Covenant Health Advantage (HMO) H4943-002 is a 2023 Medicare Advantage Plan or Part-C by Baylor Scott and White Health Plan available to residents in Texas. This plan does not provide extra prescription drug (Part-D) coverage. Baylor Scott and White Health Plan Covenant Health Advantage (HMO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $5,900 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $5,900 out-of-pocket. This can be an extremely nice safety net.

Baylor Scott and White Health Plan works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Covenant Health Advantage (HMO) you still retain Original Medicare. But you will get extra Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Baylor Scott and White Health Plan and not Original Medicare. With 2023 Medicare Advantage Plan you are always covered for urgently needed and emergency care. Plus, you receive all the benefits of Original Medicare from Baylor Scott and White Health Plan except hospice care. Original Medicare still provides you with hospice care if you sign up for Medicare Advantage in Texas.

2023 Baylor Scott and White Health Plan Medicare Advantage Plan Overview

What type of plan is Covenant Health Advantage (HMO)

Covenant Health 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 primary care physician 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 primary care physician approval, called a referral. Services received from an out-of-network provider are not typically covered.

How much does Covenant Health Advantage (HMO) cost?

Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Baylor Scott and White Health Plan charges a $0 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.

MOOP

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Covenant Health Advantage (HMO) by Baylor Scott and White Health Plan MOOP is $5,900. Once you spend $5,900 you will pay nothing for Part A or Part B covered services. Copayments and coinsurance for Medicare approved services apply toward your out-of-pocket limit. Remember Original Medicare (Parts A and B) doesn’t have a MOOP.

2023 Summary of Benefits

The benefit information provided is a summary of what Covenant Health Advantage (HMO) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Baylor Scott and White Health Plan helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

Wellness programs (e.g., fitness, nursing hotline)	Covered

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Contact lenses

Vision	$0 copay

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Eyeglass frames

Vision	$0 copay

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Eyeglass lenses

Vision	$0 copay

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Eyeglasses (frames and lenses)

Vision	$0 copay

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Other

Vision	Not covered

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Routine eye exam

Vision	$0 copay

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Upgrades

Vision	Not covered

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Transportation	$0 copay
Skilled Nursing Facility	$0 per day for days 1 through 20 $196 per day for days 21 through 100

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Occupational therapy visit

Rehabilitation services	$35 copay

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Physical therapy and speech and language therapy visit

Rehabilitation services	$35 copay

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Cleaning

Preventive dental	$0 copay

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Dental x-ray(s)

Preventive dental	$0 copay

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Fluoride treatment

Preventive dental	Not covered

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Oral exam

Preventive dental	$0 copay

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Preventive care	$0 copay
Outpatient hospital coverage	$325 copay or 20% coinsurance per visit
In-Network Other health plan deductibles?	No
Optional supplemental benefits	No

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Inpatient hospital - psychiatric

Mental health services	$318 per day for days 1 through 5 $0 per day for days 6 through 90

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Outpatient group therapy visit

Mental health services	$30 copay

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Outpatient group therapy visit with a psychiatrist

Mental health services	$30 copay

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Outpatient individual therapy visit

Mental health services	$30 copay

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Outpatient individual therapy visit with a psychiatrist

Mental health services	$30 copay

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Chemotherapy

Medicare Part B drugs	20% coinsurance

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Other Part B drugs

Medicare Part B drugs	20% coinsurance

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Diabetes supplies

Medical equipment/supplies	$0 copay

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Durable medical equipment (e.g., wheelchairs, oxygen)

Medical equipment/supplies	20% coinsurance per item

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Prosthetics (e.g., braces, artificial limbs)

Medical equipment/supplies	20% coinsurance per item

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Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$5,900 In-network
Inpatient hospital coverage	$325 per day for days 1 through 6 $0 per day for days 7 through 90

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Fitting/evaluation

Hearing	$0 copay

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Hearing aids

Hearing	$0 copay

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Hearing exam

Hearing	$40 copay

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Health plan deductible	$0
Ground ambulance	$265 copay

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Foot exams and treatment

Foot care (podiatry services)	$40 copay

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Routine foot care

Foot care (podiatry services)	Not covered

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Emergency

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

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Urgent care

Emergency care/Urgent care	$50 copay per visit (always covered)

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Primary

Doctor visits	$0 copay

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Specialist

Doctor visits	$25 copay per visit

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Diagnostic radiology services (e.g., MRI)

Diagnostic procedures/lab services/imaging	$75-300 copay

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Diagnostic tests and procedures

Diagnostic procedures/lab services/imaging	$0 copay

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Lab services

Diagnostic procedures/lab services/imaging	$0 copay

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Outpatient x-rays

Diagnostic procedures/lab services/imaging	$0 copay

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Diagnostic services

Comprehensive dental	$0 copay

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Endodontics

Comprehensive dental	50% coinsurance

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Extractions

Comprehensive dental	50% coinsurance

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Non-routine services

Comprehensive dental	Not covered

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Periodontics

Comprehensive dental	50% coinsurance

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Prosthodontics, other oral/maxillofacial surgery, other services

Comprehensive dental	50% coinsurance

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Restorative services

Comprehensive dental	50% coinsurance

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In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?	No

Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Advantage Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Covenant Health Advantage (HMO) requires you to live in that plan’s service area. The service area is listed below:

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Source:CMS. Data as of Oct 1, 2022.

Last updated on December 03, 2022

Notes: Data are subject to change as contracts are finalized. For 2023, enhanced alternative may offer extra cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2023 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.