2024 Champion Select C-SNP: H6170-003-0 for Orange County, CA
What is Plan H6170-003-0 by Champion Health Plans?
Champion Select is a C-SNP Medicare Advantage plan, by Champion Health Plans, for 2024. It has a HMO provider network. Delivery of healthcare services and costs are significantly different than in Original Medicare, and the plan offers additional benefits that are not included with Medicare Part A and Part B.
You must meet all qualification requirements to join this C-SNP plan.
Plan Basics | |
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Plan ID: | H6170-003-0 |
Plan Type: | HMO |
Plan Year: | 2024 |
Premium: | $41.00/mo Plus your Part B premium. |
Health Plan Deductible: | $0.00 |
Out-of-Pocket Maximum: | /yr |
Part B Reduction: | $0.00/mo |
Drug Plan Benefit: | Enhanced $0.00 deductible |
Rx Gap Coverage: | {gap} |
Supplemental Benefits: | Vision, Hearing |
Availability: | Orange County, CA |
Insured By: | Champion Health Plans |
Summary of Benefits |
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Health Plan Costs & Benefits
Champion Select is a Health Maintenance Organization (HMO) plan. HMO plan members usually receive health care services through the plan’s local network of providers. Referrals are almost always required to see a specialist and other providers. However, Champion Select does allow out-of-network care for emergencies and out-of-area dialysis.
The following table is a summary of the most common out-of-pocket costs you will incur if you join this Champion Health Plans plan:
Healthcare Service | Member Cost |
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Doctor Visits (In-Network) | |
Primary: | $0 Copay |
Specialist: | $0 Copay Authorization Required |
Wellness programs (e.g., fitness, nursing hotline): | |
Preventive care: | $0 Copay |
Foot Care (In-Network) | |
Foot exams and treatment (Medicare-covered): | $0 Copay Authorization Required, Referral Required |
Routine foot care: | $0 |
Chiropractic Care (In-Network) | |
Medicare-covered chiropractic care: | $0 Copay |
Routine chiropractic care: | $0 Copay |
Emergency Care / Urgent Care | |
Emergency room care: | $100 Copay |
Urgent care: | $0 Copay |
Ground ambulance: | $125 Copay |
Inpatient hospital coverage: | $0.00 per day for days 1 through 90 |
Outpatient hospital coverage: | $0 Copay Authorization Required, Referral Required |
Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $196.00 per day for days 21 and beyond |
Optional supplemental benefits: | Not Covered |
Mental Health Services (In-Network) | |
Outpatient individual therapy visit with a psychiatrist: | $0 Copay |
Outpatient group therapy visit with a psychiatrist: | $0 Copay |
Inpatient hospital - psychiatric: | $100.00 per day for days 1 through 10 $0.00 per day for days 11 through 60 $329.00 per day for days 61 and beyond |
Outpatient group therapy visit: | $0 Copay |
Outpatient individual therapy visit: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy visit: | $0 Copay Authorization Required, Referral Required |
Occupational therapy visit: | $0 Copay Authorization Required, Referral Required |
Medical Equipment / Supplies (In-Network) | |
Diabetes supplies: | $0 Copay |
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): | $0 Copay Authorization Required |
Lab services: | $0 Copay Authorization Required, Referral Required |
Outpatient x-rays: | $0 Copay Authorization Required |
Diagnostic tests and procedures: | $0 Copay Authorization Required, Referral Required |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 20% Coinsurance |
Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our Champion Select Summary of Benefits information.
Supplemental Health Plan Benefits (H6170-003-0)
The following is a summary of the supplemental benefits Champion Health Plans 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 | |
Fitting/evaluation (In-Network) | $0 Copay |
Hearing aids (In-Network) | Covered Limits may apply |
Hearing exam (In-Network) | $0 Copay |
Vision | Maximum vision benefit: | $335.00 Every year |
Eyeglasses (frames and lenses) (In-Network) | $0 Copay |
Routine eye exam (In-Network) | $0 Copay |
Contact lenses (In-Network) | Not Covered |
Additional Supplemental Benefits
None specified.
Prescription Drug Plan Costs & Benefits
Champion Select 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. The following table outlines the prescription drug plan premium details of this plan.
Basic Part D Premium: | $41.00 |
Supplemental Part D Premium: | $0.00 |
Total Part D Premium: | $41.00 |
Part D Premium with Full 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 Champion Health Plans begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Champion Select has out-of-pocket costs that you must pay when you pick up your prescriptions. The following table shows you those costs.
Drug Tier | Preferred | Standard |
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1 (Preferred Generic) | N/A | $0.00 copay |
2 (Generic) | N/A | 25% |
3 (Preferred Brand) | N/A | 25% |
4 (Non-Preferred Brand) | N/A | 25% |
5 (Specialty Tier) | N/A | 25% |
6 (Select Care Drugs) | N/A | $0.00 copay |
CMS 5-Star Rating Marks
Each year CMS rates Medicare Special Needs Plans in nine broad categories based on a 5-star system. The table below shows the quality ratings for this Champion Health Plans 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 | Plan too new to be measured |
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 |
How to Qualify to Enroll in
Champion Select
To be eligible to enroll in Champion Select, you must meet these requirements:
- You are eligible for Medicare;
- You live in Orange County (the plan’s service area); and
- You have been diagnosed with one or more severe or disabling chronic conditions.
A disabiling chronic condition (disease) is one that lasts one or more years and requires ongoing medical attention and/or limits activities of daily living. They include:
- Autoimmune disorders
- End-stage renal disease
- Cancer
- Cardiovascular disorders
- Hematologic disorders
- HIV/AIDS
- Chronic heart failure
- Chronic lung disorders
- Neurologic disorders
- Dementia
- Diabetes
- End-stage liver disease
- Neurologic disorders
- Stroke
- Mental health conditions
This plan is for individuals with dialysis Services requiring dialysis (any mode of dialysis).
Additional C-SNP Plan Options
Here are some additional Medicare SNP plans that might be worth reviewing:
Contact Champion Health Plans
Plan Website: | http://www.ChampionHealthPlan.com |
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Formulay Information: | http://ChampionHMO.com |
Pharmacy Information: | Champion Health Plans Pharmacy Page |
Prospective Members: | (844)728-5730 |
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
- Champion Health Plans, http://www.ChampionHealthPlan.com, Last Accessed October 13, 2023
- Medicaid.gov, "Medicaid & CHIP in California", Last Accessed January 4, 2024
- CMS.gov, "Chronic Condition Special Needs Plans (C-SNPs)", Last Accessed January 20, 2023
- CMS.gov, Landscape Source Files, Last Accessed January 2, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed January 2, 2024
- CMS.gov, Plan Benefits Package, Last Accessed January 3, 2024