Mass Advantage Plus HMO Summary of Benefits (2024)
Lower out-of-pocket costs overall/$100 monthly premium
With Mass Advantage Plus HMO, you save money by choosing a Primary Care Provider and using in-network care providers. And your out-of-pocket maximum (the highest amount you’d be responsible for paying) is the lowest of the three plans we offer. Part D prescription drug coverage is also included. Result? All your health care services are easily accessed in one convenient plan.
Mass Advantage Plus HMO Summary of Benefits
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Mass Advantage Plus HMO Evidence of Coverage
Download or print your Evidence of Coverage.
Monthly Premium, Deductible, and Limits on how much you pay for covered services
Monthly Plan Premium |
$100 You must continue to pay your Medicare Part B premium. |
Medical Deductible |
This plan does not have a deductible. |
Maximum Out-of Pocket Responsibility |
Your yearly limit(s) in this plan:
This is the most you will pay in copays and coinsurance for covered medical services for the year. Please note that you will still need to pay your monthly premiums and cost-sharing for Part D prescription drugs. Not all services apply to the Maximum Out-of-Pocket. Please refer to the Evidence of Coverage for more information. |
Covered Medical and Hospital Benefits
Inpatient Hospital Coverage* |
Days 1 – 5: $200 copay per day Days 6 – beyond: $0 copay per day |
Outpatient Hospital Coverage* |
Outpatient Hospital: $150 copay per stay Observation Services: $150 copay per stay |
Ambulatory Surgical Center* |
$150 copay per visit |
Skilled Nursing Facility (SNF)* |
Days 1-20: $0 copay per day Days 21-51: $75 copay per day Days 52-100: $0 copay per day |
Preventive Care | There is no coinsurance, copayment, or deductible for Medicare-covered preventive services. |
Doctor Visits* |
Primary Care: $0 copay per visit Specialist: $20 copay per visit |
Telehealth Services |
Primary Care Physician Services: $0 copay per visit Physician Specialist Services: $20 copay per visit Individual Sessions for Mental Health Specialty Services: $0 Individual Sessions for Outpatient Substance Abuse: $0 |
Diagnostic Services/ Labs/Imaging* |
Lab services: $0 copay Diagnostic tests and procedures: $0 copay Outpatient X-ray services: $0 copay Diagnostic Radiology services (such as, MRI, MRA, CT, PET): |
Chiropractic Care | Chiropractic Care (Medicare-covered): $15 copay per visit |
Outpatient Rehabilitation* |
Occupational therapy: $0 copay per visit Speech and language therapy: $0 copay per visit Physical therapy: $0 copay per visit |
Mental Health Services* |
Outpatient group therapy: $15 copay per visit Outpatient individual therapy: $15 copay per visit Inpatient Mental Health Care:
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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 | $0 copay per visit |
Ambulance* |
Ground Ambulance: $200 copay (per one-way trip) Air Ambulance: $200 copay (per one-way trip) If you are admitted to the hospital, you do not have to pay your ambulance services copay. |
Medicare Part B Drugs* |
Chemotherapy drugs: Up to 15% coinsurance Other Part B drugs: Up to 15% coinsurance |
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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Services with an * (asterisk) may require prior authorization from your doctor.
Additional Benefits
Dental Services* |
Dental services (Medicare-covered): $20 copay per visit Preventive and comprehensive dental services outlined below Preventive dental services include the following: $0 copay
Comprehensive dental services including restorative services, There is a maximum allowance of $2,000 each calendar year for The Flex Card can be used for preventive and comprehensive *You should review your EOC for additional details and coverage |
Hearing Services |
Hearing exam (Medicare-covered): $20 copay Routine and Hearing Aids services outlined below must be received from a NationsBenefits Hearing Health Care provider. Routine hearing exam: $0 copay (1 every calendar year) Entry Hearing Aids: $500 per hearing aid Basic Hearing Aids: $675 per hearing aid Prime Hearing Aids: $975 per hearing aid Preferred Hearing Aids: $1,275 per hearing aid Advanced Hearing Aids: $1,575 per hearing aid Premium Hearing Aids: $1,975 per hearing aid Limit of two hearing aids per calendar year (one per ear). |
Vision Services |
You pay a $20 copay for each Medicare-covered eye exam related to the diagnosis and treatment of diseases and conditions of the eye. Routine and vision services outlined below must be received by an in-network provider. Routine eye exam: $0 copay per visit (1 every calendar year) $200 allowance every calendar year to use towards the purchase of contact lenses, eyeglass lenses, and eyeglass frames. |
Flex Card |
The Flex Card consists of 3 separate benefit wallets:
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. **Dental services not covered through DentaQuest |
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. |
Over-the-Counter (OTC) Items |
You have $120 every quarter to spend on plan approved OTC Any unused money will carry over to the next quarter but will not |
Services with an * (asterisk) may require prior authorization from your doctor.
Part D Prescription Drugs
Deductible Stage |
No deductible |
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Initial Coverage Stage |
You pay the following until your total yearly drug costs reach $5,030. 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. Insulin: Although all of the insulins covered by our plan are on Tier 3, what you pay is lower than our plan’s Tier 3 copay. You pay $35 for a one-month supply of insulin. You pay this amount all year long until the Catastrophic Coverage stage. Vaccines: You pay $0 for your vaccines that are covered under Part B (e.g. flu vaccine, COVID vaccine) and Part D (e.g. Shingrix) all year long. |
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Coverage Gap Stage |
Tiers 1 and 2 drugs: You continue to pay the copay amounts that apply during the Initial Coverage Stage. Tiers 3, 4, and 5 drugs: After you enter the coverage gap, 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 $8,000 which is the end of the coverage gap. |
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Catastrophic Stage |
After your yearly out-of-pocket drug costs reach $8,000, you pay $0 for all covered Part D drugs for the remainder of the calendar year. |