Highmark Wholecare Medicare Assured Diamond (D-SNP) Plan Details for Northampton County, PA
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*CMS rated this Highmark Wholecare Medicare Assured plan (H5932-001-0) 4.5 (Good+) out of 5 stars.
Highmark Wholecare Medicare Assured Diamond (D-SNP) is a Dual-Eligible Medicare Advantage Special Needs Plan. The 2025 Annual Enrollment period starts October 15. Plan benefits begin
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 Dual-Eligible SNP qualification requirements to join this D-SNP plan.
| Plan Basics | |
|---|---|
| Plan ID: | H5932-001-0 |
| Plan Type: | HMO D-SNP |
| Plan Year: | 2025 |
| Premium: | $0.00/mo Plus your Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | 9,350.00 /yr |
| Part B Reduction: | $0.00/mo |
| Drug Plan Benefit: | Basic $590.00 deductible |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | Northampton County, PA |
| Insured By: | Highmark Wholecare Medicare Assured |
| Summary of Benefits |
|---|
Health Plan Cost Sharing & Benefits
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:
Doctor's Office Visits
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | $0 Copay |
| Specialist: | $0 Copay |
Emergency, Urgent, and Inpatient Hospital Coverage
| Service | Enrollee Cost |
|---|---|
| Emergency room care: | $0 Copay |
| Urgent care: | $0 Copay |
| Ground ambulance: | $0 Copay |
| Inpatient hospital care: | $1,950.00 per stay |
| Skilled Nursing Facility: | $0.00 per day for days 1 through 20 $214.00 per day for days 21 and beyond |
Foot Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Foot Exams and Treatments (Medicare-covered): | $0 Copay |
| Routine Foot Care: | $0 Copay |
Chiropractic Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Medicare-covered chiropractic: | $0 Copay Prior Authorization Required |
| Routine chiropractic: | $0 Copay Prior Authorization Required |
Mental Health Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | $0 Copay |
| Outpatient group therapy: | $0 Copay |
| Inpatient psychiatric hospital care: | $1,850.00 per stay |
Rehabilitation Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Physical therapy and speech and language therapy: | $0 Copay Prior Authorization Required |
| Occupational therapy: | $0 Copay Prior Authorization Required |
Medical Equipment and Supplies
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | $0 Copay |
| Durable medical equipment: | $0 Copay Prior Authorization Required |
| Prosthetics: | $0 Copay |
Diagnostics, Lab Services, and Imaging
| Service | Enrollee Cost (in-network) |
|---|---|
| Diagnostic radiology services: | $0 Copay Prior Authorization Required |
| Lab services: | $0 Copay Prior Authorization Required |
| Outpatient x-rays: | $0 Copay Prior Authorization Required |
| Diagnostic tests and procedures: | $0 Copay Prior Authorization Required |
Medicare Part B Drugs
| Service | Enrollee Cost (in-network) |
|---|---|
| Chemotherapy: | $0 Copay |
| Other Part B drugs (Medicare-covered): | $0 Copay |
Dental Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare Covered Preventive Dental | 26% Coinsurance Prior Authorization Required |
| Oral exam | $0 |
| Dental x-rays | $0 |
| Cleaning | $0 |
| Periodontics | Not Covered |
| Endodontics | Not Covered |
| Restorative Services | Not Covered |
| Maximum dental benefit: | $8,000.00 (Every year) |
Hearing Aids and Services
| Service | Member Cost (in-network) |
|---|---|
| Fitting/evaluation | Covered Limits may apply |
| Hearing aids | Not Covered |
| Hearing exam | Covered Limits may apply |
Vision Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare-covered eye exam (in-network) | 26% Coinsurance |
| Routine eye exam (in-network) | Covered Limits may apply |
| Eyewear benefits | None |
Feel free to download our Highmark Wholecare Medicare Assured Diamond Summary of Benefits information.
Prescription Drug Plan Costs & Benefits
Highmark Wholecare Medicare Assured Diamond includes an basic benefit Medicare Part D plan (PDP). This simply means that the plan covers the minimum amount required by the Centers for Medicare & Medicaid Services, whereas enhanced benefit plans cover more.
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. LIS, also known as Extra Help, is a Social Security program that helps people with limited income and resources lower or cut Part D costs.
The following table outlines the premium details of this prescription drug plan.
| Basic Part D Premium: | $42.70 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $42.70 |
| Low Income Premium Subsidy: | $48.36 |
| Low Income Premium Subsidy CMS Pays: | $42.70 |
| Low Income Subsidy Premium: | $0.00 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $590.00. You must pay this amount 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 you must pay when you pick up your prescriptions.
| Drug Tier | Retail | Mail Order | |
|---|---|---|---|
| Cost data not available. | |||
| *The Part D deductible does not apply. | |||
CMS 5-Star 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 |
|---|---|
| 2025 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 D-SNP Plan Options
Here are some additional Medicare SNP plans that might be worth reviewing:
- Highmark Wholecare Medicare Assured Ruby
- Highmark Wholecare Medicare Assured Ruby
- Highmark Wholecare Medicare Assured Diamond
- Highmark Wholecare Medicare Assured Diamond
Contact Highmark Wholecare Medicare Assured
| Website: | Highmark Wholecare Medicare Assured Plan Page |
|---|---|
| Providers: | Highmark Wholecare Medicare Assured Providers Page |
| Formulary: | Highmark Wholecare Medicare Assured Formulary Page |
| Pharmacy: | Highmark Wholecare Medicare Assured Pharmacy Page |
| New Member Health Plan Help: | (877)935-2168 |
| New Member Health Plan TTY: | 711 |
| New Member Part D Help: | (877)935-2168 |
| New Member Part D 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 Need Plans are not compatible with most other forms of health insurance. If you have Medicare Part A and/or Medicare Part B and join a SNP plan, you will be disenrolled from Original Medicare. You cannot simultaneously enroll in an SNP plan and Medicare Supplement Insurance.
Members of a D-SNP maintain their current Medicaid plan and Medicaid benefits. Veterans with VA Health Benefits might have the option to receive care at a nearby VA hospital.
Citations & References
- Highmark Wholecare Medicare Assured, http://www.highmarkwholecare.com, Last Accessed October 13, 2024
- Medicaid.gov, "Medicaid & CHIP in Pennsylvania", Last Accessed October 1, 2024
- CMS.gov, Landscape Source Files, Last Accessed October 2, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed October 2, 2024
- CMS.gov, Plan Benefits Package, Last Accessed October 5, 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.