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Medicare Advantage 2018

Memorial Hermann Advantage HMO Plan

Memorial Hermann Advantage HMO is a health plan with a Medicare contract available to Medicare-eligible individuals who reside in Harris, Fort Bend or Montgomery counties in Texas.

Benefits of Memorial Hermann Advantage HMO

The Memorial Hermann Advantage HMO plan offers the same health coverage benefits as Original Medicare, plus enhanced benefits like:

$0 monthly premium on our HMO plan
PPO plans are also available for a monthly premium of $25.

No referrals needed to see any specialist
Gain access to our full range of specialists without a referral from your primary care physician.

National/worldwide urgent care and emergency coverage
Travel with confidence knowing that Memorial Hermann Advantage plans have you covered no matter where you are.

Prescription drug coverage (Part D)
Control drug costs with low copays for generics and name-brands, along with access to convenient mail delivery services.

Vision and hearing benefits
Get annual hearing and eye exam coverage plus $250 toward hearing aids every year.

Maximum out-of-pocket costs
Limit the annual financial liability of your healthcare costs.

Preventive screenings and services at no additional cost
Avoid major medical issues with no-cost preventive screenings for glaucoma, prostate cancer, breast cancer and more.

Fitness benefits and incentives
Enjoy a range of incentives and benefits including no-cost memberships at local fitness centers. Learn more >

Access to a vast network of hospitals and physicians
Serving Greater Houston with 17 hospitals, numerous specialty institutes and more than 3,000 physicians.

The plan requires you to use doctors and other health care professionals that participate in the Memorial Hermann Advantage HMO plan’s network. With the exception of emergency situations like ER visits, urgent care stays and renal dialysis services, without authorization, neither Medicare nor Memorial Hermann Advantage HMO will pay for these services.

See the chart below for some of the costs associated with the Memorial Hermann Advantage HMO plan.



Plan BenefitMemorial Hermann
Advantage HMO
Monthly Plan PremiumYou pay nothing
DeductibleNo deductible
Maximum Out-of-Pocket Responsibility (does not include Part D prescription drugs)You pay no more than $6,700 annually
Inpatient Hospital CoverageYou pay $250 per day for days 1 through 5. You pay nothing for days 6 through 90.
Outpatient Hospital CoverageYou pay $300 for each Medicare-covered outpatient hospital facility visit.
Doctors VisitsPrimary Care Physician Visit: You pay $5 per visit. // Specialist Visit:
You pay $50 per visit.
Preventive CareYou pay nothing
Emergency CareYou pay $80 per visit
Urgently Needed ServicesYou pay $35 per visit
Diagnostic Services/Labs/Imaging

You pay nothing for Blood Services (Transfusions)

You pay $75 per test for Non-Radiologic Diagnostic Procedures/Tests

You pay $200 per test for Diagnostic Radiology Services (MRI, CT, PET). Prior authorization required.

You pay $5 per Lab Service

You pay $25 per session for Therapeutic Radiology Services (Radiation)

You pay $10 per x-ray for Outpatient X-rays

Hearing Services

Basic hearing and balance exam performed by a primary care doctor: $5

Hearing to diagnose and treat hearing and balance issues: You pay $50

Annual hearing exam: You pay $50

Hearing Aid(s) per year: $400 annual benefit to go towards the purchase of hearing aids

Dental ServicesLimited dental services (does not include services in connection with care, treatment, filling, removal, or replacement of teeth).

Comprehensive Services: You pay $75

In general, preventive dental services (such as cleaning, routine dental exams, and dental x-rays) are not covered by Original Medicare. 

We cover: Medicare-covered dental services limited to surgery of the jaw or facial bones, extraction of teeth to prepare the jaw for radiation treatments of neoplastic cancer disease, or services that would be covered when provided by a physician.

Prior Authorization required.
Vision ServicesExam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing

Routine Eye Exam Performed by Optician/Optometrist/Ophthalmologist: You pay $50

Eyewear per year (Contact Lenses,  Eyeglasses (frames and lenses)): $200 annual benefit to go towards the purchase of eye-wear and contacts.
Mental Health Services (including Inpatient)Inpatient Services: You pay $250 per day for days 1 through 5. You pay nothing for days 6 through 90. Our plan covers an unlimited number of days for an inpatient hospital stay. Prior Authorization required.

Outpatient Services Outpatient group  therapy visit: You pay $40.

Outpatient individual  therapy visit: You pay $40. Outpatient individual therapy visit corresponds to total cost for each Medicare-covered individual therapy visit provided by a non-physician.
Skilled Nursing FacilityYou pay nothing for days 1 through 20.

You pay $100 per day for days 21 through 100.

Our plan covers up to 100 days in a skilled nursing facility per 60 day benefit period.

Prior Authorization required.
Rehabilitation ServicesCardiac (heart) Rehab Services:
You pay $25 per visit. Prior Authorization required for cardiac rehabilitation services.

Pulmonary Services:
You pay $25 per visit.

Occupational Therapy Visit: You pay $25 per visit.

Physical Therapy and Speech and Language Therapy Visit: You pay $25 per visit.
AmbulanceYou pay $250 per one-way trip
TransportationMemorial Hermann Advantage HMO does not offer transportation services.
Medicare Part B DrugsFor Part B drugs such as chemotherapy drugs:  You pay 20% coinsurance.

Other Part B Drugs: You pay 20% coinsurance.
Foot Care (Podiatry Services)You pay $25. Foot exams and treatment Routine Foot Care Limitations may apply.
Durable Medicare Equipment/SuppliesYou pay 20% coinsurance. Prior Authorization required for items over $1,000.
Wellness Programs (e.g. Fitness)Silver&Fit® Program: You pay nothing. Memorial Hermann Advantage offers Silver&Fit® club membership, Home Fitness Program, fitness challenges and more.

24 Hour Nurse Line:  You pay nothing.
Initial Coverage – Standard Retail  Cost-Sharing
(After you pay your deductible, if applicable)
Memorial Hermann
Advantage HMO
Deductible$300 Deductible applies to Tiers 4-5
Initial Coverage Limit$3,750
Tier 1: Preferred Generic$2.00 for One-Month Supply // $4.00 for Two-Month Supply // $5.00 for Three-Month Supply
Tier 2: Generic$15.00 for One-Month Supply // $30.00 for Two-Month Supply // $37.50 for Three-Month Supply
Tier 3: Preferred Brand$45.00 for One-Month Supply // $90.00 for Two-Month Supply // $112.50 for Three-Month Supply
Tier 4: Non-Preferred Brand$99.00 for One-Month Supply // $198.00 for Two-Month Supply // $247.50 for Three-Month Supply
Tier 5: Specialty Tier Drugs27% for One-Month Supply // Not available for Two-Month Supply // Not available for Three-Month Supply
Mail Order Availability

 

Tier

One-Month Supply

Two-Month Supply

Three-Month Supply

Tier 1 (Preferred Generic)

$2.00

$4.00

$4.00

Tier 2 (Generic)

$15.00

$30.00

$30.00

Tier 3 (Preferred Brand)

$45.00

$90.00

$90.00

Tier 4 (Non-Preferred Brand)

$99.00

$198.00

$198.00

Tier 5 (Specialty Tier Drugs)

27%

Not available

Not available

 If you reside in a long-term care facility, you pay the same as at a retail pharmacy.
Coverage Gap
Most Medicare drug plans have a coverage gap (also called the “donut hole”).  This means that there’s a temporary change in what you will pay for your drugs.  The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3,750. After you enter the coverage gap, you pay 35% of the price for brand name drugs plus a portion of the dispensing fee and 44% of the price for generic drugs. Not everyone will enter the coverage gap.
Catastrophic Coverage RxAfter your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $5,000, you pay the greater of: 5% of the cost, or $3.35 copay for generic or a preferred multi-source drug (including brand drugs treated as generic) and a $8.35 copay for all other drugs.

What to Consider Before Enrolling in a Memorial Hermann Advantage HMO Plan

  • You cannot enroll in a Medicare Advantage plan if you are not already enrolled in Medicare Part A and Part B. To enroll in original Medicare, visit the Social Security Administration’s website, medicare.gov. (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage website.)
  • In order to be eligible for a Memorial Hermann Advantage HMO plan, you must live within the Harris, Fort Bend or Montgomery counties in Texas.
  • If your current doctor does not participate in the Memorial Hermann Advantage HMO plan, you can talk to an authorized plan representative at (866) 350-2715 (TTY 711) to learn about other providers or to explore our PPO plan option. View a list of Memorial Hermann Advantage HMO providers, also called the Memorial Hermann Advantage HMO Provider Directory.
  • Compare Medicare Advantage plans. Use our plan comparison page to view Memorial Hermann Advantage plans side by side, and choose which one best meets your health and financial needs.

Disclaimer Information

Memorial Hermann Advantage HMO is provided by Memorial Hermann Health Plan, Inc., a Medicare Advantage organization with a Medicare contract. Enrollment in this plan depends on contract renewal.

*You must continue to pay your Medicare Part B premium.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year.

The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

Medicare beneficiaries may also enroll in a Memorial Hermann Advantage plan through CMS Medicare Online Enrollment Center located at medicare.gov. (Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage website).


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