Wellcare Dual Access Open (D-SNP PPO) A 2022 Suffolk County, New York Medicare Advantage Special Needs Plan
Wellcare Dual Access Open is a D-SNP Medicare Advantage Special Needs Plan (PPO), from Wellcare, that's available in Suffolk County, New York. It offers all of the same basic benefits as Original Medicare, plus some additional benefits that 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 do not cover, but 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. are different.
Key Takeaways
- This is a Medicare Special Needs Plan, with a PPO provider network, exclusively for people with Medicare and MedicaidMedicaid is a public health insurance program that provides health care coverage to low-income families and individuals in the United States. benefits (dual-eligibleDual-eligible beneficiaries are those who receive both Medicare and Medicaid benefits. It includes beneficiaries enrolled in Medicare Part A and/or Part B while receiving full Medicaid and/or financial assistance through a Medicare Savings Program....).
- This is a zero-dollar D-SNP cost-sharing plan. Members have no copays when they use Medicare-approved healthcare services.
- To qualify, you must live in Suffolk County and have both Medicare Part A and Part B. Plus, you must qualify for full Medicaid.
- Wellcare Dual Access Open includes a 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... prescription drug plan.
- The annual Part D deductible is $480.00. You pay this amount before cost-sharing begins.
- If you qualify for the Social Security "Extra Help" program you can get financial assistance to help pay your Medicare Part D monthly premium, annual deductible, and prescription copaymentsA copayment, also known as a copay, is a set dollar amount you are required to pay for a medical service..
- Wellcare Dual Access Open provides the same coverage benefits as Medicare Part A and Part B (Original Medicare) and includes some extra benefits not covered by Original Medicare.
- If you are not qualifed to enroll, one of the traditional 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.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). available in Suffolk County, New York might be your best option.
| Plan Basics | |
|---|---|
| Plan ID: | H2775-112-0 |
| Plan Type: | D-SNP |
| Network Type: | PPO |
| Plan Year: | 2022 |
| Premium: | $37.30/mo Plus your Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | $5,150 In and Out-of-network $3,450 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... |
| Drug Plan Benefit: | Enhanced $480.00 deductible |
| Rx Gap Coverage: | No Gap Coverage |
| Supplemental Benefits: | Dental, Vision, Hearing |
| Availability: | Suffolk County, New York |
| Insured By: | Wellcare |
Health Plan Costs & Benefits
Wellcare Dual Access Open is a Preferred Provider Organization (PPO) plan. PPO plan members usually use in-network healthcare providers but can go out of network when necessary. However, visits to non-network providers could cost significantly more.
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
Wellcare Dual Access Open's total monthly premium in Suffolk County is $37.30. 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....
Annual Deductible
Wellcare Dual Access Open'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 Wellcare plan is $5,150 in and out-of-network $3,450 in-network. 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 copayments, all of your Medicare Part A 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 costs you will incur if you join this Wellcare plan:
| Healthcare Service | Member Cost |
|---|---|
| Health plan deductible | $0 |
| Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | $5,150 In and Out-of-network $3,450 In-network |
| Doctor Visits | |
| Primary (Out-of-Net) | 20% coinsuranceCoinsurance is a percentage of the total you are required to pay for a medical service. per visit |
| Specialist (Out-of-Net) | 20% coinsurance per visit (authorization required) |
| Specialist (In-Network) | $0 copay (authorization required) |
| Wellness programs (e.g., fitness, nursing hotline) | Covered |
| Preventive care | $0 copay |
| Mental Health Services | |
| Outpatient group therapy visit with a psychiatrist (In-Network) | $0 copay (authorization required) |
| Outpatient group therapy visit with a psychiatrist (Out-of-Net) | 20% coinsurance (authorization required) |
| Outpatient individual therapy visit (In-Network) | $0 copay (authorization required) |
| Outpatient individual therapy visit with a psychiatrist (Out-of-Net) | 20% coinsurance (authorization required) |
| Outpatient individual therapy visit with a psychiatrist (In-Network) | $0 copay (authorization required) |
| Outpatient individual therapy visit (Out-of-Net) | 20% coinsurance (authorization required) |
| Inpatient hospital - psychiatric (In-Network) | $0 copay (authorization required) |
| Outpatient group therapy visit (In-Network) | $0 copay (authorization required) |
| Outpatient group therapy visit (Out-of-Net) | 20% coinsurance (authorization required) |
| Rehabilitation Services | |
| Occupational therapy visit (In-Network) | $0 copay (authorization required) |
| Occupational therapy visit (Out-of-Net) | 20% coinsurance (authorization required) |
| Physical therapy and speech and language therapy visit (Out-of-Net) | 20% coinsurance (authorization required) |
| Medical Equipment / Supplies | |
| Prosthetics (e.g., braces, artificial limbs) (Out-of-Net) | 20% coinsurance per item (authorization required) |
| 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) (Out-of-Net) | 20% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen) (In-Network) | $0 copay (authorization required) |
| Diabetes supplies (Out-of-Net) | $0 copay or 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs) (In-Network) | $0 copay (authorization required) |
| Diagnostic Procedures / Lab Services / Imaging | |
| Outpatient x-rays (In-Network) | $0 copay (authorization required) |
| Diagnostic radiology services (e.g., MRI) (Out-of-Net) | 20% coinsurance (authorization required) |
| Diagnostic radiology services (e.g., MRI) (In-Network) | $0 copay (authorization required) |
| Diagnostic tests and procedures (In-Network) | $0 copay (authorization required) |
| Outpatient x-rays (Out-of-Net) | 20% coinsurance (authorization required) |
| Lab services (In-Network) | $0 copay (authorization required) |
| Diagnostic tests and procedures (Out-of-Net) | 20% coinsurance (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 | |
| Chemotherapy (In-Network) | $0 copay (authorization required) |
| Other Part B drugs (Out-of-Net) | 20% coinsurance (authorization required) |
| Other Part B drugs (In-Network) | $0 copay (authorization required) |
| Foot Care (podiatry Services) | |
| Routine foot care | Not covered |
| Foot exams and treatment (In-Network) | $0 copay (authorization required) |
| Hearing | |
| Hearing aids (Out-of-Net) | 40% coinsurance (authorization required, limits may apply) |
| Fitting/evaluation (In-Network) | $0 copay (authorization required, limits may apply) |
| Hearing aids (In-Network) | $0 copay (authorization required, limits may apply) |
| Hearing exam (In-Network) | $0 copay (authorization required) |
| Hearing exam (Out-of-Net) | 20% coinsurance (authorization required) |
| Preventive Dental | |
| Cleaning (Out-of-Net) | 50% coinsurance (authorization required, limits may apply) |
| Fluoride treatment (In-Network) | $0 copay (authorization required, limits may apply) |
| Fluoride treatment (Out-of-Net) | 50% coinsurance (authorization required, limits may apply) |
| Oral exam (In-Network) | $0 copay (authorization required, limits may apply) |
| Oral exam (Out-of-Net) | 50% coinsurance (authorization required, limits may apply) |
| Dental x-ray(s) (In-Network) | $0 copay (authorization required, limits may apply) |
| Cleaning (In-Network) | $0 copay (authorization required, limits may apply) |
| Comprehensive Dental | |
| Endodontics (In-Network) | $0 copay (authorization required, limits may apply) |
| Non-routine services (Out-of-Net) | 50% coinsurance (authorization required, limits may apply) |
| Periodontics (Out-of-Net) | 50% coinsurance (authorization required, limits may apply) |
| Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | $0 copay (authorization required, limits may apply) |
| Prosthodontics, other oral/maxillofacial surgery, other services (Out-of-Net) | 50% coinsurance (authorization required, limits may apply) |
| Periodontics (In-Network) | $0 copay (authorization required, limits may apply) |
| Restorative services (In-Network) | $0 copay (authorization required, limits may apply) |
| Non-routine services (In-Network) | $0 copay (authorization required, limits may apply) |
| Extractions (Out-of-Net) | 50% coinsurance (authorization required, limits may apply) |
| Extractions (In-Network) | $0 copay (authorization required, limits may apply) |
| Diagnostic services (In-Network) | $0 copay (authorization required, limits may apply) |
| Restorative services (Out-of-Net) | 50% coinsurance (authorization required, limits may apply) |
| Endodontics (Out-of-Net) | 50% coinsurance (authorization required, limits may apply) |
| Vision | |
| Eyeglass lenses (Out-of-Net) | 40% coinsurance (authorization required, limits may apply) |
| Routine eye exam (Out-of-Net) | 40% coinsurance (authorization required, limits may apply) |
| Upgrades (Out-of-Net) | 40% coinsurance (authorization required, limits may apply) |
| Eyeglass frames (Out-of-Net) | 40% coinsurance (authorization required, limits may apply) |
| Contact lenses (Out-of-Net) | 40% coinsurance (authorization required, limits may apply) |
| Eyeglass lenses (In-Network) | $0 copay (authorization required, limits may apply) |
| Eyeglasses (frames and lenses) (In-Network) | $0 copay (authorization required, limits may apply) |
| Eyeglasses (frames and lenses) (Out-of-Net) | 40% coinsurance (authorization required, limits may apply) |
| Upgrades (In-Network) | $0 copay (authorization required, limits may apply) |
| Contact lenses (In-Network) | $0 copay (authorization required, limits may apply) |
| Eyeglass frames (In-Network) | $0 copay (authorization required, limits may apply) |
| Routine eye exam (In-Network) | $0 copay (authorization required, limits may apply) |
| Emergency Care / Urgent Care | |
| Emergency | $0 copay |
| Ground ambulance | 20% coinsurance |
| Inpatient hospital coverage | $0 copay |
| Outpatient hospital coverage | $0 copay |
| Skilled Nursing Facility | $0 copay |
| Optional supplemental benefits | No |
Feel free to download our Wellcare Dual Access Open Summary of Benefits information.
Prescription Drug Plan Costs & Benefits
Wellcare Dual Access Open 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.
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: | $37.30 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $37.30 |
| Part D Premium with Full LIS Assistance: | $0.00 |
| Part D Premium with 75% LIS Assistance: | $9.30 |
| Part D Premium with 50% LIS Assistance: | $18.60 |
| Part D Premium with 25% LIS Assistance: | $28.00 |
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 $480.00. This is the amount you must pay at the pharmacy before Wellcare 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, Wellcare Dual Access Open 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) | N/A | $0.00 copay (deductible does not apply) |
| 2 (Generic) | N/A | $9.00 copay |
| 3 (Preferred Brand) | N/A | $45.00 copay |
| 4 (Non-Preferred Drug) | N/A | 49% |
| 5 (Specialty Tier) | N/A | 25% |
Our Review & 2022 CMS Rating Marks
The table below shows the quality ratings for this Wellcare plan. Each year CMS rates Medicare Special Needs Plans in nine broad categories. We do not recommend joining a plan with an overall rating of less than 3.0 (3 stars).
In terms of quality care, this D-SNP is way better than the average Medicare Advantage plan in New York. Staying healthy is the best way to save money on health care, and in MedicareWire's judgement, Wellcare Dual Access Open does a good job keeping its Suffolk County 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. The member experience with this Wellcare plan is average. Complaints and changes in plan performance are one way we can measure quality, and this plan scores good at both. If you're concerned about how this health plan will treat you when you call for assistance, don't be. Members say it's good.
| CMS Measure | Star Rating |
|---|---|
| 2022 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 |
How to Qualify to Enroll in
Wellcare Dual Access Open
To qualify for enrollment in Wellcare Dual Access Open in Suffolk County, you must be eligible for both Medicare and Medicaid. To be eligible for Medicare, you must be age 65 or older, or have Social Security Disability Insurance for 24 months. To be eligible for Medicaid, your income and assets must be at or below New York's state thresholds.
Before enrolling in Wellcare Dual Access Open, or any other dual-eligible SNP, be sure to ask the following questions:
- What costs should I expect to pay out-of-pocket (premiums, deductibles, copayments)?
- Will I be able to use my doctors? Are they in the plan's network?
- Are the plan's in-network providers and facilities in convenient locations?
- Does the plan provide coverage for services I receive from out-of-network providers?
- Do I need a referral to see a specialist?
- Are my medications on the Part D plan's formulary? What if I can't afford my medications?
- What special accommodations does the plan make for persons with disabilities?
- Does the plan offer free meal delivery after a stay in the hospital?
- What help is offered for caregivers? Is adult day care covered?
- Does the plan offer a prepaid card for over the counter medications and covered groceries?
Contact Wellcare
| Plan Website: | http://www.wellcare.com/medicare |
|---|---|
| Formulay Information: | http://www.wellcare.com/medicare |
| Pharmacy Information: | Wellcare Pharmacy Page |
| Prospective Members: | (844)917-0175 |
| 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
- Wellcare, http://www.wellcare.com/medicare, Last Accessed October 15, 2021
- Medicaid.gov, "Medicaid & CHIP in New York", Last Accessed June 15, 2022
- CMS.gov, "Dual Eligible Special Needs Plans (D-SNPs)", Last Accessed May 21, 2022
- 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
This Medicare Advantage SNP plan information page was last updated on .