Imperial Dual Plan (D-SNP) H5496 011 0 Plan Details
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*CMS rated this Imperial Health Plan of California, Inc. plan (H5496-011-0) 3.5 (Above Average) out of 5 stars.
Imperial Dual Plan (D-SNP) is a Dual-Eligible Special Needs Plan. The 2025 Annual Enrollment period starts October 15. Plan benefits begin January 1.
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: | H5496-011-0 |
| 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: | 2,999.00 /yr |
| Part B Reduction: | $0.00/mo |
| Drug Plan Benefit: | Enhanced $590.00 deductible |
| Supplemental Benefits: | Vision, Hearing |
| Availability: | See List |
| Insured By: | Imperial Health Plan of California, Inc. |
| 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 Imperial Health Plan of California, Inc. plan:
Doctor's Office Visits
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | $0 Copay |
| Specialist: | $0 Copay Prior Authorization Required, Referral Required |
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: | |
| Skilled Nursing Facility: |
Foot Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Foot Exams and Treatments (Medicare-covered): | $0 Copay Prior Authorization Required, Referral Required |
| Routine Foot Care: | $0 Copay Prior Authorization Required, Referral Required |
Chiropractic Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Medicare-covered chiropractic: | $0 Copay Prior Authorization Required, Referral Required |
| Routine chiropractic: | $0 Copay Prior Authorization Required, Referral Required |
Mental Health Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | $0 Copay |
| Outpatient group therapy: | $0 Copay |
| Inpatient psychiatric hospital care: |
Rehabilitation Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Physical therapy and speech and language therapy: | $0 Copay Prior Authorization Required, Referral Required |
| Occupational therapy: | $0 Copay Prior Authorization Required, Referral Required |
Medical Equipment and Supplies
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | $0 Copay Prior Authorization Required |
| 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, Referral Required |
| Lab services: | $0 Copay Prior Authorization Required, Referral Required |
| Outpatient x-rays: | $0 Copay Prior Authorization Required, Referral Required |
| Diagnostic tests and procedures: | $0 Copay Prior Authorization Required, Referral 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 | Not Covered |
| Oral exam | $0 |
| Dental x-rays | $0 |
| Cleaning | $0 |
| Periodontics | Not Covered |
| Endodontics | Not Covered |
| Restorative Services | Not Covered |
| Maximum dental benefit: | $500.00 (Every year) |
Hearing Aids and Services
| Service | Member Cost (in-network) |
|---|---|
| Fitting/evaluation | Covered Limits may apply |
| Hearing aids | Covered Limits may apply |
| Hearing exam | Covered Limits may apply |
Vision Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare-covered eye exam (in-network) | 20% Coinsurance |
| Routine eye exam (in-network) | Covered Limits may apply |
| Eyewear benefits | None |
Feel free to download our Imperial Dual Plan Summary of Benefits information.
Prescription Drug Plan Costs & Benefits
Imperial Dual Plan 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. 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: | $29.70 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $29.70 |
| Low Income Premium Subsidy: | $29.66 |
| Low Income Premium Subsidy CMS Pays: | $29.70 |
| 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 Imperial Health Plan of California, Inc. begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Imperial Dual Plan has out-of-pocket costs you must pay when you pick up your prescriptions.
| Drug Tier | Retail | Mail Order | Out of Network |
|---|---|---|---|
| Preferred Generic | $0.00 | $0.00 | $0.00 |
| Generic* | $0.00 | $0.00 | $0.00 |
| Preferred Brand* | 25.00% | 0.00% | 25.00% |
| Non-Preferred Drug | 25.00% | 0.00% | 25.00% |
| Specialty Tier | 25.00% | 0.00% | 25.00% |
| *The Part D deductible does not apply. | |||
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 Imperial Dual Plan .
| CMS Measure | Star Rating |
|---|---|
| 2025 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | Not enough data available |
| 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 | Not enough data available |
| Drug Safety and Accuracy of Drug Pricing |
Plan Availability
Imperial Dual Plan (H5496-011-0) is available in the following locations (click to open):
Additional D-SNP Plan Options
Here are some additional Medicare SNP plans that might be worth reviewing:
- H5496-011-0: Imperial Dual Plan ()
- H5496-005-0: Imperial Senior Value ()
Contact Imperial Health Plan of California, Inc.
| Website: | Imperial Health Plan of California, Inc. Plan Page |
|---|---|
| Providers: | Imperial Health Plan of California, Inc. Providers Page |
| Formulary: | Imperial Health Plan of California, Inc. Formulary Page |
| Pharmacy: | Imperial Health Plan of California, Inc. Pharmacy Page |
| New Member Health Plan Help: | (800)838-5914 |
| New Member Health Plan TTY: | 711 |
| New Member Part D Help: | (800)838-5914 |
| 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 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.
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
- Imperial Health Plan of California, Inc., http://www.imperialhealthplan.com, Last Accessed October 13, 2024
- Medicaid.gov, "Medicaid & CHIP in California", 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.