2022 Wellcare Patriot Giveback Open (PPO)

Wellcare Patriot Giveback Open (PPO) H9387-002 is a 2022 Medicare Advantage Plan or Part-C by Wellcare by Allwell available to residents in Kansas. This plan does not provide additional prescription drug (Part-D) coverage. The Wellcare Patriot Giveback Open (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $4,400 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $4,400 out-of-pocket. This can be a extremely nice safety net.

Wellcare Patriot Giveback Open (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.

Wellcare by Allwell works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Wellcare Patriot Giveback Open (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Wellcare by Allwell 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 Wellcare by Allwell 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 Wellcare by Allwell Medicare Advantage Plan Costs

2021 Wellcare Patriot Giveback Open (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	$0 copay
Diagnostic services	0-50% coinsurance (Out-of-Network)
Endodontics	0-50% coinsurance (Out-of-Network)
Endodontics	50% coinsurance
Extractions	50% coinsurance
Extractions	0-50% coinsurance (Out-of-Network)
Non-routine services	0-50% coinsurance (Out-of-Network)
Non-routine services	$0 copay
Periodontics	50% coinsurance
Periodontics	0-50% coinsurance (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services	0-50% coinsurance (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services	50% coinsurance
Restorative services	0-50% coinsurance (Out-of-Network)
Restorative services	20% coinsurance

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	20% coinsurance
Diagnostic radiology services (e.g., MRI)	40% coinsurance (Out-of-Network)
Diagnostic tests and procedures	40% coinsurance (Out-of-Network)
Diagnostic tests and procedures	$0 copay
Lab services	$0 copay
Lab services	40% coinsurance (Out-of-Network)
Outpatient x-rays	$10 copay
Outpatient x-rays	40% coinsurance (Out-of-Network)

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Doctor Visits

Primary	$0 copay
Primary	40% coinsurance per visit (Out-of-Network)
Specialist	40% 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	40% coinsurance (Out-of-Network)
Foot exams and treatment	$35 copay
Routine foot care	Not covered

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Ground Ambulance

$265 copay
$265 copay (Out-of-Network)

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Hearing

Fitting/evaluation	$0 copay
Fitting/evaluation	$0 copay (Out-of-Network)
Hearing aids	$0-1,580 copay (Out-of-Network)
Hearing aids	$0-1,580 copay
Hearing exam	$35 copay
Hearing exam	40% coinsurance (Out-of-Network)

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Inpatient Hospital Coverage

$325 per day for days 1 through 5 $0 per day for days 6 through 90
40% per stay (Out-of-Network)

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Medical Equipment/Supplies

Diabetes supplies	$0 copay
Diabetes supplies	40% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	40% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	40% 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	40% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance
Other Part B drugs	40% coinsurance (Out-of-Network)

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Mental Health Services

Inpatient hospital - psychiatric	40% per stay (Out-of-Network)
Inpatient hospital - psychiatric	$325 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	40% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$35 copay
Outpatient group therapy visit with a psychiatrist	40% coinsurance (Out-of-Network)
Outpatient individual therapy visit	40% coinsurance (Out-of-Network)
Outpatient individual therapy visit	$35 copay
Outpatient individual therapy visit with a psychiatrist	40% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$35 copay

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MOOP

$10,000 In and Out-of-network $4,400 In-network

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Option

No

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Optional supplemental benefits

No

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Outpatient Hospital Coverage

$325 copay per visit
40% coinsurance per visit (Out-of-Network)

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Preventive Care

$0 copay
40% coinsurance (Out-of-Network)

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Preventive Dental

Cleaning	$0 copay
Cleaning	$0 copay (Out-of-Network)
Dental x-ray(s)	$0 copay (Out-of-Network)
Dental x-ray(s)	$0 copay
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	$40 copay
Occupational therapy visit	40% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	40% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	$40 copay

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Skilled Nursing Facility

40% per stay (Out-of-Network)
$0 per day for days 1 through 20 $184 per day for days 21 through 100

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Transportation

Not covered

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Vision

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

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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 Wellcare Patriot Giveback Open (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.