SSM Health Plan Harmony (HMO-POS) H8019-003 is a 2023 Medicare Advantage Plan or Part-C by WellFirst Health available to residents in Illinois and Missouri. This plan does not provide extra prescription drug (Part-D) coverage. WellFirst Health SSM Health Plan Harmony (HMO-POS) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $3,250 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $3,250 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 Harmony (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 Harmony (HMO-POS)

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

Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. WellFirst Health 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. SSM Health Plan Harmony (HMO-POS) by WellFirst Health MOOP is $3,250. Once you spend $3,250 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 SSM Health Plan Harmony (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	$75 copay
In-Network Rehabilitation services	$40 copay

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Physical therapy and speech and language therapy visit

In-Network Rehabilitation services	$40 copay
Out-of-Network Rehabilitation services	$75 copay

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Cleaning

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

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Dental x-ray(s)

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

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Fluoride treatment

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

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Oral exam

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

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In-Network Preventive care	$0 copay
Out-of-Network Preventive care	$30 copay
Out-of-Network Outpatient hospital coverage	40% coinsurance per visit
In-Network Outpatient hospital coverage	$0-300 copay 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	$750 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	$75 copay
In-Network Mental health services	$0 copay

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Outpatient group therapy visit with a psychiatrist

Out-of-Network Mental health services	$75 copay
In-Network Mental health services	$0 copay

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Outpatient individual therapy visit

In-Network Mental health services	$0 copay
Out-of-Network Mental health services	$75 copay

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Outpatient individual therapy visit with a psychiatrist

Out-of-Network Mental health services	$75 copay
In-Network Mental health services	$0 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

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

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

In-Network Medical equipment/supplies	0-15% coinsurance per item
Out-of-Network Medical equipment/supplies	40% 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	40% coinsurance per item

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Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$10,000 In and Out-of-network $3,250 In-network
In-Network Inpatient hospital coverage	$325 per day for days 1 through 7 $0 per day for days 8 through 90
Out-of-Network Inpatient hospital coverage	$750 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

In-Network Hearing	$35 copay
Out-of-Network Hearing	$75 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

In-Network Foot care (podiatry services)	$35 copay
Out-of-Network Foot care (podiatry services)	$75 copay

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Routine foot care

Out-of-Network Foot care (podiatry services)	$75 copay
In-Network Foot care (podiatry services)	$0 copay

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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	$0-35 copay per visit (always covered)

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Primary

In-Network Doctor visits	$0 copay
Out-of-Network Doctor visits	$75 copay per visit

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Specialist

In-Network Doctor visits	$0-35 copay per visit
Out-of-Network Doctor visits	$75 copay per visit

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Diagnostic radiology services (e.g., MRI)

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

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Diagnostic tests and procedures

In-Network Diagnostic procedures/lab services/imaging	$15 copay
Out-of-Network Diagnostic procedures/lab services/imaging	40% coinsurance

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Lab services

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

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Outpatient x-rays

In-Network Diagnostic procedures/lab services/imaging	$10 copay
Out-of-Network Diagnostic procedures/lab services/imaging	40% coinsurance

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Diagnostic services

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

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Endodontics

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

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

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Periodontics

In-Network Comprehensive dental	50% coinsurance
Out-of-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 Harmony (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.