iCare Medicare Plan SNP-DE (HMO D-SNP)
iCare Medicare Plan SNP-DE (HMO D-SNP) H2237-001 Plan Details
iCare Medicare Plan SNP-DE (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Independent Care Health Plan Inc.
Plan ID: H2237-001
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
iCare Medicare Plan SNP-DE (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Independent Care Health Plan Inc.
Plan ID: H2237-001
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Wisconsin Counties Served
Waukesha
Dodge
Washington
Sheboygan
Ozaukee
Winnebago
Trempealeau
Waupaca
Brown
Outagamie
Shawano
Adams
Juneau
Green Lake
Marquette
Sauk
Richland
Dane
Lafayette
Milwaukee
Walworth
Racine
Kenosha
Jefferson
Manitowoc
Fond Du Lac
Calumet
Door
Waushara
Marinette
Oconto
Florence
Menominee
Kewaunee
Douglas
Rock
Green
Iowa
Grant
Columbia
Crawford
Monroe
Vernon
Pierce
Jackson
Gogebic
Iron
Buffalo
La Crosse
Pepin
Bayfield
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $9350 Out-of-Network: N/A |
| Initial Coverage Limit | $2000 |
| Catastrophic Coverage Limit | $2,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Coinsurance for Primary Care Office Visit 0% or 20% |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Coinsurance for Physician Specialist Office Visit 0% or 20% 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 or $2185 Prior Authorization Required for Acute Hospital Services Referral Required for Acute Hospital Services Prior authorization required |
| Urgent Care | Coinsurance for Urgent Care 0% or 20% |
| Emergency Room Visit | Copayment for Emergency Care $0 or $110 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $0 or $315 Air Ambulance: Coinsurance for Air Ambulance Services 0% or 20% Prior Authorization Required for Air Ambulance Prior authorization required |
Health Care Services and Medical Supplies
iCare Medicare Plan SNP-DE (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: Coinsurance for Medicare-covered Chiropractic Services 0% or 20% 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 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 0% or 20% 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: Coinsurance for Medicare-covered Diagnostic Procedures/Tests 0% or 20% Copayment for Medicare-covered Lab Services $0 or 30 Coinsurance for Medicare-covered Lab Services 0 or 20% 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 or 300 to $350 Coinsurance for Medicare-covered Diagnostic Radiological Services 0 or 20% Coinsurance for Medicare-covered Therapeutic Radiological Services 0% or 20% Copayment for Medicare-covered X-Ray Services $0 or 50 Coinsurance for Medicare-covered X-Ray Services 0 or 20% Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0 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 or $2036 Prior Authorization Required for Psychiatric Hospital Services Referral Required for Psychiatric Hospital Services Prior authorization required |
| Mental Health Outpatient Care | In-Network: Coinsurance for Medicare-covered Individual Sessions 0% or 20% Coinsurance for Medicare-covered Group Sessions 0% or 20% |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 0% or 20% Prior Authorization Required for Outpatient Hospital Services Referral Required for Outpatient Hospital Services Outpatient Observation Services: Coinsurance for Medicare Covered Observation Services 0% or 20% Prior Authorization Required for Outpatient Observation Services Referral Required for Outpatient Observation Services Ambulatory Surgical Center Services: Coinsurance for Ambulatory Surgical Center Services 0% or 20% Prior Authorization Required for Ambulatory Surgical Center Services Referral Required for Ambulatory Surgical Center Services Prior authorization required |
| Outpatient Substance Abuse Care | In-Network: Coinsurance for Medicare-covered Individual Sessions 0% or 20% Coinsurance for Medicare-covered Group Sessions 0% or 20% Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required |
| Podiatry Services | In-Network: Coinsurance for Medicare-Covered Podiatry Services 0% or 20% Prior Authorization Required for Podiatry Services Referral Required for Podiatry Services Prior authorization required |
| Skilled Nursing Facility Care | 0 or $In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 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 | $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 diagnostic/preventive and comprehensive benefits. |
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 or 0 Coinsurance for Medicare Covered Benefits 0 or 20% Copayment for Routine Eye Exams $0
Referral Required for Eye Exams Eyewear: Coinsurance for Medicare-Covered Benefits 0% or 20% Copayment for Contact Lenses $0
Referral Required for Eyewear |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Coinsurance for Medicare Covered Benefits 0% or 20% Copayment for Routine Hearing Exams $0
Prior Authorization Required for Hearing Exams Referral Required for Hearing Exams Hearing Aids: Copayment for Hearing Aids $0
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 |
