2022 Medicare Advantage Plan Benefit Details for the Golden State Senior Health Plan (HMO) - H2241-014-0

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2022 Medicare Advantage Plan Details
Medicare Plan Name:Golden State Senior Health Plan (HMO)
Location:San Francisco, California Click to see other locations
Plan ID:H2241 - 014 - 0 Click to see other plans
Member Services:1-877-541-4111 TTY users 711
— This plan information is for research purposes only. —
Click here to see plans for the current plan year
— This plan was sanctioned in 2022 —
Read more here.
Medicare Contact Information:Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options.
TTY users 1-877-486-2048
or contact your local SHIP for assistance
Email a copy of the Golden State Senior Health Plan (HMO) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 (see Plan Premium Details below)
Annual Rx Deductible:$0
Annual Rx Initial Coverage Limit (ICL):$4,430
Health Plan Type:Local HMO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$3,000
Additional Rx Gap Coverage?Yes, some additional gap coverage.
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers.
This plan offers select insulin at $35 or less. Learn more.
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
Cost-Sharing during
initial coverage phase:		$5.00$10.00$45.00$95.0033%
Plan Offers Mail Order?
Medicare Plan Pharmacy Numbers: BIN: 015574 PCN: ASPROD1 See BIN/PCNs for all plans
Number of Members enrolled in this plan in (H2241 - 014):64 members
Plan’s Summary Star Rating: 3.5 out of 5 Stars.
• Customer Service Rating: 5 out of 5 Stars.
• Member Experience Rating: 2 out of 5 Stars.
• Drug Cost Accuracy Rating: 4 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows: ❔
Total
Premium		Part C
Premium		Part D Basic
Premium		Part D Supplemental
Premium
$0.00$0.00$0.00$0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$0.00$0.00$0.00$0.00
Total Monthly Premium with LIS (Parts C & D):$0.00$0.00$0.00$0.00
— Plan Health Benefits —
** Base Plan **
Premium
• Health plan premium: $0
• Drug plan premium: $0
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: $0
• Other health plan deductibles: In-network: No
• Drug plan deductible: No annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $3
Optional supplemental benefits
• No
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: No
Doctor visits
• Primary: $5 copay per visit
• Specialist: $5 copay per visit (authorization required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: $0 copay (authorization required)
• Lab services: $0 copay (authorization required)
• Diagnostic radiology services (e.g., MRI): $60 copay (authorization required)
• Outpatient x-rays: $0 copay (authorization required)
Emergency care/Urgent care
• Emergency: $90 copay per visit (always covered)
• Urgent care: $20 copay per visit (always covered)
Inpatient hospital coverage
• $250 per day for days 1 through 5
$0 per day for days 6 through 90 (authorization required)
Outpatient hospital coverage
• $200 copay per visit (authorization required)
Skilled Nursing Facility
• $0 per day for days 1 through 20
$135 per day for days 21 through 43
$0 per day for days 44 through 100 (authorization required)
Preventive care
• $0 copay (authorization required)
Ground ambulance
• $200 copay
Rehabilitation services
• Occupational therapy visit: $10 copay (authorization required)
• Physical therapy and speech and language therapy visit: $10 copay (authorization required)
Mental health services
• Inpatient hospital - psychiatric: $250 per day for days 1 through 5
$0 per day for days 6 through 90 (authorization required)
• Outpatient group therapy visit with a psychiatrist: $15 copay (authorization required)
• Outpatient individual therapy visit with a psychiatrist: $30 copay (authorization required)
• Outpatient group therapy visit: $15 copay (authorization and referral required)
• Outpatient individual therapy visit: $15 copay (authorization and referral required)
Opioid treatment program services
• In-network: 20% coinsurance (authorization required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): 0-20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs): 0-20% coinsurance per item (authorization required)
• Diabetes supplies: $0 copay (authorization required)
Dialysis
• 10% coinsurance (authorization required)
Hearing
• Hearing exam: $0 copay
• Fitting/evaluation: $0 copay (limits apply)
• Hearing aids: $0 copay (limits apply)
Preventive dental
• Office visit: $8.00
• Oral exam: Covered under office visit (limits apply)
• Cleaning: Covered under office visit (limits apply)
• Fluoride treatment: Covered under office visit (limits apply)
• Dental x-ray(s): Covered under office visit (limits apply)
Comprehensive dental
• Non-routine services: $0-2 (authorization required)
• Diagnostic services: $0-85 copay (authorization required)
• Restorative services: $25-280 copay (authorization required)
• Endodontics: $20-685 copay (authorization required)
• Periodontics: $20-685 copay (authorization required)
• Extractions: $20-685 copay (authorization required)
• Prosthodontics, other oral/maxillofacial surgery, other services: $0-2 (authorization required)
Vision
• Routine eye exam: $0 copay (limits apply, authorization required)
• Other: Not covered
• Contact lenses: $0 copay (limits apply)
• Eyeglasses (frames and lenses): $0 copay (limits apply)
• Eyeglass frames: Not covered
• Eyeglass lenses: Not covered
• Upgrades: Not covered
Medically-approved non-opioid pain management services
• Chiropractic services: Not covered
• Acupuncture: Some coverage
• Therapeutic Massage: Not covered
• Alternative Therapies: Not covered
More benefits
• Transportation services: Some coverage
• Transportation services for non-emergency care: Plan-approved locations: Not covered
• Over-the-counter drug benefits: Some coverage
• Meals for short duration: Not covered
• Annual physical exams: Not covered
• Telehealth: Some coverage
• WorldWide emergency coverage: Some coverage
• Fitness Benefit: Some coverage
• In-Home Support Services: Not covered
• Bathroom Safety Devices: Not covered
• Health Education: Not covered
• In-Home Safety Assessment: Not covered
• Personal Emergency Response System (PERS): Not covered
• Medical Nutrition Therapy (MNT): Not covered
• Post discharge In-Home Medication Reconciliation: Not covered
• Re-admission Prevention: Not covered
• Wigs for Hair Loss Related to Chemotherapy: Not covered
• Weight Management Programs: Not covered
• Adult Day Health Services: Not covered
• Nutritional/Dietary Benefit: Not covered
• Home-Based Palliative Care: Not covered
• Support for Caregivers of Enrollees: Not covered
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Not covered
• Enhanced Disease Management: Not covered
• Telemonitoring Services: Not covered
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Not covered
• Counseling Services: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• $0 copay (limits apply)
Foot care (podiatry services)
• Foot exams and treatment: $5 copay (authorization required)
• Routine foot care: Not covered
Medicare Part B drugs
• Chemotherapy: 20% coinsurance (authorization required)
• Other Part B drugs: 20% coinsurance (authorization required)