Highmark Wholecare Medicare Assured Diamond (D-SNP) Plan Details for Lebanon County, PA
CMS rated this Highmark Wholecare Medicare Assured plan 4.0 (Good) out of 5 stars.
Highmark Wholecare Medicare Assured Diamond (D-SNP HMO) is a Medicare Advantage Special Needs Plan. Enroll for 2025 starting Oct 15. Get notified.
This private health insurance option offers all of the same basic benefits as Original Medicare, but out-of-pocket costs are different. It may include additional benefits that Medicare Part A and Part B do not cover.
Individuals must meet all qualification requirements for eligibility to join this HMO D-SNP plan.
2025 Highmark Wholecare Medicare Assured Diamond Cost and Coverage Notification
The 2025 cost and coverage information for Highmark Wholecare Medicare Assured Diamond will not be available until early October. We'll notify you when it is available from CMS.
Sign-Up for 2025 Medicare Plan Notification. The 2025 enrollment period begins October 15.
| Plan Basics | |
|---|---|
| Plan ID: | H5932-001-0 |
| 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 |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | Lebanon County, PA |
| Insured By: | Highmark Wholecare Medicare Assured |
| Summary of Benefits |
|---|
Health Plan Cost Sharing & Benefits
Highmark Wholecare Medicare Assured Diamond is a Health Maintenance Organization (HMO) plan. HMO D-SNP 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 Diamond 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% Coinsurance |
| Specialist: | 0% Coinsurance |
| Wellness programs (e.g., fitness, nursing hotline): | |
| Preventive care: | 0% Coinsurance |
| Foot Care (In-Network) | |
| Foot exams and treatment (Medicare-covered): | 0% Coinsurance |
| Routine foot care: | 0% Coinsurance |
| Chiropractic Care (In-Network) | |
| Medicare-covered chiropractic care: | 0% Coinsurance Prior Authorization Required |
| Routine chiropractic care: | 0% Coinsurance Prior Authorization Required |
| Emergency Care / Urgent Care | |
| Emergency room care: | 0% Coinsurance |
| Urgent care: | 0% Coinsurance |
| Ground ambulance: | 0% Coinsurance |
| Inpatient hospital coverage: | $1,950.00 per stay |
| Outpatient hospital coverage: | 0% Coinsurance Prior 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: | 0% Coinsurance |
| Outpatient group therapy visit with a psychiatrist: | 0% Coinsurance |
| Inpatient hospital - psychiatric: | $1,850.00 per stay |
| Outpatient group therapy visit: | 0% Coinsurance |
| Outpatient individual therapy visit: | 0% Coinsurance |
| Rehabilitation Services (In-Network) | |
| Physical therapy and speech and language therapy visit: | 0% Coinsurance Prior Authorization Required |
| Occupational therapy visit: | 0% Coinsurance Prior Authorization Required |
| Medical Equipment / Supplies (In-Network) | |
| Diabetes supplies: | 0% Coinsurance |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 0% Coinsurance Prior Authorization Required |
| Prosthetics (e.g., braces, artificial limbs): | 0% Coinsurance |
| Diagnostic Procedures / Lab Services / Imaging (In-Network) | |
| Diagnostic radiology services (e.g., MRI): | 0% Coinsurance Prior Authorization Required |
| Lab services: | 0% Coinsurance Prior Authorization Required |
| Outpatient x-rays: | 0% Coinsurance Prior Authorization Required |
| Diagnostic tests and procedures: | 0% Coinsurance Prior Authorization Required |
| Medicare Part B Drugs (In-Network) | |
| Chemotherapy: | 0% Coinsurance |
| Other Part B drugs (Medicare-covered) | 0% Coinsurance |
Feel free to download our Highmark Wholecare Medicare Assured Diamond Summary of Benefits information.
Supplemental Health Plan Benefits (H5932-001-0)
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: | $600.00 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 Diamond 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 details of this plan's prescription drug plan premium.
| 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 |
The Social Security Extra Help page has more information about the low-income subsidy (LIS) and how to enroll in the program.
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 Diamond 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 | $13.00 copay |
| 3 (Preferred Brand) | N/A | $38.00 copay |
| 4 (Non-Preferred Drug) | N/A | 40% |
| 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 Diamond.
| 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 Diamond
To qualify for enrollment in Highmark Wholecare Medicare Assured Diamond in Lebanon 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 Diamond, 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:
- None.
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.
Health Plan Compatibility
Medicare Advantage Special Needs Plans (SNPs) are generally incompatible with most other health insurance options. Enrolling in an SNP plan while having Medicare Part A and/or Medicare Part B will result in disenrollment from Original Medicare. Additionally, it is not possible to simultaneously hold a Medicare Supplement Insurance policy and be part of an SNP plan.
With a D-SNP, members keep the same Medicaid plan and Medicaid benefits. If you are a Veteran and have VA Health Benefits, you may be able to care from your local VA hospital.
Citations & References
- Highmark Wholecare Medicare Assured, http://www.highmarkwholecare.com, Last Accessed October 13, 2023
- Medicaid.gov, "Medicaid & CHIP in Pennsylvania", Last Accessed January 4, 2024
- CMS.gov, "Dual Eligible Special Needs Plans (D-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
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.