SSM Health Plan FlexSpend (HMO-POS) H8019-005 is a 2023 Medicare Advantage Plan or Part-C by WellFirst Health available to residents in Illinois and Missouri. This plan includes extra prescription drug (Part-D) coverage. WellFirst Health SSM Health Plan FlexSpend (HMO-POS) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $2,750 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $2,750 out-of-pocket. This can be an extremely nice safety net.

WellFirst Health works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for SSM Health Plan FlexSpend (HMO-POS) you still retain Original Medicare. But you will get extra Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from WellFirst Health 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 WellFirst Health except hospice care. Original Medicare still provides you with hospice care if you sign up for Medicare Advantage in Illinois or Medicare Advantage in Missouri.

2023 WellFirst Health Medicare Advantage Plan Overview

What type of plan is SSM Health Plan FlexSpend (HMO-POS)

SSM Health Plan FlexSpend (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 SSM Health Plan FlexSpend (HMO-POS) cost?

Monthly Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. WellFirst Health charges a $0 consolidated premium. The Part C premium is $0 this charge covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

Part-D Deductible and Premium

An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. SSM Health Plan FlexSpend (HMO-POS) has a monthly drug premium of $0 and a $0 drug deductible. This WellFirst Health plan offers a $0 Part-D Basic Premium that is Not 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. This Premium covers any enhanced plan benefits offered by WellFirst Health above and beyond the standard PDP benefits. This can include extra coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $0. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

WellFirst Health Gap Coverage

In 2023 once you and your plan provider have spent $4660 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 extra coverage. This WellFirst Health plan does offer extra coverage through the gap.

MOOP

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. SSM Health Plan FlexSpend (HMO-POS) by WellFirst Health MOOP is $2,750. Once you spend $2,750 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.

Formulary and Drug Coverage

SSM Health Plan FlexSpend (HMO-POS) 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.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$2	$7
Tier 2	$8	$13
Tier 3	$42	$47
Tier 4	$95	$100
Tier 5	33%	33%
Tier 6	$0	$0

The complete SSM Health Plan FlexSpend (HMO-POS) Formulary.
*Initial Coverage Phase and 30 day supply

2023 Summary of Benefits

The benefit information provided is a summary of what SSM Health Plan FlexSpend (HMO-POS) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from WellFirst Health 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

In-Network Vision	$0 copay

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Eyeglass frames

In-Network Vision	$0 copay

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Eyeglass lenses

In-Network Vision	$0 copay

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Eyeglasses (frames and lenses)

In-Network Vision	$0 copay

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Other

Vision	Not covered

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Routine eye exam

In-Network Vision	$0 copay

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Upgrades

In-Network Vision	$0 copay

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In-Network Transportation	$0 copay
In-Network Skilled Nursing Facility	$0 per day for days 1 through 20 $196 per day for days 21 through 100
Out-of-Network Skilled Nursing Facility	$150 per day for days 1 through 100

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Occupational therapy visit

Out-of-Network Rehabilitation services	$60 copay
In-Network Rehabilitation services	$35 copay

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Physical therapy and speech and language therapy visit

In-Network Rehabilitation services	$35 copay
Out-of-Network Rehabilitation services	$60 copay

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Cleaning

Out-of-Network Preventive dental	$0 copay
In-Network Preventive dental	$0 copay

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Dental x-ray(s)

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	$0 copay

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Fluoride treatment

Out-of-Network Preventive dental	$0 copay
In-Network Preventive dental	$0 copay

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Oral exam

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	$0 copay

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In-Network Preventive care	$0 copay
Out-of-Network Preventive care	$30 copay
In-Network Outpatient hospital coverage	$0-300 copay per visit
Out-of-Network Outpatient hospital coverage	40% coinsurance per visit
In-Network Other health plan deductibles?	No
Optional supplemental benefits	No

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Inpatient hospital - psychiatric

Out-of-Network Mental health services	$500 per day for days 1 through 7 $0 per day for days 8 through 90
In-Network Mental health services	$325 per day for days 1 through 7 $0 per day for days 8 through 90

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Outpatient group therapy visit

Out-of-Network Mental health services	$30 copay
In-Network Mental health services	$0 copay

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Outpatient group therapy visit with a psychiatrist

In-Network Mental health services	$0 copay
Out-of-Network Mental health services	$30 copay

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Outpatient individual therapy visit

In-Network Mental health services	$0 copay
Out-of-Network Mental health services	$30 copay

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Outpatient individual therapy visit with a psychiatrist

In-Network Mental health services	$0 copay
Out-of-Network Mental health services	$30 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	$2-47 copay or 20% coinsurance
Out-of-Network Medicare Part B drugs	20% coinsurance

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Diabetes supplies

In-Network Medical equipment/supplies	$0 copay per item
Out-of-Network Medical equipment/supplies	40% coinsurance per item

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

In-Network Medical equipment/supplies	0-20% coinsurance per item
Out-of-Network Medical equipment/supplies	40% coinsurance per item

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

Out-of-Network Medical equipment/supplies	40% coinsurance per item
In-Network Medical equipment/supplies	20% coinsurance per item

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Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$5,000 In and Out-of-network $2,750 In-network
Out-of-Network Inpatient hospital coverage	$500 per day for days 1 through 7 $0 per day for days 8 through 90
In-Network Inpatient hospital coverage	$325 per day for days 1 through 7 $0 per day for days 8 through 90

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Fitting/evaluation

In-Network Hearing	$0 copay

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Hearing aids

In-Network Hearing	$0 copay

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Hearing exam

Out-of-Network Hearing	$60 copay
In-Network Hearing	$35 copay

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Health plan deductible	$0
In-Network Ground ambulance	$300 copay
Out-of-Network Ground ambulance	$300 copay

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Foot exams and treatment

Out-of-Network Foot care (podiatry services)	$50 copay
In-Network Foot care (podiatry services)	$35 copay

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Routine foot care

In-Network Foot care (podiatry services)	$35 copay
Out-of-Network Foot care (podiatry services)	$50 copay

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Emergency

Emergency care/Urgent care	$100 copay per visit (always covered)

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Urgent care

Emergency care/Urgent care	$0-35 copay per visit (always covered)

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Primary

Out-of-Network Doctor visits	$50 copay per visit
In-Network Doctor visits	$0 copay

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Specialist

In-Network Doctor visits	$0-35 copay per visit
Out-of-Network Doctor visits	$50 copay per visit

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Diagnostic radiology services (e.g., MRI)

In-Network Diagnostic procedures/lab services/imaging	$0-120 copay
Out-of-Network Diagnostic procedures/lab services/imaging	40% coinsurance

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Diagnostic tests and procedures

Out-of-Network Diagnostic procedures/lab services/imaging	20% coinsurance
In-Network Diagnostic procedures/lab services/imaging	$10 copay

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Lab services

In-Network Diagnostic procedures/lab services/imaging	$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging	20% coinsurance

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Outpatient x-rays

Out-of-Network Diagnostic procedures/lab services/imaging	40% coinsurance
In-Network Diagnostic procedures/lab services/imaging	$20 copay

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Diagnostic services

Out-of-Network Comprehensive dental	50% coinsurance
In-Network Comprehensive dental	0-50% coinsurance

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Endodontics

In-Network Comprehensive dental	50% coinsurance
Out-of-Network Comprehensive dental	50% coinsurance

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Extractions

In-Network Comprehensive dental	50% coinsurance
Out-of-Network Comprehensive dental	50% coinsurance

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Non-routine services

Out-of-Network Comprehensive dental	50% coinsurance
In-Network Comprehensive dental	50% coinsurance

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Periodontics

Out-of-Network Comprehensive dental	50% coinsurance
In-Network Comprehensive dental	50% coinsurance

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Prosthodontics, other oral/maxillofacial surgery, other services

Out-of-Network Comprehensive dental	50% coinsurance
In-Network Comprehensive dental	50% coinsurance

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Restorative services

In-Network Comprehensive dental	50% coinsurance
Out-of-Network 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 SSM Health Plan FlexSpend (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.