| In-network | |
|---|---|
| 住院承保1 | $250 共付额 每天 1-5天 $0 共付额 每天 6天或以上 |
| 门诊医院承保：1 | $250 共付额，在医院内进行的门诊手术 |
| 门诊手术中心1 | $200 共付额，门诊手术中心的门诊手术 |
| 初级护理提供者拜访 | $0 共付额 |
| 专科医生看诊 | $20 共付额 |
| 预防性护理 | $0 copay |
| 急救护理 | $130 共付额 如果您在 24 小时内住院，无需支付急救护理共付额。 |
| 紧急需要的服务 | $25 共付额 如果您在 24 小时内住院，无需支付紧急护理共付额。 |
Plan Details
Providence Medicare Focus Medical (HMO)
Overview
|
Monthly Premium |
$120 |
|
Annual Deductible |
$0 |
|
Maximum Out-of-Pocket |
$4,200 In-network |
其他福利
0 美元预防性牙科共付额
250 美元眼镜津贴和眼科检查
助听器共付额 + 0 美元检查费
OTC 物品每 6 个月为 100 美元
健身房会员
Extra Help
Extra Help, also known as a Part D Low-Income Subsidy, or LIS, is a federal program that helps lower prescription costs and Part D (prescription) costs for Medicare Advantage members. Learn more about Extra Help by connecting with one of our team members who can help walk you through how the program works.
Learn more提供商网络
Search the integrated network to find in-network providers or pharmacies. When searching, please select your plan as your provider network.
Search the networkImportant information about this plan
This plan is available in Clackamas, Hood River, Lane, Multnomah, Washington and Yamhill Counties in Oregon and Clark County in Washington.
Does not include any Part B premium you may have to pay. You must continue to pay your Medicare Part B premium.
- Find out if you qualify for Extra Help with your premiums
- Medical appeals, determination, and grievance processes
For more information about Providence Medicare Advantage Plans, please contact the sales team.
This information is available in a different format, including audio CDs. If you need plan information in another format, please call Customer Service at 503-574-8000 or 1-800-603-2340 (TTY: 711). Service is available between 8 a.m. to 8 p.m. (Pacific Time) 7 days a week from October 1st through March 31st and Monday - Friday, from April 1st through September 30th.
有关这些福利的重要说明
我们的计划会员享有原始 Medicare 承保的所有福利，另外，作为普罗维登斯 Medicare Advantage 计划的会员。
Benefit Summary
-
Benefits
-
Diagnostic Services + Labs & Imaging1
In-network 诊断放射学服务（例如，MRI、超声、CT 扫描） 每天的总费用的 15%，最多 $250 放射治疗服务 总费用的 15% 门诊 X 射线检查 $0 共付额 诊断测试和程序 总费用的 20% 实验室服务 $0 共付额 -
Hearing Services
In-network Medicare 承保 $20 共付额 常规检查 $0 共付额 助听器 每台助听器的共付额为 499 美元 - Standard
每台助听器的共付额为 699 美元 - 预付
每台助听器的共付额为 999 美元 - 保费 -
Dental Services
In-network Medicare 承保 $0 共付额 嵌入式预防 $0 共付额，包括检查、清洁、X 光、涂氟治疗。某些限制条件适用。 可选 针对额外保费提供承保。点击查看更多详情。 -
Vision Services
In-network Medicare 承保 $20 共付额
$0 共付额，青光眼筛查常规检查 每 日历年 进行一次常规视力检查（包括屈光检查），无需共同保险或共付额。 Medicare 承保的眼镜 $0 共付额，一副 Medicare 承保的眼镜或每次白内障手术后的隐形眼镜 常规眼镜或隐形眼镜 每 日历年 任何组合的常规处方眼镜，最高可获 $250 -
Mental Health Services1
In-network 住院治疗 $200 共付额 每天 1-7 天
$0 共付额 8-90 天门诊个人和团体治疗访视 $20 共付额 -
Skilled Nursing Facility1
In-network 专业护理机构 1-20 天 $0 共付额
$218 共付额，21-100 天每天 -
Physical Therapy1
In-network 物理疗法 $20 共付额 -
Ambulance1
In-network 救护车 $275 共付额 -
Medicare Part B Drugs1
In-network Medicare B 部分药物 0% - 20% of the total cost
(Insulin cost share up to $35 per month) -
替代性护理 1
网络内 替代护理（脊椎推拿、针灸和自然疗法服务） 脊椎推拿：$20 共付额；每日历年 18 次就诊
针灸：${copay} 共付额；每日历年 18 次就诊
自然疗法：$20 共付额；每日历年 6 次就诊 -
Meal Delivery Program
In-network 餐饮配送计划
（仅限出院后）$0 共付额，14 天每天 2 餐，在符合条件住院治疗后 -
Over-the-Counter Items
In-network 非处方商品 $100 津贴额 每 6 个月（零售卡、目录、在线、邮寄和电话订购） -
Personal Emergency Response System
In-network 个人应急响应系统 (PERS) $0 共付额 -
健身计划
网络内 健康计划 $0 共付额，在参与计划的健身俱乐部每月健身会籍 -
Wig
In-network 假发 因化疗导致脱发而购买一顶假发，无需共同保险或共付额。
1Services may require prior authorization.
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