Senior Health Plan Platinum (HMO) Benefits

CommunityCare Senior Health Plan (HMO) | HMO
Plan website: www.ccok.com
Plan Phone Number: (800) 642-8065
U.S. News Preferred Broker Phone: (888) 245-3931

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Inpatient Care

Hospital Care

No limit to the number of days covered by the plan each hospital stay.

For Medicare-covered hospital stays:

Days 1 - 7: $300 copay per day

Days 8 - 90: $0 copay per day

$0 copay for additional non-Medicare-covered hospital days

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

$30 copay for each Medicare-covered primary care doctor visit.

$50 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 copay for Medicare-covered:

lab services

therapeutic radiology services

$0 to $300 copay for Medicare-covered diagnostic procedures and tests

$0 to $300 copay for Medicare-covered X-rays

$0 to $300 copay for Medicare-covered diagnostic radiology services (not including X-rays)

Emergency Care

$65 copay for Medicare-covered emergency room visits

Worldwide coverage.

If you are admitted to the hospital within 48-hour(s) for the same condition you pay $0 for the emergency room visit.

Durable Medical Equipment

Authorization rules may apply.

$0 to $50 copay [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 copay for Medicare-covered:

Diabetes monitoring supplies

Therapeutic shoes or inserts

Ambulance Services

Authorization rules may apply.

$150 copay for Medicare-covered ambulance benefits.

If you are admitted to the hospital you pay $0 for Medicare-covered ambulance benefits.

Urgently Needed Care

$30 to $50 copay for Medicare-covered urgently-needed-care visits

Outpatient Services

Authorization rules may apply.

$300 copay for each Medicare-covered ambulatory surgical center visit

$0 to $300 copay for each Medicare-covered outpatient hospital facility visit

Chiropractic Services

$20 copay for each Medicare-covered chiropractic visit

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.

$30 copay for each Medicare-covered individual therapy visit

$30 copay for each Medicare-covered group therapy visit

$30 copay for each Medicare-covered individual therapy visit with a psychiatrist

$30 copay for each Medicare-covered group therapy visit with a psychiatrist

$50 copay for Medicare-covered partial hospitalization program services

Podiatry Services

$50 copay for each Medicare-covered podiatry visit

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

Substance Abuse Care

Authorization rules may apply.

$40 copay for Medicare-covered individual substance abuse outpatient treatment visits

$30 copay for Medicare-covered group substance abuse outpatient treatment visits

Outpatient Rehabilitation Services

Authorization rules may apply.

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

$30 copay for Medicare-covered Occupational Therapy visits

$30 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits

Prosthetic Devices

Authorization rules may apply.

$0 copay for Medicare-covered:

prosthetic devices

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.

Cardiac and Pulmonary Rehabilitation Services

Authorization rules may apply.

$0 copay for:

Medicare-covered Cardiac Rehabilitation Services

Medicare-covered Intensive Cardiac Rehabilitation Services

Medicare-covered Pulmonary Rehabilitation Services

Kidney Disease and Conditions

Authorization rules may apply.

$0 copay for Medicare-covered renal dialysis

$0 copay for Medicare-covered kidney disease education services

Additional Benefits

Dental Services

In general preventive dental benefits (such as cleaning) not covered.

$30 to $50 copay for Medicare-covered dental benefits

Hearing Services

Hearing aids not covered.

$30 copay for Medicare-covered diagnostic hearing exams

$30 copay for up to 1 supplemental routine hearing exam(s) every year

Vision Services

$0 to $50 copay for Medicare-covered exams to diagnose and treat diseases and conditions of the eye including an annual glaucoma screening for people at risk

$50 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.

$50 copay for up to 1 pair(s) of eyeglasses (lenses and frames) every two years

Over-the-Counter Items

The plan does not cover Over-the-Counter items.

Mental Health Care

Contact the plan for details about coverage in a Psychiatric Hospital beyond 190 days.

For Medicare-covered hospital stays:

Days 1 - 5: $300 copay per day

Days 6 - 90: $0 copay per day

$0 copay for additional non-Medicare-covered hospital days

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 SNF stays:

Days 1 - 20: $0 copay per day

Days 21 - 100: $100 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

This plan does not cover supplemental routine transportation.

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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