2024 Wellpoint I Carelon Home Care I-SNP: H1423-008-0 for Maricopa County, AZ
What is Plan H1423-008-0 by Amerigroup?
Wellpoint I Carelon Home Care is a I-SNP Medicare Advantage plan, by Amerigroup, 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 I-SNP plan.
Plan Basics | |
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Plan ID: | H1423-008-0 |
Plan Type: | HMO |
Plan Year: | 2024 |
Premium: | $0.00/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: | Dental, Vision, Hearing |
Availability: | Maricopa County, AZ |
Insured By: | Amerigroup |
Summary of Benefits |
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Health Plan Costs & Benefits
Wellpoint I Carelon Home Care 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, Wellpoint I Carelon Home Care 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 Amerigroup plan:
Healthcare Service | Member Cost |
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Doctor Visits (In-Network) | |
Primary: | $0 Copay |
Specialist: | $0 Copay Referral 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 |
Routine foot care: | $0 Copay Authorization Required |
Chiropractic Care (In-Network) | |
Medicare-covered chiropractic care: | $0 Copay Authorization Required |
Routine chiropractic care: | $0 Copay Authorization Required |
Emergency Care / Urgent Care | |
Emergency room care: | $120 Copay |
Urgent care: | $0 Copay |
Ground ambulance: | $250 Copay |
Inpatient hospital coverage: | $175.00 per day for days 1 through 5 $0.00 per day for days 6 and beyond |
Outpatient hospital coverage: | $100 Copay Authorization Required |
Skilled Nursing Facility: | $0.00 per stay |
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: | $175.00 per day for days 1 through 5 $0.00 per day for days 6 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 |
Occupational therapy visit: | $0 Copay Authorization Required |
Medical Equipment / Supplies (In-Network) | |
Diabetes supplies: | $0 Copay Authorization Required |
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): | $150 Copay Authorization Required |
Lab services: | $0 Copay Authorization Required |
Outpatient x-rays: | $0 Copay Authorization Required |
Diagnostic tests and procedures: | $0 Copay Authorization Required |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 20% Coinsurance |
Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our Wellpoint I Carelon Home Care Summary of Benefits information.
Supplemental Health Plan Benefits (H1423-008-0)
The following is a summary of the supplemental benefits Amerigroup includes with this plan:
Supplemental Healthcare Service | Member Cost |
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Preventive Dental | Maximum dental benefit: | $750.00 Every year |
Oral exam (In-Network) | Covered |
Fluoride treatment (In-Network) | Covered |
Dental x-ray(s) (In-Network) | Covered |
Cleaning (In-Network) | Covered |
Comprehensive Dental | |
Periodontics (In-Network) | Covered |
Non-routine services (In-Network) | Covered |
Diagnostic services (In-Network) | Covered |
Extractions (In-Network) | Covered |
Endodontics (In-Network) | Covered |
Restorative services (In-Network) | Covered |
Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Covered |
Hearing | |
Fitting/evaluation (In-Network) | $0 Copay Authorization Required |
Hearing aids (In-Network) | Covered Limits may apply |
Hearing exam (In-Network) | $0 Copay Authorization Required |
Vision | Maximum vision benefit: | $250.00 Every year |
Eyeglasses (frames and lenses) (In-Network) | $0 Copay |
Routine eye exam (In-Network) | $0 Copay |
Contact lenses (In-Network) | $0 Copay |
Additional Supplemental Benefits
None specified.
Prescription Drug Plan Costs & Benefits
Wellpoint I Carelon Home Care 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: | $0.00 |
Supplemental Part D Premium: | $0.00 |
Total Part D Premium: | $0.00 |
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 Amerigroup begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Wellpoint I Carelon Home Care 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 | $7.50 copay |
3 (Preferred Brand) | N/A | $40.00 copay |
4 (Non-Preferred Drug) | N/A | $85.00 copay |
5 (Specialty Tier) | N/A | 33% |
6 (Select Care Drugs) | N/A | $0.00 copay |
5-Star Rating Marks
Each year the Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage I-SNP's in nine broad categories using a 5-star rating system. Medicare's star ratings will help you understand the quality of care and service you can expect if you join this Amerigroup plan.
CMS Measure | Star Rating |
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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
Wellpoint I Carelon Home Care
To be eligible to enroll in Wellpoint I Carelon Home Care, you must meet three requirements:
- You are eligible for Medicare;
- You live in Maricopa County (the plan’s service area); and
- You require the level of care provided in an institutionalized setting, such as a long-term care nursing facility, for 90 days or more.
If you live at home and require an equivalent level of skilled care, you may be eligible for an Institutional Equivalent Special Needs Plan (IE-SNP).
Before joining Wellpoint I Carelon Home Care, consider these questions:
- Does the plan's provider network include my nursing home or home care provider?
- What costs should I expect with my coverage (premiums, deductibles, copayments)?
- Is there an annual limit on my out-of-pocket costs?
- 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 special accommodations does the plan make for persons with disabilities?
- What special language and cultural accommodations does the plan make?
Additional I-SNP Plan Options
Here are some additional Medicare SNP plans that might be worth reviewing:
Contact Amerigroup
Plan Website: | https://shop.amerigroup.com/medicare |
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Formulay Information: | https://shop.amerigroup.com/medicare |
Pharmacy Information: | Amerigroup Pharmacy Page |
Prospective Members: | (855)593-0904 |
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
- Amerigroup, https://shop.amerigroup.com/medicare, Last Accessed October 13, 2023
- Medicaid.gov, "Medicaid & CHIP in Arizona", Last Accessed January 4, 2024
- CMS.gov, "Institutional Special Needs Plans (I-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