Mass Advantage Basic HMO Summary of Benefits (2023)
At zero premium, our Basic HMO plan gives you full access to Mass Advantage’s network of pre-qualified providers who will work with you for any care you might need.
Our most affordable plan/$0 monthly premium
With Mass Advantage Basic HMO, you pay no premium and choose your own Primary Care Provider (PCP). Your PCP oversees your overall care and makes sure any additional services you need are well-coordinated. You’re also saving money by sticking with Mass Advantage’s network providers--medical providers who have been carefully pre-screened and meet our high standards of care and service excellence. Part D prescription drug coverage is also included, so all of your healthcare services are easy to access.
Mass Advantage Basic HMO Summary of Benefits
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Mass Advantage Basic HMO Evidence of Coverage
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Monthly Premium, Deductible, and Limits on how much you pay for covered services
Monthly Plan Premium |
$0 You must continue to pay your Medicare Part B premium. |
Medical Deductible |
This plan does not have a deductible. |
Pharmacy (Part D) Deductible |
$195 deductible for Tiers 3, 4 and 5 |
Maximum Out-of Pocket Responsibility |
$6,500 for services you receive from in-network providers This is the most you will pay for copays, coinsurance, and other costs for Medicare-covered medical services, supplies, and Part B-covered medication for the plan year. What you pay out-ofpocket for Part D prescription drugs and certain supplemental benefits (dental, hearing aids) do not apply to this amount. Please refer to the Evidence of Coverage for more information. |
Covered Medical and Hospital Benefits
Inpatient Hospital Coverage* |
Days 1 – 5: $370 copay per day Days 6 – beyond: $0 copay per day |
Outpatient Hospital Coverage* |
Outpatient Hospital: $300 copay per stay Observation Services: $350 copay per stay |
Ambulatory Surgical Center* |
$300 copay per visit |
Doctor Visits |
Primary Care: $0 copay per visit Specialist: $40 copay per visit |
Preventive Care | There is no coinsurance, copayment, or deductible for Medicare-covered preventive services. |
Emergency Care |
$90 copay per visit If you are admitted to the hospital within 24 hours, you do not have to pay your emergency care copay. Worldwide Emergency Coverage: $90 copay per visit |
Urgently Needed Services | $10 copay per visit |
Diagnostic Services/ Labs/Imaging* |
Lab services: $0 copay Diagnostic tests and procedures: $20 copay Outpatient X-ray services: $0 copay Diagnostic Radiology services (such as, MRI, MRA, CT, PET): |
Hearing Services |
Routine and Hearing Aids services outlined below must be
Limit of two hearing aids per calendar year (one per ear). Medicare-covered Hearing care: $40 copay for each Medicarecovered hearing care service if required for another medical procedure and deemed medically necessary by a physician. |
Dental Services* |
Preventive and Comprehensive dental services outlined below must be received from a DentaQuest provider. Preventive dental services include the following: $0 copay
Comprehensive dental services include the following: 50%
*You should review your EOC for additional details and There is a maximum allowance of $1,000 each calendar year for comprehensive dental services. You are responsible for amounts beyond the benefit limit. Medicare-covered Dental Care: $40 copay for each Medicare-covered dental care service if required for another medical procedure and deemed medically necessary by a physician. |
Vision Services |
Routine and vision services outlined below must be received by an EyeQuest provider.
Medicare-covered Vision Care: $40 copay for each Medicare-covered eye exam related to the diagnosis and treatment of diseases and conditions of the eye. |
Mental Health Services* |
Outpatient group therapy: $25 copay per visit Outpatient individual therapy: $25 copay per visit Inpatient Mental Health Care:
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Skilled Nursing Facility (SNF)* |
Days 1-20: $0 copay per day Days 21-51: $196 copay per day Days 52-100: $0 copay per day |
Outpatient Rehabilitation* |
Occupational therapy: $20 copay per visit Speech and language therapy: $10 copay per visit Physical therapy: $10 copay per visit |
Ambulance* |
Ground Ambulance: $300 copay (per one-way trip) Air Ambulance: $300 copay (per one-way trip) If you are admitted to the hospital, you do not have to pay your ambulance services copay. |
Transportation* |
$0 copay for 12 one-way rides per year for plan approved health-related locations. Members can use taxi, ridesharing, and medical transportation services under this benefit. |
Medicare Part B Drugs* |
Chemotherapy drugs: 20% coinsurance Other Part B drugs: 20% coinsurance |
Services with an * (asterisk) may require prior authorization from your doctor.
Part D Prescription Drugs
Deductible Stage |
$195 deductible for Tiers 3, 4 and 5** **Select Insulins: Cost-sharing is applicable in the Deductible, Initial Coverage, and Coverage Gap phases of the Part D benefit, and only apply to beneficiaries who are not eligible for Low Income Subsidy cost-sharing. Part D Vaccines: Cost-sharing of $0 is applicable in the Deductible, Initial Coverage, and Coverage Gap phases of the Part D benefit. |
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Initial Coverage Stage |
You pay the following until your total yearly drug costs reach $4,660. Total yearly drug costs are the drug costs paid by both you and our Part D plan. Standard Retail Cost-Sharing
Standard Mail Order
Your cost-sharing may be different if you use a Long-Term Care pharmacy, or an out-of-network pharmacy. **Select Insulins: Cost-sharing is applicable in the Deductible, Initial Coverage, and Coverage Gap phases of the Part D benefit, and only apply to beneficiaries who are not eligible for Low Income Subsidy cost-sharing. Part D Vaccines: Cost-sharing of $0 is applicable in the Deductible, Initial Coverage, and Coverage Gap phases of the Part D benefit. |
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Coverage Gap Stage |
You will continue to pay the Tier 1 and Tier 2 copay for drugs while in the coverage gap stage. For Tiers 3, 4, and 5 drugs: After you enter the coverage gap stage, you pay 25% of the plan’s cost for covered brand name drugs (plus a portion of the dispensing fee) and 25% of the plan’s cost for covered generic drugs until your costs total $7,400 which is the end of the coverage gap. **Select Insulins: Cost-sharing is applicable in the Deductible, Initial Coverage, and Coverage Gap phases of the Part D benefit, and only applies to beneficiaries who are not eligible for Low Income Subsidy cost-sharing. Part D Vaccines: Cost-sharing of $0 is applicable in the Deductible, Initial Coverage, and Coverage Gap phases of the Part D benefit. |
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Catastrophic Stage |
After your yearly out-of-pocket drug costs reach $7,400, you
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Additional Benefits
Over-the-Counter (OTC) Items |
You have $50 every quarter to spend on plan approved OTC items. OTC items must be ordered through Convey Health Solutions. You are allowed to order once per quarter. Any unused money will carry over to the next quarter but will not carry over to the next benefit year. |
Chiropractic Care | Chiropractic Care (Medicare-covered): $20 copay per visit |
Telehealth Services |
Primary Care Visits: $0 copay per visit Specialist Visits: $40 copay per visit Individual Sessions for Mental Health Specialty Services: $0 Individual Sessions for Outpatient Substance Abuse: $0 |
Medical Equipment/ Supplies* |
Durable Medical Equipment (e.g., wheelchairs, oxygen): 20% coinsurance Prosthetics (e.g., braces, artificial limbs): 20% coinsurance Diabetic supplies:
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Flex Card |
Flex Card: $300 every year The flex card is available to members to pay for:
The flex card is preloaded with the full benefit amount and members choose where to use it. Members may pay a portion or the full cost of an item or buy a combination of items up to the allotted limit. Flex card is not eligible for cost sharing for covered benefits. |
Services with an * (asterisk) may require a referral and/or prior authorization from your doctor.