Contigo Plus (C-SNP) Plan Details for Manati Municipio, PR
CMS rated this Triple S Advantage plan (H5774-022-0) 4.5 stars (Good+), making it a top-rated plan from this insurance company.
Contigo Plus (C-SNP HMO) is a Special Needs Plan (SNP). 2025 plan enrollment begins Oct 15. Get notified.
This Triple S Advantage HMO plan is required to provide all of the same benefits as Original Medicare, but out-of-pocket costs are different. This private health insurance option may include extra benefits not covered by Medicare Part A or Part B.
Eligible individuals must meet all qualification requirements to join this Triple S Advantage plan.
2025 Contigo Plus Cost and Coverage Notification
The 2025 cost and coverage information for Contigo Plus 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 | |
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Plan ID: | H5774-022-0 |
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: | $100.00/mo |
Drug Plan Benefit: | Enhanced $0.00 deductible |
Supplemental Benefits: | Vision, Hearing |
Availability: | Manati Municipio, PR |
Insured By: | Triple S Advantage |
Summary of Benefits |
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Health Plan Cost Sharing & Benefits
Contigo Plus is a Health Maintenance Organization (HMO) plan. HMO C-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, Contigo Plus 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 Triple S Advantage plan:
Healthcare Service | Member Cost |
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Doctor Visits (In-Network) | |
Primary: | $0 |
Specialist: | $3 Copay Prior Authorization Required |
Wellness programs (e.g., fitness, nursing hotline): | |
Preventive care: | $0 |
Foot Care (In-Network) | |
Foot exams and treatment (Medicare-covered): | $0 |
Routine foot care: | $0 |
Chiropractic Care (In-Network) | |
Medicare-covered chiropractic care: | $5 Copay |
Routine chiropractic care: | $5 Copay |
Emergency Care / Urgent Care | |
Emergency room care: | $50 Copay |
Urgent care: | $0 |
Ground ambulance: | $0 |
Inpatient hospital coverage: | $0.00 per stay |
Outpatient hospital coverage: | $25 Copay Prior Authorization Required |
Skilled Nursing Facility: | Unknown |
Optional supplemental benefits: | Not Covered |
Mental Health Services (In-Network) | |
Outpatient individual therapy visit with a psychiatrist: | $0 |
Outpatient group therapy visit with a psychiatrist: | $0 |
Inpatient hospital - psychiatric: | Coming Soon |
Outpatient group therapy visit: | $0 |
Outpatient individual therapy visit: | $0 |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy visit: | $0 |
Occupational therapy visit: | $5 Copay Prior Authorization Required |
Medical Equipment / Supplies (In-Network) | |
Diabetes supplies: | $0 |
Durable medical equipment (e.g., wheelchairs, oxygen): | 10% Coinsurance Prior Authorization Required |
Prosthetics (e.g., braces, artificial limbs): | 10% Coinsurance |
Diagnostic Procedures / Lab Services / Imaging (In-Network) | |
Diagnostic radiology services (e.g., MRI): | $25 Copay Prior Authorization Required |
Lab services: | 15% Coinsurance Prior Authorization Required |
Outpatient x-rays: | $0 |
Diagnostic tests and procedures: | 15% Coinsurance Prior Authorization Required |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 10% Coinsurance |
Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our Contigo Plus Summary of Benefits information.
Supplemental Health Plan Benefits (H5774-022-0)
The following is a summary of the supplemental benefits Triple S Advantage includes with this plan:
Supplemental Healthcare Service | Member Cost |
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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) | $20 Copay |
Hearing aids (In-Network) | Covered Limits may apply |
Hearing exam (In-Network) | $20 Copay |
Vision | Maximum vision benefit: | $775.00 Every year |
Eyeglasses (frames and lenses) (In-Network) | Covered Limits may apply |
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
Contigo Plus 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: | $0.00 |
Supplemental Part D Premium: | $0.00 |
Total Part D Premium: | $0.00 |
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 $0.00. This is the amount you must pay at the pharmacy before Triple S Advantage begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Contigo Plus 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) | $0.00 copay | $5.00 copay |
2 (Generic) | $0.00 copay | $8.00 copay |
3 (Preferred Brand) | $0.00 copay | $20.00 copay |
4 (Non-Preferred Brand) | $10.00 copay | $55.00 copay |
5 (Specialty Tier) | 33% | 33% |
6 (Select Care Drugs) | $0.00 copay | $3.00 copay |
CMS 5-Star Rating Marks
Each year Medicare rates C-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 Contigo Plus.
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
Contigo Plus
To be eligible to enroll in Contigo Plus, you must meet these requirements:
- You are eligible for Medicare;
- You live in Manati Municipio (the plan’s service area); and
- You have been diagnosed with one or more severe or disabling chronic conditions.
A disabiling chronic condition (disease) is one that lasts one or more years and requires ongoing medical attention and/or limits activities of daily living. They include:
- Autoimmune disorders
- End-stage renal disease
- Cancer
- Cardiovascular disorders
- Hematologic disorders
- HIV/AIDS
- Chronic heart failure
- Chronic lung disorders
- Neurologic disorders
- Dementia
- Diabetes
- End-stage liver disease
- Neurologic disorders
- Stroke
- Mental health conditions
This plan is for individuals with cardiovascular disorders, chronic heart failure, and/or diabetes.
Additional C-SNP Plan Options
Here are some additional Medicare SNP plans that might be worth reviewing:
- None.
Contact Triple S Advantage
Plan Website: | http://www.sssadvantage.com |
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Formulay Information: | http://www.sssadvantage.com |
Pharmacy Information: | Triple S Advantage Pharmacy Page |
Prospective Members: | (833)221-2234 |
TTY Users: | (866)620-2520 |
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
Special Needs Plans (SNPs) under Medicare Advantage typically do not work with other types of health insurance. If you have Medicare Part A or Part B and decide to join an SNP plan, you will be removed from Original Medicare. Furthermore, you cannot be enrolled in an SNP plan and hold Medicare Supplement Insurance at the same time.
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
- Triple S Advantage, http://www.sssadvantage.com, Last Accessed October 13, 2023
- Medicaid.gov, "Medicaid & CHIP in Puerto Rico", Last Accessed January 4, 2024
- CMS.gov, "Chronic Condition Special Needs Plans (C-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 Blue Shield, 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.