Optima Community Complete (HMO D-SNP) By Optima Medicare
Optima Community Complete (HMO D-SNP) is a 2022 Medicare Advantage Special Needs Plan plan by Optima Medicare. This plan from Optima Medicare works with Medicare to give you significant coverage beyond original Medicare. If you decide to sign up you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Optima Medicare and not Original Medicare. All Medicare SNPs also provide Medicare additional Part-D drug coverage. Optima Community Complete (HMO D-SNP) H2563-004 is a Dual Eligible Special Needs Plan (D-SNP). A Dual Eligible SNP is for beneficiaries who are eligible for both Medicare and Medicaid. If you have Medicare and get help from Medicaid you can join any Medicare SNP you qualify for or switch plans at any time.
2022 Medicare Special Needs Plan Details
| Plan Name: | Optima Community Complete (HMO D-SNP) |
|---|---|
| Plan ID: | H2563-004 |
| Special Needs Type: | Dual-Eligible |
| Provider: | Optima Medicare |
| Plan Year: | 2022 |
| Plan Type: | Local HMO |
| Monthly Premium C+D: | $35.10 |
| Part C Premium: | $0.00 |
| Part D (Drug) Premium: | $35.10 |
| Part D Supplemental Premium | $0.00 |
| Total Part D Premium: | $35.10 |
| Drug Deductible: | $480.00 |
| Tiers with No Deductible: | 0 |
| Benchmark: | below the regional benchmark |
| Type of Medicare Health Plan: | Defined Standard Benefit |
| Drug Benefit Type: | Basic | Gap Coverage: | No Gap Coverage |
The Optima Community Complete (HMO D-SNP) H2563-004 is available to residents in Virginia, and all Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. Optima Community Complete (HMO D-SNP) 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 need special care for a physician specialist, your primary care physician will make the arrangements and tell you where you can go in the network. You will need your PCPs okay, called a referral. Without getting a referral or services received from out-of-network providers are not typically covered by the 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 brand-name drugs and 25% on generic drugs unless your plan offers additional coverage. This Optima Medicare plan offer additional coverage through the gap.
Optima Community Complete (HMO D-SNP) Part-C Premium
Optima Medicare plan 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.
H2563-004 Part-D Deductible and Premium
Optima Community Complete (HMO D-SNP) has a monthly drug premium of $35.10 and a $480.00 drug deductible. This Optima Medicare plan offers a $35.10 Part D Basic Premium that is 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 Optima Medicare 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 $35.10 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.
Optima Medicare 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 Optima Medicare plan 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 Optima Community Complete (HMO D-SNP) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $8.80 for 75% low income subsidy $17.50 for 50% and $26.30 for 25%.
| Full LIS Premium: | $0.00 |
|---|---|
| 75% LIS Premium: | $8.80 |
| 50% LIS Premium: | $17.50 |
| 25% LIS Premium: | $26.30 |
H2563-004 Formulary or Drug Coverage
Optima Community Complete (HMO D-SNP) 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 Optima Community Complete (HMO D-SNP) H2563-004 Formulary here.
| Drug Tier | Copay Preferred Pharmacy |
Copay Nonpreferred Pharmacy |
|---|---|---|
| Tier 1 | NA | $0 |
| Tier 2 | NA | $0 |
| Tier 3 | NA | $0 |
| Tier 4 | NA | $0 |
| Tier 5 | NA | $0 |
Reviews for Optima Community Complete (HMO D-SNP) H2563
| 2021 Overall Rating | ||
|---|---|---|
| Part C Summary Rating | ||
| Part D Summary Rating | ||
| Staying Healthy: Screenings, Tests, Vaccines | ||
| Managing Chronic (Long Term) Conditions | ||
| Member Experience with Health Plan | ||
| Complaints and Changes in Plans Performance | ||
| Health Plan Customer Service | ||
| Drug Plan Customer Service | ||
| Complaints and Changes in the Drug Plan | ||
| Member Experience with the Drug Plan | ||
| Drug Safety and Accuracy of Drug Pricing |
Staying Healthy, Screening, Testing, & Vaccines
| Total Preventative Rating | ||
|---|---|---|
| Breast Cancer Screening | ||
| Colorectal Cancer Screening | ||
| Annual Flu Vaccine | ||
| Monitoring Physical Activity |
Managing Chronic And Long Term Care for Older Adults
| Total Rating | ||
|---|---|---|
| SNP Care Management | ||
| Medication Review | ||
| Functional Status Assessment | ||
| Osteoporosis Management | ||
| Diabetes Care - Eye Exam | ||
| Diabetes Care - Kidney Disease | ||
| Diabetes Care - Blood Sugar | ||
| Rheumatoid Arthritis | ||
| Reducing Risk of Falling | ||
| Improving Bladder Control | ||
| Medication Reconciliation | ||
| Statin Therapy |
Member Experience with Health Plan
| Total Experience Rating | ||
|---|---|---|
| Getting Needed Care | ||
| Getting Appointments | ||
| Customer Service | ||
| Health Care Quality | ||
| Rating of Health Plan | ||
| Care Coordination |
Member Complaints and Changes in Optima Community Complete (HMO D-SNP) Plans Performance
| Total Rating | ||
|---|---|---|
| Complaints about Health Plan | ||
| Members Leaving the Plan | ||
| Health Plan Quality Improvement |
Health Plan Customer Service Rating for Optima Community Complete (HMO D-SNP)
| Total Customer Service Rating | ||
|---|---|---|
| Timely Decisions About Appeals | ||
| Reviewing Appeals Decisions | ||
| Call Center, TTY, Foreign Language |
Optima Community Complete (HMO D-SNP) Drug Plan Customer Service Ratings
| Total Rating | ||
|---|---|---|
| Call Center, TTY, Foreign Language |
Ratings For Member Complaints and Changes in the Drug Plans Performance
| Total Rating | ||
|---|---|---|
| Complaints about the Drug Plan | ||
| Members Choosing to Leave the Plan | ||
| Drug Plan Quality Improvement |
Member Experience with the Drug Plan
| Total Rating | ||
|---|---|---|
| Rating of Drug Plan | ||
| Getting Needed Prescription Drugs |
Drug Safety and Accuracy of Drug Pricing
| Total Rating | ||
|---|---|---|
| MPF Price Accuracy | ||
| Drug Adherence for Diabetes Medications | ||
| Drug Adherence for Hypertension (RAS antagonists) | ||
| Drug Adherence for Cholesterol (Statins) | ||
| MTM Program Completion Rate for CMR | ||
| Statin with Diabetes |
Coverage Area for Optima Community Complete (HMO D-SNP)
| State: |
Medicare Plans in Virginia| County: | |
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Source: CMS.
Plans as of September 1, 2021.
Notes: Data are subject to change. All contracts for 2022 have not been finalized. For 2022, enhanced alternative plans may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part Part D benefit.
Includes 2022 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.