2022 Capital Health Plan Preferred Advantage (HMO)

Capital Health Plan Preferred Advantage (HMO) H5938-006 is a 2022 Medicare Advantage Plan or Part-C by Capital Health Plan available to residents in Florida. This plan includes additional prescription drug (Part-D) coverage. The Capital Health Plan Preferred Advantage (HMO) has a monthly premium of $92.00 and has an in-network maximum out-of-pocket limit of $3,400 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $3,400 out-of-pocket. This can be a extremely nice safety net.

Capital Health Plan Preferred Advantage (HMO) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered.

Capital Health Plan works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Capital Health Plan Preferred Advantage (HMO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Capital Health Plan and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Capital Health Plan except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 Capital Health Plan Medicare Advantage Plan Costs

Capital Health Plan Preferred Advantage (HMO) Part-C Premium

Capital Health Plan charges a $23.60 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H5938-006 Part-D Deductible and Premium

Capital Health Plan Preferred Advantage (HMO) has a monthly drug premium of $68.40 and a $0.00 drug deductible. This Capital Health Plan plan offers a $68.40 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Capital Health Plan above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $68.40 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Capital Health Plan Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Capital Health Plan plan does offer additional coverage through the gap.

Premium Assistance

The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Capital Health Plan Preferred Advantage (HMO) medicare insurance offers a $34.10 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $42.70 for 75% low income subsidy $51.20 for 50% and $59.80 for 25%.

H5938-006 Formulary or Drug Coverage

Capital Health Plan Preferred Advantage (HMO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Capital Health Plan Preferred Advantage (HMO) H5938-006 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	NA	$3
Tier 2	NA	$7
Tier 3	NA	$45
Tier 4	NA	$95
Tier 5	NA	33%
Tier 6	NA	$0

*Initial Coverage Phase and 30 day supply

2021 Capital Health Plan Preferred Advantage (HMO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	Not covered
Endodontics	Not covered
Extractions	Not covered
Non-routine services	Not covered
Periodontics	Not covered
Prosthodontics, other oral/maxillofacial surgery, other services	Not covered
Restorative services	Not covered

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$100 copay
Diagnostic tests and procedures	$0 copay
Lab services	$0 copay
Outpatient x-rays	$0 copay

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Doctor Visits

Primary	$10 copay per visit
Specialist	$25 copay per visit

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Emergency care/Urgent Care

Emergency	$120 copay per visit (always covered)
Urgent care	$20 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$25 copay
Routine foot care	Not covered

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Ground Ambulance

$250 copay

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Hearing

Fitting/evaluation	Not covered
Hearing aids - inner ear	Not covered
Hearing aids - outer ear	Not covered
Hearing aids - over the ear	Not covered
Hearing exam	$25 copay

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Inpatient Hospital Coverage

$300 per stay $0 per day for days 91 and beyond

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Medical Equipment/Supplies

Diabetes supplies	0-20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item

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Medicare Part B Drugs

Chemotherapy	20% coinsurance
Other Part B drugs	20% coinsurance

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Mental Health Services

Inpatient hospital - psychiatric	$300 per stay
Outpatient group therapy visit	$25 copay
Outpatient group therapy visit with a psychiatrist	$25 copay
Outpatient individual therapy visit	$25 copay
Outpatient individual therapy visit with a psychiatrist	$25 copay

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MOOP

$3,400 In-network

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Option

No

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Optional supplemental benefits

No

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Outpatient Hospital Coverage

$200 copay per visit

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Preventive Care

$0 copay

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Preventive Dental

Cleaning	Not covered
Dental x-ray(s)	Not covered
Fluoride treatment	Not covered
Oral exam	Not covered

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Rehabilitation Services

Occupational therapy visit	$25 copay
Physical therapy and speech and language therapy visit	$25 copay

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Skilled Nursing Facility

$20 per day for days 1 through 20 $75 per day for days 21 through 100

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Transportation

Not covered

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Vision

Contact lenses	$0 copay
Eyeglass frames	Not covered
Eyeglass lenses	Not covered
Eyeglasses (frames and lenses)	$0 copay
Other	Not covered
Routine eye exam	$10-25 copay
Upgrades	Not covered

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for Capital Health Plan Preferred Advantage (HMO) H5938

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in Capital Health Plan Preferred Advantage (HMO) Plans Performance

Health Plan Customer Service Rating for Capital Health Plan Preferred Advantage (HMO)

Capital Health Plan Preferred Advantage (HMO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Capital Health Plan Preferred Advantage (HMO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.