Wellcare No Premium (HMO) H6975-005 2024 Plan Details and Costs (2024)

  • Home
  • Medicare
  • Medicare Plans
  • Wellcare No Premium (HMO)

Wellcare No Premium (HMO) H6975-005 2024 Plan Details and Costs (1)

Wellcare No Premium (HMO) H6975-005 Plan Details

Not enough data available

Wellcare No Premium (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Wellcare Health Plans, Inc.
Plan ID: H6975-005

$0.00

Monthly Premium

Wellcare No Premium (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Wellcare Health Plans, Inc.
Plan ID: H6975-005

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Get Medicare Help

Wellcare No Premium (HMO) H6975-005 2024 Plan Details and Costs (2)

Wellcare No Premium (HMO) H6975-005 Plan Details

Not enough data available

Wellcare No Premium (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Wellcare Health Plans, Inc.
Plan ID: H6975-005

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Get Medicare Help

$0.00

Monthly Premium

Alabama Counties Served

Colbert Lawrence Lauderdale Noxubee Winston Dade Madison Baldwin Mobile Saint Clair Blount Cherokee Etowah Walker Coosa Chilton Autauga Dallas Jefferson Bibb Shelby Talladega Clay Cullman Escambia Houston Dale Geneva Coffee Washington Covington Cleburne Perry Calhoun Sumter Choctaw

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $4500
Out-of-Network: N/A
Initial Coverage Limit $5030
Catastrophic Coverage Limit $8,000
Primary Care Doctor Visit

In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00

Specialty Doctor Visit

In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $15.00
Prior Authorization Required for Doctor Specialty Visit
Prior authorization required

Inpatient Hospital Care

In-Network:

Acute Hospital Services:
$300.00 per day for days 1 to 7
$0.00 per day for days 8 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required

Urgent Care

Copayment for Urgent Care $25.00
Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $120.00
Maximum Plan Benefit of $50,000

Emergency Room Visit

Copayment for Emergency Care $120.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $120.00
Maximum Plan Benefit of $50,000

Ambulance Transportation

In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $300.00

Air Ambulance:
Copayment for Air Ambulance Services $300.00

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required

Health Care Services and Medical Supplies

Wellcare No Premium (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services

In-Network:
Copayment for Medicare-covered Chiropractic Services $15.00
Prior Authorization Required for Chiropractic Services
Prior authorization required

Diabetes Supplies, Training, Nutrition Therapy and Monitoring

In-Network:
Copayment for Medicare-covered Diabetic Supplies $0.00
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Prior authorization required

Durable Medical Eqipment (DME)

In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required

Diagnostic Tests, Lab and Radiology Services, and X-Rays

In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $20.00
Copayment for Medicare-covered Lab Services $0.00 to $50.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $250.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required

Home Health Care

In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required

Mental Health Inpatient Care

In-Network:

Psychiatric Hospital Services:
$265.00 per day for days 1 to 7
$0.00 per day for days 8 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required

Mental Health Outpatient Care

In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required

Outpatient Services / Surgery

In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $250.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $120.00 to $250.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $250.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required

Outpatient Substance Abuse Care

In-Network:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required

Over-the-counter (OTC) Items

In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $109.00 every month
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit

Podiatry Services

In-Network:
Copayment for Medicare-Covered Podiatry Services $15.00
Prior Authorization Required for Podiatry Services
Prior authorization required

Skilled Nursing Facility Care

In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$203.00 per day for days 21 to 50
$0.00 per day for days 51 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care

In-Network:

Preventive Dental:
Copayment for Oral Exams $0.00

  • Maximum 2 visits every year

Copayment for Prophylaxis (Cleaning) $0.00

  • Maximum 2 visits every year

Copayment for Fluoride Treatment $0.00

  • Maximum 1 visit every year

Copayment for Dental X-Rays $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Referral Required for Preventive Dental

Comprehensive Dental:
Copayment for Medicare-covered Benefits $15.00
Copayment for Non-routine Services $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Diagnostic Services $0.00

  • Maximum 1 visit every year

Copayment for Restorative Services $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Endodontics $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Periodontics $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Extractions $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Maximum Plan Benefit of $2000.00 every year for Non-Medicare Covered Comprehensive
Prior Authorization Required for Comprehensive Dental
Prior authorization required

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits

In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00 to $15.00
Copayment for Routine Eye Exams $0.00

  • Maximum 1 Routine Eye Exam every year

Prior Authorization Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Maximum Plan Allowance of $300.00 every year for all Non-Medicare covered eyewear
Prior Authorization Required for Eyewear
Prior authorization required

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits

In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $15.00
Copayment for Routine Hearing Exams $0.00

  • Maximum 1 visit every year

Copayment for Fitting/Evaluation for Hearing Aid $0.00

  • Maximum 1 visit every year

Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $0.00

  • Maximum 2 Hearing Aids every year

Maximum Plan Benefit of $1000.00 every year per ear
Prior Authorization Required for Hearing Aids
Prior authorization required

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs

In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vagin*l cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:

  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit

    Back to Plans in Alabama

    Wellcare No Premium (HMO) H6975-005 2024 Plan Details and Costs (2024)

    References

    Top Articles
    Latest Posts
    Article information

    Author: Mr. See Jast

    Last Updated:

    Views: 6705

    Rating: 4.4 / 5 (75 voted)

    Reviews: 82% of readers found this page helpful

    Author information

    Name: Mr. See Jast

    Birthday: 1999-07-30

    Address: 8409 Megan Mountain, New Mathew, MT 44997-8193

    Phone: +5023589614038

    Job: Chief Executive

    Hobby: Leather crafting, Flag Football, Candle making, Flying, Poi, Gunsmithing, Swimming

    Introduction: My name is Mr. See Jast, I am a open, jolly, gorgeous, courageous, inexpensive, friendly, homely person who loves writing and wants to share my knowledge and understanding with you.