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New York MedicareAdvantage Plans

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Medicare Advantage Plans in Suffolk County, New York

Below are Medicare Advantage plans available to residents of Suffolk county, New York. 10 carriers offer 31 plans throughout the county of Suffolk. Residents may choose plans from carriers such as QUALITY HEALTH PLANS, Fidelis Care and Comprehensive Care Management Corp.. This data has been made available by the Centers for Medicare & Medicaid Services (CMS) and is for informational purposes only. Some data may be inaccurate or incomplete. Please note that plans can vary by city, county, and state and all plans listed may not be available in all areas. To speak to an advisor and find the Medicare Advantage plan in Suffolk county that is right for you complete the form at the top of the page.

Medicare Advantage Health Plans in the county of Suffolk

Carrier Plan Title Plan Type
QUALITY HEALTH PLANS Advantage Platinum NY (HMO) (H2773-001) HMO

    Premium and Other Important Information

    • $3 400 out-of-pocket limit for Medicare-covered services.
    • $40 monthly plan premium in addition to your monthly Medicare Part B premium.
    • Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married co

    Doctor Office Visits

    • $0 copay for each primary care doctor visit for Medicare-covered benefits.
    • $15 copay for each in-area network urgent care Medicare-covered visit
    • $15 copay for each specialist visit for Medicare-covered benefits.
    QUALITY HEALTH PLANS Advantage Silver NY (HMO) (H2773-002) HMO

      Premium and Other Important Information

      • $3 400 out-of-pocket limit for Medicare-covered services.
      • $0 monthly plan premium in addition to your monthly Medicare Part B premium.
      • Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married co

      Doctor Office Visits

      • $0 copay for each primary care doctor visit for Medicare-covered benefits.
      • $15 copay for each in-area network urgent care Medicare-covered visit
      • $25 copay for each specialist visit for Medicare-covered benefits.
      QUALITY HEALTH PLANS Advantage Health NY - SNP (HMO SNP) (H2773-003) HMO

        Premium and Other Important Information

        • $3 400 out-of-pocket limit for Medicare-covered services.
        • $0 monthly plan premium in addition to your monthly Medicare Part B premium.
        • Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married co

        Doctor Office Visits

        • $0 copay for each primary care doctor visit for Medicare-covered benefits.
        • $15 copay for each in-area network urgent care Medicare-covered visit
        • $20 copay for each specialist visit for Medicare-covered benefits.
        QUALITY HEALTH PLANS Advantage Value One NY - Dual (HMO SNP) (H2773-004) HMO

          Premium and Other Important Information

          • * Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services
          • $0 annual deductible.*
          • ** Please consult with your plan about cost sharing when receiving services from out-of-network providers.
          • $6 700 out-of-pocket limit for Medicare-covered services. However in this plan you will have no cost sharing responsibility for Medicare-covered services based on your level of Medicaid eligibility.
          • $0 monthly plan premium*

          Doctor Office Visits

          • Authorization rules may apply.
          • $0 copay for each primary care doctor visit for Medicare-covered benefits.*
          • $0 copay for the cost of each in-area network urgent care Medicare-covered visit.*
          • $0 copay for each specialist doctor visit for Medicare-covered benefits.*
          Fidelis Care Fidelis Medicare Advantage without Rx (HMO-POS) (H3328-001) HMO with POS Option

            Premium and Other Important Information

            • $6 700 out-of-pocket limit for Medicare-covered services.
            • $0.00 monthly plan premium in addition to your monthly Medicare Part B premium.
            • Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more i

            Doctor Office Visits

            • $20 copay for each primary care doctor visit for Medicare-covered benefits.
            • $40 copay for each in-area network urgent care Medicare-covered visit
            • $40 copay for each specialist visit for Medicare-covered benefits.
            Fidelis Care Fidelis Medicare Advantage Flex (HMO-POS) (H3328-003) HMO with POS Option

              Premium and Other Important Information

              • $6 700 out-of-pocket limit for Medicare-covered services.
              • $750 plan coverage limit every year for Non-Medicare Supplemental benefits. Contact the plan for services that apply.
              • $39.8 monthly plan premium in addition to your monthly Medicare Part B premium.
              • Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married co

              Doctor Office Visits

              • $5 copay for each primary care doctor visit for Medicare-covered benefits.
              • $30 copay for each in-area network urgent care Medicare-covered visit
              • $30 copay for each specialist visit for Medicare-covered benefits.
              Fidelis Care Fidelis Dual Advantage Flex (HMO SNP) (H3328-013) HMO

                Premium and Other Important Information

                • * Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services
                • $0 annual deductible.*
                • ** Please consult with your plan about cost sharing when receiving services from out-of-network providers.
                • $6 700 out-of-pocket limit for Medicare-covered services. However in this plan you will have no cost sharing responsibility for Medicare-covered services based on your level of Medicaid eligibility.
                • $400 plan coverage limit every year for Non-Medicare Supplemental benefits. Contact the plan for services that apply.
                • $0 monthly plan premium*

                Doctor Office Visits

                • $0 copay for each primary care doctor visit for Medicare-covered benefits.*
                • $0 copay for the cost of each in-area network urgent care Medicare-covered visit.*
                • $0 copay for each specialist doctor visit for Medicare-covered benefits.*
                Comprehensive Care Management Corp. CCMC PACE Dual Eligible (PACE) (H3329-001) National PACE
                  Comprehensive Care Management Corp. CCMC - PACE - Medicare only (PACE) (H3329-002) National PACE
                    EmblemHealth Medicare HMO VIP (HMO) (H3330-021) HMO

                      Premium and Other Important Information

                      • $3 400 out-of-pocket limit for Medicare-covered services.
                      • $0 monthly plan premium in addition to your monthly Medicare Part B premium.
                      • $21 monthly plan premium in addition to your monthly Medicare Part B premium.
                      • $118 monthly plan premium in addition to your monthly Medicare Part B premium.
                      • Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married co

                      Doctor Office Visits

                      • $15 copay for each primary care doctor visit for Medicare-covered benefits.
                      • $25 copay for each in-area network urgent care Medicare-covered visit
                      • $25 copay for each specialist visit for Medicare-covered benefits.
                      EmblemHealth Medicare HMO Dual Eligible (HMO SNP) (H3330-029) HMO

                        Premium and Other Important Information

                        • * Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services
                        • ** Please consult with your plan about cost sharing when receiving services from out-of-network providers.
                        • $3 400 out-of-pocket limit for Medicare-covered services.*
                        • $39.8 monthly plan premium in addition to your monthly Medicare Part B premium.*

                        Doctor Office Visits

                        • $0 copay for each primary care doctor visit for Medicare-covered benefits.*
                        • $0 copay for the cost of each in-area network urgent care Medicare-covered visit.*
                        • $0 copay for each specialist doctor visit for Medicare-covered benefits.*
                        EmblemHealth Medicare HMO VIP Essential (HMO) (H3330-032) HMO

                          Premium and Other Important Information

                          • $3 400 out-of-pocket limit for Medicare-covered services.
                          • $0 monthly plan premium in addition to your monthly Medicare Part B premium.
                          • $123 monthly plan premium in addition to your monthly Medicare Part B premium.
                          • Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married co

                          Doctor Office Visits

                          • $0 copay for each primary care doctor visit for Medicare-covered benefits.
                          • $10 copay for each in-area network urgent care Medicare-covered visit
                          • $10 copay for each specialist visit for Medicare-covered benefits.
                          EmblemHealth Medicare HMO VIP High Option (HMO) (H3330-033) HMO

                            Premium and Other Important Information

                            • $3 400 out-of-pocket limit for Medicare-covered services.
                            • $154 monthly plan premium in addition to your monthly Medicare Part B premium.
                            • $180 monthly plan premium in addition to your monthly Medicare Part B premium.
                            • $271 monthly plan premium in addition to your monthly Medicare Part B premium.
                            • Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married co

                            Doctor Office Visits

                            • $0 copay for each primary care doctor visit for Medicare-covered benefits.
                            • $0 copay for the cost of each in-area network urgent care Medicare-covered visit.
                            • $0 copay for each specialist doctor visit for Medicare-covered benefits.
                            Empire BlueCross BlueShield Empire MediBlue Freedom III (PPO) (H3342-002) Local Preferred Provider Organization

                              Premium and Other Important Information

                              • $2 800 out-of-pocket limit for Medicare-covered services.
                              • $106 monthly plan premium in addition to your monthly Medicare Part B premium.
                              • Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married co
                              • Some physicians providers and suppliers that are out of a plan's network (i.e. out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept

                              Doctor Office Visits

                              • $10 copay for each primary care doctor visit for Medicare-covered benefits.
                              • $20 copay for each in-area network urgent care Medicare-covered visit
                              • $20 copay for each specialist visit for Medicare-covered benefits.
                              • $30 copay for each primary care doctor visit
                              • $50 copay for each specialist visit
                              Empire BlueCross BlueShield Empire MediBlue Freedom I (PPO) (H3342-012) Local Preferred Provider Organization

                                Premium and Other Important Information

                                • Package: 1 - Preventive Dental Package:
                                • Package: 2 - Comprehensive Dental and Vision Package:
                                • $12 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: Preventive Dental
                                • $30 monthly premium in addition to your $0 monthly plan premium and the monthly Medicare Part B premium for the following optional benefits: Preventive Dental Comprehensive Dental Eye Exams Eye Wear
                                • $4 500 out-of-pocket limit for Medicare-covered services.
                                • $0 monthly plan premium in addition to your monthly Medicare Part B premium.
                                • Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married co
                                • Some physicians providers and suppliers that are out of a plan's network (i.e. out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept

                                Doctor Office Visits

                                • $15 copay for each primary care doctor visit for Medicare-covered benefits.
                                • $35 copay for each in-area network urgent care Medicare-covered visit
                                • $35 copay for each specialist visit for Medicare-covered benefits.
                                • $40 copay for each primary care doctor visit
                                • $65 copay for each specialist visit
                                Empire BlueCross BlueShield Empire MediBlue Freedom II (PPO) (H3342-015) Local Preferred Provider Organization

                                  Premium and Other Important Information

                                  • $3 400 out-of-pocket limit for Medicare-covered services.
                                  • $66 monthly plan premium in addition to your monthly Medicare Part B premium.
                                  • Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married co
                                  • Some physicians providers and suppliers that are out of a plan's network (i.e. out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept

                                  Doctor Office Visits

                                  • $10 copay for each primary care doctor visit for Medicare-covered benefits.
                                  • $25 copay for each in-area network urgent care Medicare-covered visit
                                  • $25 copay for each specialist visit for Medicare-covered benefits.
                                  • $30 copay for each primary care doctor visit
                                  • $50 copay for each specialist visit
                                  WellCare WellCare Liberty (HMO SNP) (H3361-043) HMO

                                    Premium and Other Important Information

                                    • * Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services
                                    • $0 annual deductible.*
                                    • ** Please consult with your plan about cost sharing when receiving services from out-of-network providers.
                                    • $6 700 out-of-pocket limit for Medicare-covered services. However in this plan you will have no cost sharing responsibility for Medicare-covered services based on your level of Medicaid eligibility.
                                    • $0 monthly plan premium*

                                    Doctor Office Visits

                                    • $0 copay for each primary care doctor visit for Medicare-covered benefits.*
                                    • $0 copay for the cost of each in-area network urgent care Medicare-covered visit.*
                                    • $0 copay for each specialist doctor visit for Medicare-covered benefits.*
                                    WellCare WellCare Choice (HMO-POS) (H3361-106) HMO with POS Option

                                      Premium and Other Important Information

                                      • $6 700 out-of-pocket limit for Medicare-covered services.
                                      • $0 monthly plan premium in addition to your monthly Medicare Part B premium.
                                      • Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married co

                                      Doctor Office Visits

                                      • $0 copay for each primary care doctor visit for Medicare-covered benefits.
                                      • $35 copay for each in-area network urgent care Medicare-covered visit
                                      • $20 copay for each specialist visit for Medicare-covered benefits.
                                      WellCare WellCare Access (HMO SNP) (H3361-109) HMO

                                        Premium and Other Important Information

                                        • * Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services
                                        • $0 annual deductible.*
                                        • ** Please consult with your plan about cost sharing when receiving services from out-of-network providers.
                                        • $6 700 out-of-pocket limit for Medicare-covered services. However in this plan you will have no cost sharing responsibility for Medicare-covered services based on your level of Medicaid eligibility.
                                        • $0 monthly plan premium*

                                        Doctor Office Visits

                                        • $0 copay for each primary care doctor visit for Medicare-covered benefits.*
                                        • $0 copay for the cost of each in-area network urgent care Medicare-covered visit.*
                                        • $0 copay for each specialist doctor visit for Medicare-covered benefits.*
                                        WellCare WellCare Rx (HMO) (H3361-130) HMO

                                          Premium and Other Important Information

                                          • $6 700 out-of-pocket limit for Medicare-covered services.
                                          • $37.5 monthly plan premium in addition to your monthly Medicare Part B premium.
                                          • Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married co

                                          Doctor Office Visits

                                          • $0 copay for each primary care doctor visit for Medicare-covered benefits.
                                          • $35 copay for each in-area network urgent care Medicare-covered visit
                                          • $10 copay for each specialist visit for Medicare-covered benefits.
                                          Empire BlueCross BlueShield Empire MediBlue Plus (HMO) (H3370-004) HMO

                                            Premium and Other Important Information

                                            • $3 400 out-of-pocket limit for Medicare-covered services.
                                            • $78 monthly plan premium in addition to your monthly Medicare Part B premium.
                                            • Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married co

                                            Doctor Office Visits

                                            • $15 copay for each primary care doctor visit for Medicare-covered benefits.
                                            • $25 copay for each in-area network urgent care Medicare-covered visit
                                            • $25 copay for each specialist visit for Medicare-covered benefits.
                                            UnitedHealthcare UnitedHealthcare Nursing Home Plan (HMO SNP) (H3379-002) HMO

                                              Premium and Other Important Information

                                              • $5 000 out-of-pocket limit for Medicare-covered services.
                                              • $36.3 monthly plan premium in addition to your monthly Medicare Part B premium.
                                              • Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married co

                                              Doctor Office Visits

                                              • $0 copay for each primary care doctor visit for Medicare-covered benefits.
                                              • 20% of the cost for each in-area network urgent care Medicare-covered visit
                                              • 0% to 20% of the cost for each specialist visit for Medicare-covered benefits.
                                              EmblemHealth Medicare PPO PPO I (PPO) (H5528-009) Local Preferred Provider Organization

                                                Premium and Other Important Information

                                                • $3 400 out-of-pocket limit for Medicare-covered services.
                                                • $5 100 out-of-pocket limit for Medicare-covered services.
                                                • $57.00 monthly plan premium in addition to your monthly Medicare Part B premium.
                                                • Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more i
                                                • Some physicians providers and suppliers that are out of a plan's network (i.e. out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept

                                                Doctor Office Visits

                                                • $5 copay for each primary care doctor visit for Medicare-covered benefits.
                                                • $15 copay for each in-area network urgent care Medicare-covered visit
                                                • $15 copay for each specialist visit for Medicare-covered benefits.
                                                • 25% of the cost for each primary care doctor visit
                                                • 25% of the cost for each specialist visit
                                                EmblemHealth Medicare PPO PPO II (PPO) (H5528-010) Local Preferred Provider Organization

                                                  Premium and Other Important Information

                                                  • $3 400 out-of-pocket limit for Medicare-covered services.
                                                  • $5 100 out-of-pocket limit for Medicare-covered services.
                                                  • $65 monthly plan premium in addition to your monthly Medicare Part B premium.
                                                  • Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married co
                                                  • Some physicians providers and suppliers that are out of a plan's network (i.e. out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept

                                                  Doctor Office Visits

                                                  • $15 copay for each primary care doctor visit for Medicare-covered benefits.
                                                  • $25 copay for each in-area network urgent care Medicare-covered visit
                                                  • $25 copay for each specialist visit for Medicare-covered benefits.
                                                  • 25% of the cost for each primary care doctor visit
                                                  • 25% of the cost for each specialist visit
                                                  EmblemHealth Medicare PPO PPO III (PPO) (H5528-011) Local Preferred Provider Organization

                                                    Premium and Other Important Information

                                                    • $3 400 out-of-pocket limit for Medicare-covered services.
                                                    • $5 100 out-of-pocket limit for Medicare-covered services.
                                                    • $120 monthly plan premium in addition to your monthly Medicare Part B premium.
                                                    • Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married co
                                                    • Some physicians providers and suppliers that are out of a plan's network (i.e. out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept

                                                    Doctor Office Visits

                                                    • $5 copay for each primary care doctor visit for Medicare-covered benefits.
                                                    • $15 copay for each in-area network urgent care Medicare-covered visit
                                                    • $15 copay for each specialist visit for Medicare-covered benefits.
                                                    • 25% of the cost for each primary care doctor visit
                                                    • 25% of the cost for each specialist visit
                                                    EmblemHealth Medicare PPO PPO High Option (PPO) (H5528-021) Local Preferred Provider Organization

                                                      Premium and Other Important Information

                                                      • $3 400 out-of-pocket limit for Medicare-covered services.
                                                      • $5 100 out-of-pocket limit for Medicare-covered services.
                                                      • $211 monthly plan premium in addition to your monthly Medicare Part B premium.
                                                      • Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married co
                                                      • Some physicians providers and suppliers that are out of a plan's network (i.e. out-of-network) accept "assignment" from Medicare and will only charge up to a Medicare-approved amount. If you choose to see an out-of-network physician who does NOT accept

                                                      Doctor Office Visits

                                                      • $0 copay for each primary care doctor visit for Medicare-covered benefits.
                                                      • $0 copay for the cost of each in-area network urgent care Medicare-covered visit.
                                                      • $0 copay for each specialist doctor visit for Medicare-covered benefits.
                                                      • 35% of the cost for each primary care doctor visit
                                                      • 35% of the cost for each specialist visit
                                                      Comprehensive Care Management Corp. CCM Direct Complete Plan (HMO SNP) (H5989-002) HMO

                                                        Premium and Other Important Information

                                                        • In 2012 the annual Part B deductible amount is $140. Contact the plan for services that apply.
                                                        • $6 700 out-of-pocket limit for Medicare-covered services.
                                                        • $39.7 monthly plan premium in addition to your monthly Medicare Part B premium.
                                                        • Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay higher Part B and Part D premiums because of their yearly income (over $85 000 for singles $170 000 for married co

                                                        Doctor Office Visits

                                                        • Authorization rules may apply.
                                                        • $0 copay for each primary care doctor visit for Medicare-covered benefits.
                                                        • 20% of the cost for each specialist visit for Medicare-covered benefits.
                                                        Comprehensive Care Management Corp. CCM Direct Total Plan (HMO SNP) (H5989-008) HMO

                                                          Premium and Other Important Information

                                                          • * Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services
                                                          • ** Please consult with your plan about cost sharing when receiving services from out-of-network providers.
                                                          • $3 400 out-of-pocket limit for Medicare-covered services.*
                                                          • $0 monthly plan premium in addition to your monthly Medicare Part B premium.*

                                                          Doctor Office Visits

                                                          • Authorization rules may apply.
                                                          • 0% or 20% of the cost for each primary care doctor visit for Medicare-covered benefits.*
                                                          • 0% or 20% of the cost for each specialist visit for Medicare-covered benefits.*
                                                          GuildNet GuildNet Gold (HMO-POS SNP) (H6864-001) HMO with POS Option

                                                            Premium and Other Important Information

                                                            • * Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services
                                                            • $0 annual deductible.*
                                                            • ** Please consult with your plan about cost sharing when receiving services from out-of-network providers.
                                                            • $3 400 out-of-pocket limit. All plan services included. However in this plan you will have no cost sharing responsibility for Medicare-covered services based on your level of Medicaid eligibility. Contact plan for details regarding cost sharing
                                                            • $0 monthly plan premium*

                                                            Doctor Office Visits

                                                            • $0 copay for each primary care doctor visit for Medicare-covered benefits.*
                                                            • $0 copay for the cost of each in-area network urgent care Medicare-covered visit.*
                                                            • $0 copay for each specialist doctor visit for Medicare-covered benefits.*
                                                            GuildNet GuildNet Health Advantage (HMO-POS SNP) (H6864-002) HMO with POS Option

                                                              Premium and Other Important Information

                                                              • * Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services
                                                              • ** Please consult with your plan about cost sharing when receiving services from out-of-network providers.
                                                              • $3 400 out-of-pocket limit. All plan services included.*
                                                              • $0 monthly plan premium in addition to your monthly Medicare Part B premium.*

                                                              Doctor Office Visits

                                                              • 0% or 15% of the cost for each primary care doctor visit for Medicare-covered benefits.*
                                                              • 0% or 15% of the cost for each in-area network urgent care Medicare-covered visit*
                                                              • 0% or 15% of the cost for each specialist visit for Medicare-covered benefits.*
                                                              ActiveSaver MSA or BlueSaver MSA ActiveSaver MSA (MSA) (H9788-004) Medical Savings Account

                                                                Premium and Other Important Information

                                                                • Balance billing means that a provider may charge and bill you more than the plan's payment amount for services There is a limit on what providers may charge for Medicare-covered services
                                                                • $4 250 annual deductible
                                                                • Note that only Medicare-covered services will count toward your annual deductible.
                                                                • Medicare will deposit $2 500 into your bank account.
                                                                • You will not have a monthly plan premium. Medicare pays the monthly plan premium for the Medicare MSA Plan.
                                                                • Most people will pay the standard monthly Part B premium in addition to their MA plan premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more i
                                                                • Balance billing counts towards your plan deductible.

                                                                Doctor Office Visits

                                                                • Once you reach the plan deductible Medicare MSA plans cover Original Medicare benefits. Co-pay for Medicare MSAs is $0 once deductible is met.

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