2024 CCA Medicare Maximum D-SNP: H0876-001-0 for Bristol County, RI
What is Plan H0876-001-0 by CCA Health Rhode Island?
CCA Medicare Maximum, is a 2024 D-SNP Special Needs Plan, with 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 D-SNP plan.
Plan Basics | |
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Plan ID: | H0876-001-0 |
Plan Type: | HMO |
Plan Year: | 2024 |
Premium: | $43.50/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 |
Rx Gap Coverage: | {gap} |
Supplemental Benefits: | Dental, Vision, Hearing |
Availability: | Bristol County, RI |
Insured By: | CCA Health Rhode Island |
Summary of Benefits |
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Health Plan Costs & Benefits
CCA Medicare Maximum 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, CCA Medicare Maximum 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 CCA Health Rhode Island plan:
Healthcare Service | Member Cost |
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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 Authorization Required |
Routine foot care: | 0% Coinsurance Authorization Required |
Chiropractic Care (In-Network) | |
Medicare-covered chiropractic care: | 0% Coinsurance |
Routine chiropractic care: | 0% Coinsurance |
Emergency Care / Urgent Care | |
Emergency room care: | 0% Coinsurance |
Urgent care: | 0% Coinsurance |
Ground ambulance: | 0% Coinsurance |
Inpatient hospital coverage: | $1,500.00 per stay |
Outpatient hospital coverage: | 0% Coinsurance Authorization Required |
Skilled Nursing Facility: | Unknown |
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: | $1,500.00 per stay |
Outpatient group therapy visit: | 0% Coinsurance |
Outpatient individual therapy visit: | 0% Coinsurance Authorization Required |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy visit: | 0% Coinsurance Authorization Required |
Occupational therapy visit: | 0% Coinsurance Authorization Required |
Medical Equipment / Supplies (In-Network) | |
Diabetes supplies: | 0% Coinsurance Authorization Required |
Durable medical equipment (e.g., wheelchairs, oxygen): | 0% Coinsurance 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 Authorization Required |
Lab services: | 0% Coinsurance Authorization Required |
Outpatient x-rays: | 0% Coinsurance Authorization Required |
Diagnostic tests and procedures: | 0% Coinsurance Authorization Required |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 0% Coinsurance |
Other Part B drugs (Medicare-covered) | 0% Coinsurance |
Feel free to download our CCA Medicare Maximum Summary of Benefits information.
Supplemental Health Plan Benefits (H0876-001-0)
The following is a summary of the supplemental benefits CCA Health Rhode Island includes with this plan:
Supplemental Healthcare Service | Member Cost |
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Preventive Dental | Maximum dental benefit: | $4,000.00 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) | Covered Limits may apply |
Hearing aids (In-Network) | Covered Limits may apply |
Hearing exam (In-Network) | Covered Limits may apply |
Vision | Maximum vision benefit: | $350.00 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
CCA Medicare Maximum 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: | $43.50 |
Supplemental Part D Premium: | $0.00 |
Total Part D Premium: | $43.50 |
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 $545.00. This is the amount you must pay at the pharmacy before CCA Health Rhode Island begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, CCA Medicare Maximum 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 | 20% |
2 (Generic) | N/A | 25% |
3 (Preferred Brand) | N/A | 25% |
4 (Non-Preferred Brand) | N/A | 25% |
5 (Specialty Tier) | N/A | 25% |
CMS 5-Star Rating Marks
Each year CMS rates Medicare Special Needs Plans in nine broad categories based on a 5-star system. The table below shows the quality ratings for this CCA Health Rhode Island plan.
CMS Measure | Star Rating |
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2024 Overall Rating | |
Staying Healthy: Screenings, Tests, Vaccines | Plan too new to be measured |
Managing Chronic (Long Term) Conditions | Plan too new to be measured |
Member Experience with Health Plan | Plan too new to be measured |
Complaints and Changes in Plans Performance | Plan too new to be measured |
Health Plan Customer Service | Plan too new to be measured |
Drug Plan Customer Service | |
Complaints and Changes in the Drug Plan | Plan too new to be measured |
Member Experience with the Drug Plan | Plan too new to be measured |
Drug Safety and Accuracy of Drug Pricing | Plan too new to be measured |
How to Qualify to Enroll in
CCA Medicare Maximum
To qualify for enrollment in CCA Medicare Maximum in Bristol 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 Rhode Island's state thresholds.
Before enrolling in CCA Medicare Maximum, 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:
Contact CCA Health Rhode Island
Plan Website: | http://ccahealthri.org/become-a-member |
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Formulay Information: | https://www.commonwealthcarealliance.org/members/pharmacy-program |
Pharmacy Information: | CCA Health Rhode Island Pharmacy Page |
Prospective Members: | (866)275-1222 |
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
- CCA Health Rhode Island, http://ccahealthri.org/become-a-member, Last Accessed October 13, 2023
- Medicaid.gov, "Medicaid & CHIP in Rhode Island", 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