Highmark Wholecare Medicare Assured Ruby D-SNP: H5932-009-0
What is Plan H5932-009-0 from Highmark Wholecare Medicare Assured?
Highmark Wholecare Medicare Assured Ruby is a D-SNP Medicare Advantage plan, by Highmark Wholecare Medicare Assured, 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 D-SNP plan.
| Plan Basics | |
|---|---|
| Plan ID: | H5932-009-0 |
| Plan Type: | HMO |
| Plan Year: | 2024 |
| Premium: | $40.20/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 $545.00 deductible |
| Rx Gap Coverage: | {gap} |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | Elk County, PA |
| Insured By: | Highmark Wholecare Medicare Assured |
| Summary of Benefits |
|---|
Health Plan Costs & Benefits
Highmark Wholecare Medicare Assured Ruby 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, Highmark Wholecare Medicare Assured Ruby 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 Highmark Wholecare Medicare Assured plan:
| Healthcare Service | Member Cost |
|---|---|
| Doctor Visits (In-Network) | |
| Primary: | $0 |
| Specialist: | $25 Copay |
| Wellness programs (e.g., fitness, nursing hotline): | |
| Preventive care: | $0 |
| Foot Care (In-Network) | |
| Foot exams and treatment (Medicare-covered): | $25 Copay |
| Routine foot care: | $25 Copay |
| Chiropractic Care (In-Network) | |
| Medicare-covered chiropractic care: | $15 Copay Authorization Required |
| Routine chiropractic care: | $15 Copay Authorization Required |
| Emergency Care / Urgent Care | |
| Emergency room care: | $95 Copay |
| Urgent care: | $25 Copay |
| Ground ambulance: | $250 Copay |
| Inpatient hospital coverage: | $250.00 per day for days 1 through 6 $0.00 per day for days 7 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 and beyond |
| Optional supplemental benefits: | Not Covered |
| Mental Health Services (In-Network) | |
| Outpatient individual therapy visit with a psychiatrist: | $25 Copay |
| Outpatient group therapy visit with a psychiatrist: | $25 Copay |
| Inpatient hospital - psychiatric: | $250.00 per day for days 1 through 6 $0.00 per day for days 7 and beyond |
| Outpatient group therapy visit: | $25 Copay |
| Outpatient individual therapy visit: | $0 |
| Rehabilitation Services (In-Network) | |
| Physical therapy and speech and language therapy visit: | $20 Copay Authorization Required |
| Occupational therapy visit: | $20 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): | $175 Copay Authorization Required |
| Lab services: | $0 |
| Outpatient x-rays: | $20 Copay Authorization Required |
| 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 Highmark Wholecare Medicare Assured Ruby Summary of Benefits information.
Supplemental Health Plan Benefits (H5932-009-0)
The following is a summary of the supplemental benefits Highmark Wholecare Medicare Assured includes with this plan:
| Supplemental Healthcare Service | Member Cost |
|---|---|
| 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) | Covered Limits may apply |
| Hearing aids (In-Network) | Covered Limits may apply |
| Hearing exam (In-Network) | Covered Limits may apply |
| Vision | Maximum vision benefit: | $200.00 Every year |
| Eyeglasses (frames and lenses) (In-Network) | Not Covered |
| Routine eye exam (In-Network) | Covered Limits may apply |
| Contact lenses (In-Network) | Covered Limits may apply |
Additional Supplemental Benefits
None specified.
Prescription Drug Plan Costs & Benefits
Highmark Wholecare Medicare Assured Ruby 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: | $40.20 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $40.20 |
| 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 $545.00. This is the amount you must pay at the pharmacy before Highmark Wholecare Medicare Assured begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Highmark Wholecare Medicare Assured Ruby 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 |
|---|---|---|
| 1 (Preferred Generic) | N/A | $4.00 copay |
| 2 (Generic) | N/A | $20.00 copay |
| 3 (Preferred Brand) | N/A | $47.00 copay |
| 4 (Non-Preferred Drug) | N/A | 46% |
| 5 (Specialty Tier) | N/A | 25% |
CMS Rating Marks
Each year Medicare rates D-SNP plans, using a 5-star rating system, in nine major categories. These ratings are designed to help you understand the quality of care and service you can expect if you qualify and choose to join Highmark Wholecare Medicare Assured Ruby.
| CMS Measure | Star Rating |
|---|---|
| 2024 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
Highmark Wholecare Medicare Assured Ruby
To qualify for enrollment in Highmark Wholecare Medicare Assured Ruby in Elk 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 Pennsylvania's state thresholds.
Before enrolling in Highmark Wholecare Medicare Assured Ruby, 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?
Additional D-SNP Plan Options
Here are some additional Medicare SNP plans that might be worth reviewing:
- Geisinger Gold Secure Rx
- Wellcare Dual Access
- Highmark Wholecare Medicare Assured Diamond
- Wellcare Dual Access Open
- UHC Dual Complete PA-S002
Contact Highmark Wholecare Medicare Assured
| Plan Website: | http://www.highmarkwholecare.com |
|---|---|
| Formulay Information: | http://www.highmarkwholecare.com |
| Pharmacy Information: | Highmark Wholecare Medicare Assured Pharmacy Page |
| Prospective Members: | (800)685-5209 |
| 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
- Highmark Wholecare Medicare Assured, http://www.highmarkwholecare.com, Last Accessed October 13, 2022
- Medicaid.gov, "Medicaid & CHIP in Pennsylvania", Last Accessed January 20, 2023
- CMS.gov, "Dual Eligible Special Needs Plans (D-SNPs)", Last Accessed January 20, 2023
- CMS.gov, Landscape Source Files, Last Accessed January 21, 2023
- CMS.gov, Medicare Part C & D Performance, Last Accessed January 21, 2023
- CMS.gov, Plan Benefits Package, Last Accessed January 21, 2023