Essence (HMO-POS) H5211-003 is a 2023 Medicare Advantage Plan or Part-C by Security Health Plan of Wisconsin, Inc. available to residents in Wisconsin. This plan does not provide extra prescription drug (Part-D) coverage. Security Health Plan of Wisconsin, Inc. Essence (HMO-POS) has a monthly premium of $20.00 and has an in-network maximum out-of-pocket limit of $3,400 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $3,400 out-of-pocket. This can be an extremely nice safety net.

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

2023 Security Health Plan of Wisconsin, Inc. Medicare Advantage Plan Overview

What type of plan is Essence (HMO-POS)

Essence (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 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.

With a HMO-POS point-of-service you have the option to go out-of-network or see a specialist without a referral. But, you may pay more for out-of-network care you receive than from an in-network provider.

How much does Essence (HMO-POS) cost?

Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Security Health Plan of Wisconsin, Inc. charges a $20.00 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. Essence (HMO-POS) by Security Health Plan of Wisconsin, Inc. MOOP is $3,400. Once you spend $3,400 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 Essence (HMO-POS) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Security Health Plan of Wisconsin, Inc. 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	Not covered

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Eyeglass frames

Vision	Not covered

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Eyeglass lenses

Vision	Not covered

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Eyeglasses (frames and lenses)

In-Network Vision	$0 copay

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Other

In-Network Vision	$0-50 copay
Out-of-Network Vision	$0-50 copay

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Routine eye exam

In-Network Vision	$0-50 copay
Out-of-Network Vision	$0-50 copay

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Upgrades

Vision	Not covered

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Transportation	Not covered
Out-of-Network Skilled Nursing Facility	$0 per day for days 1 through 6 $20 per day for days 7 through 45 $0 per day for days 46 through 100
In-Network Skilled Nursing Facility	$0 per day for days 1 through 6 $20 per day for days 7 through 45 $0 per day for days 46 through 100

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Occupational therapy visit

Out-of-Network Rehabilitation services	$20 copay
In-Network Rehabilitation services	$20 copay

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Physical therapy and speech and language therapy visit

In-Network Rehabilitation services	$20 copay
Out-of-Network Rehabilitation services	$20 copay

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Cleaning

In-Network Preventive dental	$0 copay

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Dental x-ray(s)

In-Network Preventive dental	$0 copay

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Fluoride treatment

Preventive dental	Not covered

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Oral exam

In-Network Preventive dental	$0 copay

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Out-of-Network Preventive care	$0 copay
In-Network Preventive care	$0 copay
In-Network Outpatient hospital coverage	$0-200 copay per visit
Out-of-Network Outpatient hospital coverage	$0-200 copay per visit
In-Network Other health plan deductibles?	Yes
Optional supplemental benefits	Yes

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Inpatient hospital - psychiatric

In-Network Mental health services	$300 per day for days 1 through 5 $0 per day for days 6 through 90
Out-of-Network Mental health services	$300 per day for days 1 through 5 $0 per day for days 6 through 90

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Outpatient group therapy visit

In-Network Mental health services	$40 copay
Out-of-Network Mental health services	$40 copay

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Outpatient group therapy visit with a psychiatrist

In-Network Mental health services	$40 copay
Out-of-Network Mental health services	$40 copay

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Outpatient individual therapy visit

In-Network Mental health services	$40 copay
Out-of-Network Mental health services	$40 copay

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Outpatient individual therapy visit with a psychiatrist

In-Network Mental health services	$40 copay
Out-of-Network Mental health services	$40 copay

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Chemotherapy

In-Network Medicare Part B drugs	20% coinsurance
Out-of-Network Medicare Part B drugs	20% coinsurance

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Other Part B drugs

In-Network Medicare Part B drugs	20% coinsurance
Out-of-Network Medicare Part B drugs	20% coinsurance

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Diabetes supplies

In-Network Medical equipment/supplies	$0 copay

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

Out-of-Network Medical equipment/supplies	0-20% coinsurance per item
In-Network Medical equipment/supplies	0-20% coinsurance per item

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

In-Network Medical equipment/supplies	20% coinsurance per item
Out-of-Network Medical equipment/supplies	0-20% coinsurance per item

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Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$3,400 In and Out-of-network $3,400 In-network $3,400 Out-of-network
In-Network Inpatient hospital coverage	$300 per day for days 1 through 5 $0 per day for days 6 through 90
Out-of-Network Inpatient hospital coverage	$300 per day for days 1 through 5 $0 per day for days 6 through 90

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Fitting/evaluation

Out-of-Network Hearing	$50 copay
In-Network Hearing	$50 copay

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Hearing aids

In-Network Hearing	$500 copay

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Hearing exam

Out-of-Network Hearing	$50 copay
In-Network Hearing	$50 copay

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Health plan deductible	$0
In-Network Ground ambulance	$200 copay

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Foot exams and treatment

Out-of-Network Foot care (podiatry services)	$50 copay
In-Network Foot care (podiatry services)	$50 copay

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Routine foot care

Foot care (podiatry services)	Not covered

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Emergency

Emergency care/Urgent care	$125 copay per visit (always covered)

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Urgent care

Emergency care/Urgent care	$0-50 copay per visit (always covered)

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Primary

In-Network Doctor visits	$0 copay
Out-of-Network Doctor visits	$0 copay

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Specialist

In-Network Doctor visits	$50 copay per visit
Out-of-Network Doctor visits	$50 copay per visit

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Diagnostic radiology services (e.g., MRI)

Out-of-Network Diagnostic procedures/lab services/imaging	$200 copay
In-Network Diagnostic procedures/lab services/imaging	$200 copay

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Diagnostic tests and procedures

Out-of-Network Diagnostic procedures/lab services/imaging	$0 copay
In-Network Diagnostic procedures/lab services/imaging	$0 copay

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Lab services

In-Network Diagnostic procedures/lab services/imaging	$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging	$0 copay

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Outpatient x-rays

In-Network Diagnostic procedures/lab services/imaging	$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging	$0 copay

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Diagnostic services

Comprehensive dental	Not covered

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Endodontics

Comprehensive dental	Not covered

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Extractions

Comprehensive dental	Not covered

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Non-routine services

Comprehensive dental	Not covered

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Periodontics

Comprehensive dental	Not covered

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Prosthodontics, other oral/maxillofacial surgery, other services

Comprehensive dental	Not covered

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Restorative services

Comprehensive dental	Not covered

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In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?	Yes, contact plan for further details

Essence (HMO-POS) Reviews

Is Essence (HMO-POS) a good plan? Essence (HMO-POS) received a 4.5 overall star rating from the CMS. The CMS uses a Star Rating System to measure how well Medicare Advantage and Part D plans perform. Plans are rated on a one-to-five scale, with one star representing poor performance and five stars representing excellent performance. Medicare Advantage with prescription drug (Part D) coverage (MA-PD) contracts are rated on up to 38 unique quality and performance measures. You can use the CMS star rating to compare Essence Reviews among several different plans.

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with H5211-003 Health Plan

Member Complaints and Changes in Plans Performance

Health Plan Customer Service Rating for Security Health Plan of Wisconsin, Inc.

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

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 Essence (HMO-POS) 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.