may apply) |
| Comprehensive Dental | |
| Endodontics | 20-50% coinsurance (limits may apply) |
| Diagnostic services | 0-20% coinsurance (limits may apply) |
| Non-routine services | 20-50% coinsurance (limits may apply) |
| Prosthodontics, other oral/maxillofacial surgery, other services | 50% coinsurance (limits may apply) |
| Restorative services | 20-50% coinsurance (limits may apply) |
| Periodontics | 20-50% coinsurance (limits may apply) |
| Vision | |
| Eyeglass frames | $0 copay (limits may apply) |
| Contact lenses | $0 copay (limits may apply) |
| Upgrades | $0 copay (limits may apply) |
| Eyeglass lenses | $0 copay (limits may apply) |
| Eyeglasses (frames and lenses) | $0 copay (limits may apply) |
| Other | Not covered |
| Emergency Care / Urgent Care | |
| Urgent care | $25 copay per visit (always covered) |
| Ground ambulance | $250 copay |
| Inpatient hospital coverage | $350 per stay |
| Outpatient hospital coverage | $200 copay per visit |
| Skilled Nursing Facility | $0 per day for days 1 through 20 $125 per day for days 21 through 100 |
| Optional supplemental benefits | No |
Feel free to download our Memorial Hermann Advantage Summary of Benefits information.
Prescription Drug Plan Costs & Benefits
Memorial Hermann Advantage includes an enhanced benefit Medicare Part DMedicare Part D plans are an option Medicare beneficiaries can use to get prescription drug coverage. Part D plans provide cost-sharing on covered medications in four different phases: deductible, initial coverage, coverage gap, and catastrophic. Each... 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.
Enhanced plans generally have higher monthly premiums than basic benefit plans but offer more benefits. For example, many enhanced PDPs do not have an annual deductible, may offer additional coverage during the coverage gap (aka, "donut hole"), and may have a broader list of supported drugs, known as a formularyA formulary is a list of prescription drugs covered by a prescription drug plan or another insurance plan offering prescription drug benefits. Medications not on a plan's formulary are generally not covered.. Some enhanced PDPs even cover excluded drugs. It's important to remember that benefits vary from plan to 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 subsidySocial Security's Low-Income Subsidy (LIS) program helps Medicare beneficiaries pay for their Medicare Part D prescription drugs by paying some of the costs. Also known as "Extra Help", beneficiaries who qualify for LIS receive premium... (LIS) assistance. The following table outlines the prescription drug plan premium details of this plan.
| Basic Part D Premium: | $0.00 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $0.00 |
| Part D Premium with Full LIS Assistance: | $0.00 |
| Part D Premium with 75% LIS Assistance: | $0.00 |
| Part D Premium with 50% LIS Assistance: | $0.00 |
| Part D Premium with 25% LIS Assistance: | $0.00 |
For more information about the Low-Income Subsidy (aka, "Extra Help") program, 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 Memorial Hermann Health Plan begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Memorial Hermann Advantage has copayments (a fixed dollar amount) and/or coinsurances (a percentage amount) that you must pay when you pick up your prescriptions. The following table shows you those costs.
| Tier | Preferred | Standard |
|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $10.00 copay |
| 2 (Generic) | $5.00 copay | $18.00 copay |
| 3 (Preferred Brand) | $39.00 copay | $47.00 copay |
| 4 (Non-Preferred Drug) | $92.00 copay | $100.00 copay |
| 5 (Specialty Tier) | 33% | 33% |
| 6 (Select Care Drugs) | $0.00 copay | $8.00 copay |
CMS Rating Marks and Our Review
This Medicare Advantage HMO plan is way better than average. Here's how we can make this claimA request for payment that you submit to Medicare or other health insurance when you get items and services that you think are covered.. Staying healthy is the best way to save money on health care, and Memorial Hermann Advantage does a good job keeping its members in top health through preventive care, including screenings, tests, and vaccines. When it comes to helping members manage their chronic health conditions, this plan does an average job. Medicare beneficiaries enrolled in this Memorial Hermann Health Plan plan enjoy a good member experience. When it comes to complaints and changes in performance, this plan gets the highest marks. This plan's customer service rating is below average.
Memorial Hermann Advantage offers some dental and hearing benefits, but not vision. With no additional monthly premium, this plan can save you money if you're healthy. Memorial Hermann Advantage has a moderate maximum out-of-pocket (MOOP) limit of $3,400 per year, which does not include prescriptions. With this MOOP, you're in the same range as Original Medicare for a 5-day stay in the hospital. With no annual deductible, members of this health plan have first dollar coverage, which is comforting on a fixed budget.
Each year Medicare rates health plans (Part C) and drug plans (Part D) in several major categories. These ratings are designed to help you understand the quality of care and service you can expect if you join this plan:
| CMS Measure | Star Rating |
|---|---|
| 2023 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 | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
Additional HMO Medicare Advantage Plan Options
Here are some additional Medicare Advantage plans (HMOs) that might be worth reviewing:
- KelseyCare Advantage Silver
- Humana Gold Plus H0028-042
- Blue Cross Medicare Advantage Value
- Wellcare No Premium
- Wellcare Assist
Contact Memorial Hermann Health Plan
| Plan Website: | http://healthplan.memorialhermann.org/medicare |
|---|---|
| Formulay Information: | http://healthplan.memorialhermann.org/medicare |
| Pharmacy Information: | Memorial Hermann Health Plan Pharmacy Page |
| Prospective Members: | (866)434-1282 |
| TTY Users: | (711)- |
If you qualify for Medicare 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.
Citations & References
- Memorial Hermann Health Plan, http://healthplan.memorialhermann.org/medicare, Last Accessed October 15, 2021
- Medicare.gov, "How Do Medicare Advantage Plans Work", Last Accessed June 28, 2021
- Medicare.gov, "Your Medicare Choices", Last Accessed March 17, 2022
- Medicare.gov, "Medicare & You in Different Formats", Last Accessed November 1, 2021
- Medicare.gov, "Your Medicare Coverage", Last Accessed September 11, 2021
- CMS.gov, Landscape Source Files, Last Accessed October 26, 2021
- CMS.gov, Medicare Part C & D Performance, Last Accessed October 6, 2021
- CMS.gov, Plan Benefits Package, Last Accessed October 4, 2021
The Medicare Advantage plan information on this page was last updated on .