iCare Medicare Plan (HMO D-SNP)
iCare Medicare Plan (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Independent Care Health Plan Inc.
Plan ID: H2237-001
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
iCare Medicare Plan (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Independent Care Health Plan Inc.
Plan ID: H2237-001
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Wisconsin Counties Served
Basic Costs and Coverage
Coverage | Cost |
---|---|
Monthly Deductible | $0 |
Out of Pocket Max |
In-Network: $8850 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 $0.00 Prior Authorization Required for Doctor Specialty Visit Referral Required for Doctor Specialty Visit Prior authorization required |
Inpatient Hospital Care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $0.00 Your plan covers an unlimited number of days for an inpatient stay. Prior Authorization Required for Acute Hospital Services Referral Required for Acute Hospital Services Prior authorization required |
Urgent Care | Copayment for Urgent Care $0.00 |
Emergency Room Visit | Copayment for Emergency Care $0.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours |
Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $0.00 Air Ambulance: Copayment for Air Ambulance Services $0.00 Please see Evidence of Coverage for Prior Authorization rules Prior authorization required |
Health Care Services and Medical Supplies
iCare Medicare Plan (HMO D-SNP) 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 $0.00 Prior Authorization Required for Chiropractic Services Referral Required for Chiropractic Services Prior authorization required |
Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0.00 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00 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: Copayment for Medicare-covered Durable Medical Equipment $0.00 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 Copayment for Medicare-covered Lab Services $0.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Referral Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 Copayment for Medicare-covered Therapeutic Radiological Services $0.00 Copayment for Medicare-covered X-Ray Services $0.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Referral 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 Referral Required for Home Health Services Prior authorization required |
Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $0.00 Prior Authorization Required for Psychiatric Hospital Services Referral Required for Psychiatric Hospital Services Prior authorization required |
Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 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 Prior Authorization Required for Outpatient Hospital Services Referral Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0.00 Prior Authorization Required for Outpatient Observation Services Referral Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 Prior Authorization Required for Ambulatory Surgical Center Services Referral Required for Ambulatory Surgical Center Services Prior authorization required |
Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required |
Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: *Please see Healthy Options Allowance under "Flexible Extras"* Copayment for Over-The-Counter (OTC) Items $0.00 Amount does rollover month to month if member does not use it, that’s up to $1,800 a year. Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit |
Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $0.00 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 $0.00 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Referral 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: $0 copayment for scaling and root planing (deep cleaning) up to 1 per quadrant every 3 years. $0 copayment for comprehensive oral evaluation or periodontal exam, occlusal adjustment, scaling for moderate inflammation up to 1 every 3 years. $0 copayment for bridge recementation, bridges, complete dentures, crown recementation, panoramic film or diagnostic x-rays, partial dentures up to 1 every 5 years. $0 copayment for crown, root canal, root canal retreatment up to 1 per tooth per lifetime. $0 copayment for bitewing x-rays, intraoral x-rays up to 1 set(s) per year. $0 copayment for adjustments to dentures, denture rebase, denture reline, denture repair, emergency diagnostic exam, tissue conditioning up to 1 per year. $0 copayment for emergency treatment for pain, fluoride treatment, oral surgery, periodic oral exam, prophylaxis (cleaning) up to 2 per year. $0 copayment for periodontal maintenance up to 4 per year. $0 copayment for amalgam and/or composite filling, necessary anesthesia with covered service, simple or surgical extraction up to unlimited per year. $4,000 maximum benefit coverage amount per year for all preventive and comprehensive benefits. Out of Network: |
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 Copayment for Routine Eye Exams $0.00
Prior Authorization Required for Eye Exams Referral Required for Eye Exams Eyewear: Copayment for Medicare-Covered Benefits $0.00 Copayment for Contact Lenses $0.00
Prior Authorization Required for Eyewear Referral 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 $0.00 Copayment for Routine Hearing Exams $0.00
Prior Authorization Required for Hearing Exams Referral Required for Hearing Exams Hearing Aids: Copayment for Hearing Aids $0.00
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 & vaginal 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:
Yearly "Wellness" visit |
Prescription Drug Costs and Coverage
The iCare Medicare Plan (HMO D-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $0 per year.
Coverage |
Cost
|
---|---|
Coverage & Cost
|
|
Annual Drug Deductible | $0 |
Preferred Generic |
|
Generic |
|
Preferred Brand |
|
Non-Preferred Drug |
|
Specialty Tier |
|
Annual Drug Deductible | $0 |
Preferred Generic |
|
Generic |
|
Preferred Brand |
|
Non-Preferred Drug |
|
Specialty Tier |
|
Annual Drug Deductible | $0 |
Preferred Generic |
|
Generic |
|
Preferred Brand |
|
Non-Preferred Drug |
|
Specialty Tier |
|