Mount Carmel MediGold No Premium Choice (PPO)
Mount Carmel MediGold No Premium Choice (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Trinity Health
Plan ID: H1846-005
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Mount Carmel MediGold No Premium Choice (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Trinity Health
Plan ID: H1846-005
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Ohio Counties Served
Basic Costs and Coverage
Coverage | Cost |
---|---|
Monthly Deductible | $150 |
Out of Pocket Max |
In-Network: $5700 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 Out-of-Network: Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $25.00 |
Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $40.00 Out-of-Network: Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $60.00 |
Inpatient Hospital Care | In-Network: Acute Hospital Services: $375.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: Coinsurance for Acute Hospital Services per Stay 40% |
Urgent Care | Copayment for Urgent Care $45.00 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $90.00 |
Emergency Room Visit | Copayment for Emergency Care $90.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 48 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $90.00 Copayment for Worldwide Emergency Transportation $275.00 to $325.00 |
Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $275.00 Air Ambulance: Copayment for Air Ambulance Services $325.00 Please see Evidence of Coverage for Prior Authorization rules Prior authorization required Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $275.00 to $325.00 Copayment for Medicare Covered Ambulance Services - Air $275.00 to $325.00 |
Health Care Services and Medical Supplies
Mount Carmel MediGold No Premium Choice (PPO) 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 $20.00 Prior Authorization Required for Chiropractic Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Chiropractic Services $60.00 |
Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0.00 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% 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 Out-of-Network: Coinsurance for Medicare Covered Diabetic Supplies and Services 30% |
Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Durable Medical Equipment 30% |
Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $60.00 Copayment for Medicare-covered Lab Services $10.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $210.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $50.00 Prior authorization required Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40% Copayment for Medicare Covered Lab Services $20.00 Coinsurance for Medicare Covered Diagnostic Radiological Services 40% Coinsurance for Medicare Covered Therapeutic Radiological Services 40% Coinsurance for Medicare Covered Outpatient X-Ray Services 40% |
Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Out-of-Network: Coinsurance for Medicare Covered Home Health 50% |
Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $370.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: Coinsurance for Psychiatric Hospital Services per Stay 40% |
Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 Out-of-Network: Copayment for Medicare Covered Individual Sessions $60.00 Copayment for Medicare Covered Group Sessions $60.00 |
Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $10.00 to $300.00 Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $300.00 Out-of-Network: Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 40% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40% |
Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $40.00 Copayment for Medicare-covered Group Sessions $40.00 Out-of-Network: Coinsurance for Medicare Covered Individual or Group Sessions 40% |
Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $105.00 every three months Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit Out-of-Network: Over-The-Counter (OTC) Items: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $105.00 |
Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $40.00 Out-of-Network: Copayment for Medicare Covered Podiatry Services $60.00 |
Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $203.00 per day for days 21 to 56 $0.00 per day for days 57 to 100 Out-of-Network: Coinsurance for Skilled Nursing Facility Services per Stay 50% |
Dental Benefits
The following dental services are covered from in-network providers.
Coverage | Cost |
---|---|
Dental Care | In-Network: Preventive Dental: Copayment for Oral Exams $0.00
Comprehensive Dental: Copayment for Medicare-covered Benefits $40.00 Out-of-Network: Medicare Covered Dental Services: Coinsurance for Medicare Covered Comprehensive Dental 40% Non-Medicare Covered Dental Services: Copayment for Non-Medicare Covered Preventive Dental $0.00 Coinsurance for Non-Medicare Covered Preventive Dental 50% to 70% Copayment for Non-Medicare Covered Comprehensive Dental $0.00 Coinsurance for Non-Medicare Covered Comprehensive Dental 50% to 70% |
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 to $40.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Maximum Plan Allowance of $150.00 every year for all Non-Medicare covered eyewear for in and out of network services combined Out-of-Network: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $50.00 Coinsurance for Medicare Covered Eyewear 40% Non-Medicare Covered Vision Services: Copayment for Non-Medicare Covered Eye Exams $0.00 to $50.00 Copayment for Non-Medicare Covered Eyewear $0.00 to $50.00 |
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 $40.00 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for Hearing Aids $599.00 to $899.00
Out-of-Network: Medicare Covered Hearing Services: Copayment for Medicare Covered Hearing Exams $60.00 Non-Medicare Covered Hearing Services: Copayment for Non-Medicare Covered Hearing Exams $60.00 to $899.00 Copayment for Non-Medicare Covered Hearing Aids $60.00 to $899.00 |
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 Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0.00 |