Mass Advantage Plus HMO Summary of Benefits (2023)
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
Download or print your Summary of Benefits.
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. |
Deductible |
This plan does not have a deductible. |
Pharmacy (Part D) Deductible |
This plan does not have a deductible. |
Maximum Out-of Pocket Responsibility |
$3,450 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-of pocket for Part D prescription drugs and certain supplemental Please refer to the Evidence of Coverage for more information. |
Covered Medical and Hospital Benefits
Inpatient Hospital Coverage* |
Days 1 – 5: $150 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 |
Doctor Visits* |
Primary Care: $0 copay per visit Specialist: $20 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: $120 copay per visit. |
Urgently Needed Services | $0 copay per visit |
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): $225 copay |
Hearing Services |
Routine and Hearing Aids services outlined below must be received from a NationsBenefits Hearing Health Care provider.
Medicare-covered Hearing care: $40 copay for each Medicare-covered 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 Oral exam is covered once every 36 months
• Prosthodontics, including dentures, other oral/maxillofacial surgery, and other services* *You should review your Evidence of Coverage (EOC) for additional details and coverage limits. There is a maximum allowance of $1,500 every calendar year; it applies to all comprehensive dental benefits. You are responsible for amounts beyond this limit. Medicare-covered Dental Care: $20 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: $20 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: $15 copay per visit Outpatient individual therapy: $15 copay per visit
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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 |
Outpatient Rehabilitation* |
Occupational therapy: $0 copay per visit Speech and language therapy: $0 copay per visit Physical therapy: $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. |
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: 15% coinsurance Other Part B drugs: 15% coinsurance |
Services with an * (asterisk) may require prior authorization from your doctor.
Part D Prescription Drugs
Deductible Stage | No deductible | ||||||||||||||||||||||||||||||||||||
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 Initial Coverage, and Coverage Gap phases of the Part D benefit, and only apply to beneficiaries who are not eligible for Low Income Subsidy costsharing. 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 pay the greater of:
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Additional Benefits
Over-the-Counter (OTC) Items |
You have $100 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: $20 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: $500 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. The parking benefit mentioned above is part of a special supplemental program for the chronically ill. Not all members qualify. |
Services with an * (asterisk) may require a referral and/or prior authorization from your doctor.