2022 Summit Health Core (HMO-POS)

Summit Health Core (HMO-POS) H2765-001 is a 2022 Medicare Advantage Plan or Part-C by Summit Health Plan, Inc available to residents in Oregon. This plan does not provide additional prescription drug (Part-D) coverage. The Summit Health Core (HMO-POS) has a monthly premium of $22.00 and has an in-network maximum out-of-pocket limit of $4,000 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $4,000 out-of-pocket. This can be a extremely nice safety net.

Summit Health Core (HMO-POS) 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.

Summit Health Plan, Inc works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Summit Health Core (HMO-POS) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Summit Health Plan, Inc 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 Summit Health Plan, Inc except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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

2022 Summit Health Plan, Inc Medicare Advantage Plan Costs

2021 Summit Health Core (HMO-POS) 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	$0 copay
Diagnostic services	$0 copay (Out-of-Network)
Endodontics	$0 copay (Out-of-Network)
Endodontics	$0 copay
Extractions	$0 copay (Out-of-Network)
Extractions	$0 copay
Non-routine services	$0 copay (Out-of-Network)
Non-routine services	$0 copay
Periodontics	$0 copay
Periodontics	$0 copay (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services	$0 copay (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services	$0 copay
Restorative services	$0 copay
Restorative services	$0 copay (Out-of-Network)

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	30% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI)	20% coinsurance
Diagnostic tests and procedures	30% coinsurance (Out-of-Network)
Diagnostic tests and procedures	$0 copay
Lab services	$0 copay
Lab services	30% coinsurance (Out-of-Network)
Outpatient x-rays	20% coinsurance
Outpatient x-rays	30% coinsurance (Out-of-Network)

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Doctor Visits

Primary	30% coinsurance per visit (Out-of-Network)
Primary	$10 copay per visit
Specialist	30% coinsurance per visit (Out-of-Network)
Specialist	$35 copay per visit

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$35 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	30% coinsurance (Out-of-Network)
Foot exams and treatment	$35 copay
Routine foot care	Not covered

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Ground Ambulance

$250 copay
$250 copay (Out-of-Network)

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Hearing

Fitting/evaluation	Not covered
Hearing aids	$699-999 copay
Hearing exam	$35 copay
Hearing exam	30% coinsurance (Out-of-Network)

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Inpatient Hospital Coverage

30% per stay (Out-of-Network)
$350 per day for days 1 through 5 $0 per day for days 6 through 90

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Medical Equipment/Supplies

Diabetes supplies	$0 copay
Diabetes supplies	30% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	30% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	30% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item

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Medicare Part B Drugs

Chemotherapy	20% coinsurance
Chemotherapy	30% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance
Other Part B drugs	30% coinsurance (Out-of-Network)

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Mental Health Services

Inpatient hospital - psychiatric	30% per stay (Out-of-Network)
Inpatient hospital - psychiatric	$350 per day for days 1 through 5 $0 per day for days 6 through 90
Outpatient group therapy visit	$35 copay
Outpatient group therapy visit	30% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$35 copay
Outpatient group therapy visit with a psychiatrist	30% coinsurance (Out-of-Network)
Outpatient individual therapy visit	$35 copay
Outpatient individual therapy visit	30% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	30% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$35 copay

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MOOP

$4,200 In and Out-of-network $4,200 In-network $4,200 Out-of-network

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Option

No

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Optional supplemental benefits

Yes

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Outpatient Hospital Coverage

$350 copay per visit
30% coinsurance per visit (Out-of-Network)

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Package #1

Deductible
Monthly Premium	$5.00

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Preventive Care

$0 copay
30% coinsurance (Out-of-Network)

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Preventive Dental

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

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Rehabilitation Services

Occupational therapy visit	$35 copay
Occupational therapy visit	30% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	30% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	$35 copay

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Skilled Nursing Facility

$0 per day for days 1 through 20 $150 per day for days 21 through 100
30% per stay (Out-of-Network)

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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	$0 copay
Upgrades	$0 copay

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Wellness Programs (e.g. fitness nursing hotline)

Covered

Ready to Enroll?

Click Here

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

Coverage Area for Summit Health Core (HMO-POS)

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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.