Cigna-HealthSpring TotalCare (HMO SNP) Benefits

Cigna-HealthSpring | HMO
Plan website: www.mycignahealthspring.com
Plan Phone Number: (888) 767-1879
U.S. News Preferred Broker Phone: (888) 245-3931
This is a Special Needs Plan (SNP). You can enroll in this plan if you qualify – call the Plan Phone Number at (888) 767-1879 for more information.

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Inpatient Care

Hospital Care

Plan covers 90 days each benefit period.

For Medicare-covered hospital stays $0 or

Days 1 - 6: $275 copay per day*

Days 7 - 90: $0 copay per day*

Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.

Outpatient Care

Doctor Office Visits

Authorization rules may apply.

$0 copay for each Medicare-covered primary care doctor visit.*

$0 copay for each Medicare-covered specialist visit.*

Doctor and Hospital Choice

You must go to network doctors specialists and hospitals.

Referral required for network hospitals and specialists (for certain benefits).

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

Authorization rules may apply.

0% of the cost for Medicare-covered lab services*

0% or 0% to 20% of the cost for Medicare-covered diagnostic procedures and tests*

0% or 20% of the cost for Medicare-covered X-rays*

0% or 0% to 20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)*

0% or 20% of the cost for Medicare-covered therapeutic radiology services*

Emergency Care

$0 or $65 copay for Medicare-covered emergency room visits*

$50 000 plan coverage limit for supplemental emergency services outside the U.S. and its territories every year.

If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit.

Durable Medical Equipment

Authorization rules may apply.

0% or 20% of the cost for Medicare-covered durable medical equipment*

Diabetes Programs and Supplies

Authorization rules may apply.

$0 copay for Medicare-covered Diabetes self-management training*

0% or 0% to 20% of the cost for Medicare-covered Diabetes monitoring supplies*

0% or 20% of the cost for Medicare-covered Therapeutic shoes or inserts*

Diabetic Supplies and Services are limited to specific manufacturers products and/or brands. Contact the plan for a list of covered supplies.

Ambulance Services

Authorization rules may apply.

0% or 20% of the cost for Medicare-covered ambulance benefits.*

$0 or $150 copay for Medicare-covered ambulance benefits.*

Urgently Needed Care

$0 copay for Medicare-covered urgently-needed-care visits*

Outpatient Services

Authorization rules may apply.

$0 or $275 copay for each Medicare-covered ambulatory surgical center visit*

$0 or $275 copay for each Medicare-covered outpatient hospital facility visit*

Chiropractic Services

$0 copay for Medicare-covered chiropractic visits*

Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part).

Outpatient Mental Health Care

Authorization rules may apply.

$0 copay for:

each Medicare-covered individual therapy visit*

each Medicare-covered group therapy visit*

$0 copay for:

each Medicare-covered individual therapy visit with a psychiatrist*

each Medicare-covered group therapy visit with a psychiatrist*

$0 copay for Medicare-covered partial hospitalization program services*

Podiatry Services

$0 copay for Medicare-covered podiatry visits*

Medicare-covered podiatry visits are for medically necessary foot care.

Substance Abuse Care

Authorization rules may apply.

$0 copay for:

each Medicare-covered individual substance abuse outpatient treatment visit*

each Medicare-covered group substance abuse outpatient treatment visit*

Outpatient Rehabilitation Services

Authorization rules may apply.

Medically necessary physical therapy occupational therapy and speech and language pathology services are covered.

$0 copay for Medicare-covered Occupational Therapy visits*

$0 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits*

Prosthetic Devices

Authorization rules may apply.

0% or 20% of the cost for Medicare-covered prosthetic devices*

0% or 20% of the cost for Medicare-covered medical supplies related to prosthetics splints and other devices*

Preventive Services

$0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare.

Plan covers a physical exam annually.

Cardiac and Pulmonary Rehabilitation Services

Authorization rules may apply.

$0 or $10 copay for Medicare-covered Cardiac Rehabilitation Services*

$0 or $10 copay for Medicare-covered Intensive Cardiac Rehabilitation Services*

$0 or $10 copay for Medicare-covered Pulmonary Rehabilitation Services*

Kidney Disease and Conditions

0% or 20% of the cost for Medicare-covered renal dialysis*

$0 copay for Medicare-covered kidney disease education services*

Additional Benefits

Dental Services

$0 copay for the following preventive dental benefits:

up to 1 oral exam(s) every six months

up to 1 cleaning(s) every six months

up to 1 dental x-ray(s) every year

$0 copay for Medicare-covered dental benefits*

Plan offers additional supplemental comprehensive dental benefits.

$1 000 plan coverage limit for supplemental comprehensive dental benefits every year

Hearing Services

In general supplemental routine hearing exams and hearing aids not covered.

$0 copay for: Medicare-covered diagnostic hearing exams*

Vision Services

$0 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye including an annual glaucoma screening for people at risk*

$0 copay for up to 1 supplemental routine eye exam(s) every year

$0 copay for one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery *

up to 1 pair(s) of eyeglasses (lenses and frames) every year

contact lenses

up to 1 pair(s) of eyeglass lenses every year

up to 1 eyeglass frame(s) every year

$200 plan coverage limit for supplemental eyewear every year

Plan offers additional vision benefits. Contact plan for details.

Over-the-Counter Items

Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit.

Mental Health Care

You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.

For Medicare-covered hospital stays $0 or

Days 1 - 6: $245 copay per day*

Days 7 - 90: $0 copay per day*

Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.

Skilled Nursing Facility (SNF)

Authorization rules may apply.

Plan covers up to 100 days each benefit period

No prior hospital stay is required.

For Medicare-covered SNF stays $0 or

Days 1 - 5: $0 copay per day*

Days 6 - 20: $25 copay per day*

Days 21 - 100: $150 copay per day*

For SNF stays:

Days 1 - 5: $0 copay per day

Days 6 - 20: $25 copay per day

Days 21 - 100: $150 copay per day

Home Health Care

Authorization rules may apply.

$0 copay for Medicare-covered home health visits*

Hospice

You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice.

Transportation

Authorization rules may apply.

$0 copay for up to 20 one-way trip(s) to plan-approved location every year

Acupuncture

This plan does not cover Acupuncture and other alternative therapies.

Wellness/Education & Other Benefits

The plan covers the following supplemental education/wellness programs:

Nursing Hotline

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