2022 Clover Health Choice Value (PPO)

Clover Health Choice Value (PPO) H5141-039 is a 2022 Medicare Advantage Plan or Part-C by Clover Health available to residents in Pennsylvania. This plan includes additional prescription drug (Part-D) coverage. The Clover Health Choice Value (PPO) has a monthly premium of $40.70 and has an in-network maximum out-of-pocket limit of $7,550 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $7,550 out-of-pocket. This can be a extremely nice safety net.

Clover Health Choice Value (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Clover Health works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Clover Health Choice Value (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Clover Health 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 Clover Health except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 Clover Health Medicare Advantage Plan Costs

Clover Health Choice Value (PPO) Part-C Premium

Clover Health charges a $0.00 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.

H5141-039 Part-D Deductible and Premium

Clover Health Choice Value (PPO) has a monthly drug premium of $40.70 and a $480.00 drug deductible. This Clover Health plan offers a $40.70 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 Clover Health 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 $40.70 . 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.

Clover Health 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 Clover Health plan does not 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 Clover Health Choice Value (PPO) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $10.20 for 75% low income subsidy $20.30 for 50% and $30.50 for 25%.

H5141-039 Formulary or Drug Coverage

Clover Health Choice Value (PPO) 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 Clover Health Choice Value (PPO) H5141-039 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$0	$12
Tier 2	22%	25%
Tier 3	22%	25%
Tier 4	25%	25%
Tier 5	25%	25%

*Initial Coverage Phase and 30 day supply

2021 Clover Health Choice Value (PPO) 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	$20 copay (Out-of-Network)
Endodontics	$20 copay
Extractions	$20 copay (Out-of-Network)
Extractions	$20 copay
Non-routine services	Not covered
Periodontics	$20 copay
Periodontics	$20 copay (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services	$20 copay (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services	$20 copay
Restorative services	$20 copay (Out-of-Network)
Restorative services	$20 copay

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$0-175 copay
Diagnostic radiology services (e.g., MRI)	$0-175 copay (Out-of-Network)
Diagnostic tests and procedures	$0-175 copay
Diagnostic tests and procedures	$0-175 copay (Out-of-Network)
Lab services	$0 copay (Out-of-Network)
Lab services	$0 copay
Outpatient x-rays	$30 copay (Out-of-Network)
Outpatient x-rays	$30 copay

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Doctor Visits

Primary	$0 copay
Primary	$0 copay (Out-of-Network)
Specialist	$0 copay
Specialist	$0 copay (Out-of-Network)

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$25 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$0 copay
Foot exams and treatment	$0 copay (Out-of-Network)
Routine foot care	Not covered

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Ground Ambulance

$190 copay (Out-of-Network)
$190 copay

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Hearing

Fitting/evaluation	Not covered
Hearing aids	$699-999 copay
Hearing aids	$999 copay (Out-of-Network)
Hearing exam	$0 copay (Out-of-Network)
Hearing exam	$0 copay

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Inpatient Hospital Coverage

$225 per day for days 1 through 5 $0 per day for days 6 through 90
$225 per day for days 1 through 5 $0 per day for days 6 through 90 (Out-of-Network)

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Medical Equipment/Supplies

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

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Medicare Part B Drugs

Chemotherapy	20% coinsurance
Chemotherapy	20% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance

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Mental Health Services

Inpatient hospital - psychiatric	$225 per day for days 1 through 5 $0 per day for days 6 through 90 (Out-of-Network)
Inpatient hospital - psychiatric	$225 per day for days 1 through 5 $0 per day for days 6 through 90
Outpatient group therapy visit	$0 copay (Out-of-Network)
Outpatient group therapy visit	$0 copay
Outpatient group therapy visit with a psychiatrist	$0 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$0 copay
Outpatient individual therapy visit	$0 copay
Outpatient individual therapy visit	$0 copay (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$0 copay (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$0 copay

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MOOP

$7,550 In and Out-of-network $7,550 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 (Out-of-Network)
$200 copay per visit

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Preventive Care

$0 copay
$0 copay (Out-of-Network)

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Preventive Dental

Cleaning	$0 copay
Cleaning	$0 copay (Out-of-Network)
Dental x-ray(s)	$0 copay
Dental x-ray(s)	$0 copay (Out-of-Network)
Fluoride treatment	$0 copay (Out-of-Network)
Fluoride treatment	$0 copay
Oral exam	$0 copay (Out-of-Network)
Oral exam	$0 copay

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Rehabilitation Services

Occupational therapy visit	$5 copay (Out-of-Network)
Occupational therapy visit	$5 copay
Physical therapy and speech and language therapy visit	$5 copay (Out-of-Network)
Physical therapy and speech and language therapy visit	$5 copay

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Skilled Nursing Facility

$0 per day for days 1 through 20 $178 per day for days 21 through 100 (Out-of-Network)
$0 per day for days 1 through 20 $178 per day for days 21 through 100

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Transportation

$0 copay (Out-of-Network)
$0 copay

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Vision

Contact lenses	$0 copay (Out-of-Network)
Contact lenses	$0 copay
Eyeglass frames	Not covered
Eyeglass lenses	Not covered
Eyeglasses (frames and lenses)	$0 copay (Out-of-Network)
Eyeglasses (frames and lenses)	$0 copay
Other	Not covered
Routine eye exam	$0 copay (Out-of-Network)
Routine eye exam	$0 copay
Upgrades	Not covered

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for Clover Health Choice Value (PPO) H5141

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in Clover Health Choice Value (PPO) Plans Performance

Health Plan Customer Service Rating for Clover Health Choice Value (PPO)

Clover Health Choice Value (PPO) 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?

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

Coverage Area for Clover Health Choice Value (PPO)

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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.