Medicare Advantage Plans in Fairfield County 2010

"MA Plans": provide medical coverage, but offer no Part D drug plan.
These plans may be used by enrolled members who receive their prescription drugs elsewhere like the Veteran's Healthcare System, employer group pharmacy plan, etc.

FAIRFIELD COUNTY

COMPANY NAME

PLAN NAME

TYPE OF PLAN

SUMMARY OF BENEFITS (PDF)

PLAN MONTHLY PREMIUM

OUT-OF-POCKET MAX.

INPATIENT HOSPITAL CARE

HOSPITAL CO-PAY TYPE

PCP OFFICE VISIT CO-PAY

SPECIALIST OFFICE VISIT CO-PAY

OUTPATIENT SERVICES/SURGICAL

AMBULANCE (Medicare covered)

DIAGNOSTIC TESTS, X-RAYS, AND LAB SERVICES (Medicare Approved)

RX DRUG COVERAGE

GAP COVERAGE

PART B DRUGS (including chemotherapy)

DENTAL

Anthem Blue Cross and Blue Shield of CT.

MediBlue HMO Essential

HMO

Print out summary

$6,000

$250 copay for days 1-7,
then $0 copay for additional days

Per day copay

$25

$35

$35-$300

$175

$0-$105 copay. $35-$105 copay for Medicare-covered diagnostic radiology services. 20% for therapeutic radiology.

N/A

Plan pays 80%

Medicare covered only

ConnectiCare, Inc.

ConnectiCare VIP Option 2

HMO with POS option

Print out summary

$119

$2,500

$100 days 1-7 In-Network, then $0 copay for additional days. Out-of-network, $200 days 1-7, then $0.

Per day copay

$10 in- Network. $40 out-of-network.

$25 in- Network. $40 out-of-network.

$0 - $100 in-network

$100

$0 to $30 copay. $100 copay for Medicare-covered diagnostic radiology services (in-network)

N/A

Plan pays 90%

Two cleanings, two oral exams. $25 copays

ConnectiCare, Inc.

ConnectiCare VIP Prime 4

HMO

Print out summary

$4,000

$200 copay for days 1-7, then $0 copay for additional days

Per day copay

$20

$30

$0 to $125

$100

$0 to $30 copay. $175 copay for Medicare-covered diagnostic radiology services

N/A

Plan pays 90%

Medicare covered benefits only.
$30 copay.

Health Net of Connecticut

Health Net Green

HMO

Print out summary

$3,000
Applies to hospital copays only

$200 copay for days 1-8, then $0 copay for additional days.

Per day copay

$20

$30

$125 copay

$125

$0 to $20 copay. $175 to $200 copay for Medicare-covered diagnostic radiology services

N/A

Covered at 100%

Optional for additional premium

"MAPD Plans": provide medical coverage, as well as a Part D drug plan. These plans may be used by enrolled members who do not have other Part D drug coverage elsewhere.

FAIRFIELD COUNTY

COMPANY NAME

PLAN NAME

TYPE OF PLAN

SUMMARY OF BENEFITS (PDF)

PLAN MONTHLY PREMIUM

OUT-OF-POCKET MAX.

INPATIENT HOSPITAL CARE

HOSPITAL CO-PAY TYPE

PCP OFFICE VISIT CO-PAY

SPECIALIST OFFICE VISIT CO-PAY

OUTPATIENT SERVICES/SURGICAL

AMBULANCE (Medicare covered)

DIAGNOSTIC TESTS, X-RAYS, AND LAB SERVICES

RX DRUG COVERAGE

GAP COVERAGE

PART B DRUGS (including chemotherapy)

DENTAL

Anthem Blue Cross and Blue Shield of CT.

MediBlue Value

HMO

Print out summary

$6,000

$250 copay for days 1-7, then $0 copay for additional days

Per day copay

$25

$35

$35-$300

$170

$0-$105 copay. $25-$45-$105 copay for Medicare-covered diagnostic radiology services. 20% for therapeutic radiology.

Yes

Plan pays 80%

Medicare covered only

Anthem Blue Cross and Blue Shield of CT.

MediBlue Plus

HMO

Print out summary

$72

$4,000

$200 copay for days 1-7,then $0 copay for additional days

Per day copay

$20

$30

$30-$275

$175

$0-$90 copay. $30-$90 copay for Medicare-covered diagnostic radiology services. 20% for therapeutic radiology.

Yes

Plan pays 80%

Medicare covered only

Anthem Blue Cross and Blue Shield
of CT.

MediBlue Select

HMO

Print out summary

$122

$4,000

$100 copay for days 1-7, then $0 copay for additional days

Per day copay

$10

$20

$20-$100

$100

$0-$60 copay. $20-$60 copay for Medicare-covered diagnostic radiology services. 20% for therapeutic radiology.

Yes

Plan pays 80%

(2) Cleanings, (1) exam, (1) x-ray annually, included

ConnectiCare, Inc

ConnectiCare VIP Prime 1

HMO

Print out summary

$3,400

$250 copay for days 1-10, then $0 copay for additional days

Per day copay

$25

$40

$0 to $175

$100

$0 to $30 copay. $175 copay for Medicare-covered diagnostic radiology services

Yes

Plan pays 90%

Medicare covered benefits only.
$40 copay.

ConnectiCare, Inc

ConnectiCare VIP Prime 2

HMO

Print out summary

$68

$3,400

$200 copay for days 1-7, then $0 copay for additional days

Per day copay

$20

$35

$0 to $150

$100

$0 to $30 copay. $175 copay for Medicare-covered diagnostic radiology services

Yes

Plan pays 90%

Medicare covered benefits only.
$35 copay.

ConnectiCare, Inc

ConnectiCare VIP Prime 3

HMO

Print out summary

$129

$2,500

$100 copay for days 1-7, then $0 copay for additional days

Per admission

$10

$25

$0 to $100

$100

$0 to $30 copay. $100 copay for Medicare-covered diagnostic radiology services

Yes

Plan pays 90%

Two cleanings, two oral exams. $25 copays

Health Net of Connecticut

Health Net Ruby 1

HMO

Print out summary

$122

$1,000
Applies to hospital copays only

$50 copay days 1-3, then $100 copay days 4-10, then $0 for additional days

Per day copay

$10

$20

$0 to $75 copay

$125

$0 to $20 copay. $50
copay for Medicare-covered diagnostic radiology services

Yes

Covered at 100%

Optional for additional premium

Health Net of Connecticut

Health Net Ruby 2

HMO

Print out summary

$12

$3,500
Applies to hospital copays only

$250 copay for days 1-7, then $0 for additional days.

Per day copay

$20

$30

$125 copay

$125

$0 to $20 copay. $150 copay for Medicare-covered diagnostic radiology services

Yes

Covered at 100%

Optional for additional premium

Health Net of Connecticut

Health Net Ruby 3

HMO

Print out summary

$71

$1,500
Applies to hospital copays only

$100 copay for days 1-10, then $0 copay for additional days

Per day copay

$15

$25

$50 to $100 copay

$125

$0 to $20 copay. $100 copay for Medicare-covered diagnostic & therapeutic radiology services

Yes

Covered at 100%

Optional for additional premium

Medicare HMO plans that have a "POS option: allows members to seek treatment outside of the HMO network for a higher copay/deductible. The out-of-network provider can than bill your Medicare Advantage plan for services rendered.

FAIRFIELD COUNTY

COMPANY NAME

PLAN NAME

TYPE OF PLAN

SUMMARY OF BENEFITS (PDF)

PLAN MONTHLY PREMIUM

OUT-OF-POCKET MAX.

INPATIENT HOSPITAL CARE

HOSPITAL CO-PAY TYPE

PCP OFFICE VISIT CO-PAY

SPECIALIST OFFICE VISIT CO-PAY

OUTPATIENT SERVICES/SURGICAL

AMBULANCE (Medicare covered)

DIAGNOSTIC TESTS, X-RAYS, AND LAB SERVICES

RX DRUG COVERAGE

GAP COVERAGE

PART B DRUGS (including chemotherapy)

DENTAL

ConnectiCare, Inc

ConnectiCare VIP Option 1

HMO with POS option

Print out summary

$168

$2,500

$100 days 1-7 In-Network, then $0 copay for additional days. Out-of-network, $200 days 1-7, then $0.

Per day copay

$10 in- network. $40 out-of-network.

$25 in- Network. $40 out-of-network.

$0 - $100 in-network, 20% out-of-network.

$100

$0 to $30 copay. $100 copay for Medicare-covered diagnostic radiology services (in-network)

Yes

Plan pays 90%

Two cleanings, two oral exams. $25 copays

ConnectiCare, Inc.

ConnectiCare VIP Option 2

HMO with POS option

Print out summary

$119

$2,500

$100 days 1-7 In-Network, then $0 copay for additional days. Out-of-network, $200 days 1-7, then $0.

Per day copay

$10 in- network. $40 out-of-network

$25 in- Network. $40 out-of-network.

$0 - $100 in-network, 20% out-of-network.

$100

$0 to $30 copay. $100 copay for Medicare-covered diagnostic radiology services

N/A

Plan pays 90%

Two cleanings, two oral exams. $25 copays

WellCare

WellCare Choice

HMO with POS Option

Print out summary

$29

$3,250

$200 copay days 1-7 in network.

Per day copay

$10 copay / 20%
out of network

$30 / 20% out of network

$100 to $150 copay in Network / 20% out of network

$100

$0 to $100copay. $50-$200 copay for Medicare-covered diagnostic radiology services. $30 for Therapeutic Radiology services.
(Out of Network)
You pay 20%

Yes

You pay 20% in Network

None

WellCare

WellCare Premium

HMO with POS Option

Print out summary

$99

$1,750

$50 copay days 1-7 in network.

Per day copay

$0 copay / 20%
out of network

$15 / 20% out of network

$25 in Network / 20% out of network

$100

$0 to $75 copay. $50 - $75 copay for Medicare-covered diagnostic radiology services. $15 for Therapeutic Radiology services.
(Out of Network)
You pay 20%

Yes

You pay 20% in Netowrk

None

FAIRFIELD COUNTY

COMPANY NAME

PLAN NAME

TYPE OF PLAN

SUMMARY OF BENEFITS (PDF)

PLAN MONTHLY PREMIUM

OUT-OF-POCKET MAX.

INPATIENT HOSPITAL CARE

HOSPITAL CO-PAY TYPE

PCP OFFICE VISIT CO-PAY

SPECIALIST OFFICE VISIT CO-PAY

OUTPATIENT SERVICES/SURGICAL

AMBULANCE (Medicare covered)

DIAGNOSTIC TESTS, X-RAYS, AND LAB SERVICES

RX DRUG COVERAGE

GAP COVERAGE

PART B DRUGS (including chemotherapy)

DENTAL

Health Net of Connecticut

Health Net Navy 1

HMO with POS Option

Print out summary

$162

$1,200 Applies to hospital copays only, in-network.

$100 copay days 1-3, $150 copay days 4-5, the $0 copay for additional days.
(out-of-network)
$0 copay for Out-of-Network hospital stays

Per day copay

$20 copay in network, $50 copay out-of-network

$35 copay in network, $50 copay out-of-network

$50 to $100 copay In Network.
$100-$200 copay Out-of-Network.

$150

$0 to $20 copay. $100 copay for Medicare-covered diagnostic radiology services. $20 for Therapeutic Radiology services.
(Out of Network)
You pay $45 copay .Medicare-covered diagnostic radiology $200 copay

Yes

Covered 100% In-Network.

Optional for additional premium

Health Net of Connecticut

Health Net Navy 2

HMO with POS Option

Print out summary

$89

$1,500 Applies to hospital copays only. Out-of-network max. out of pocket $1,200.

$100 copay days 1-10, $0 copay for additional days
(out-of-network)
$100 copay days 1-10 for Out-of-Network hospital stays

Per day copay

$15 copay in network, $50 copay out-of-network

$25 copay in network, $50 copay out-of-network

$50 to $100 copay In Network.
20% Out-of-Network.

$150

$0 to $25 copay. $100 copay for Medicare-covered diagnostic radiology services. $20 for Therapeutic Radiology services.
(Out of Network)
You pay $45 copay .Medicare-covered diagnostic radiology $200 copay

Yes

Covered 100% In-Network.

Optional for additional premium

UnitedHealthcare

Secure Horizons AARP Medicare Complete Choice

Regional PPO

Print out summary

$3,800 in-network

$7,600 out-of-network

$225 copay days
1-6 in network.

$375 copay days
1-21out-of- network.

Per day copay

$15 in network, $30 copay out-of-network

$35 in network, $40 copay out-of-network

20% coinsurance
In Network.

30% coinsurance Out-of-Network.

$150

$0 to $16 copay.

You pay 20%
of charges for Medicare-covered diagnostic and therapeutic radiology services.
You pay 30% out of network diagnostic and therapeutic radiology services.

Yes

You pay 20% in-network.

You pay 30% out-of-network.

Medicare covered only

"SNP Plans": provide medical coverage, as well as a Part D drug plan. These plans are designed to offer improved specific care to members with a particular chronic or disabling condition.

FAIRFIELD COUNTY

COMPANY NAME

PLAN NAME

TYPE OF PLAN

SUMMARY OF BENEFITS (PDF)

PLAN MONTHLY PREMIUM

OUT-OF-POCKET MAX.

INPATIENT HOSPITAL CARE

HOSPITAL CO-PAY TYPE

PCP OFFICE VISIT CO-PAY

SPECIALIST OFFICE VISIT CO-PAY

OUTPATIENT SERVICES/SURGICAL

AMBULANCE (Medicare covered)

DIAGNOSTIC TESTS, X-RAYS, AND LAB SERVICES

RX DRUG COVERAGE

GAP COVERAGE

PART B DRUGS (including chemotherapy)

DENTAL

UnitedHealthcare

Evercare® Plan IP

PPO for Nursing Home Residents

Print out summary

$36.40

$0 for Qualified Medicare Beneficiaries, or Full Medicaid Beneficiaries

All cost share based on level of Medicaid eligibility

$0 copay
days 1-60

$0 copay
days 61-100

$0 copay days 101-150 per lifetime reserve days.

Per "Benefit" Period

You pay 20%

You pay:

20% coinsurance in network.

30% out of network

You pay 20%

You pay 30% out-of-network

$0 copay to 20% coinsurance.
You pay 20% coinsurance for for Medicare-covered therapeutic & diagnostic radiology services, and 30% out-of-network.

Yes. $310 deductible, then you pay 20% until you reach the coverage gap

You pay 20% in-network.

You pay 30% out-of-network.

You pay 20% of Medicare covered services only

WellCare

Access HMO

HMO for Duel Eligibles

Print out summary

$34.60
$0 for Qualified Medicare Beneficiaries, or Full Medicaid Beneficiaries

All cost share based on level of Medicaid eligibility

$0 copay
days 1-60

$0 copay
days 61-100

$0 copay days 101-150 per lifetime reserve days.

Per "Benefit" Period

$0 copay

Covered 100%

$0 copay

Yes

You pay 0%

Yes

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