Wellcare Advantage Premium Enhanced (PFFS) H2816-037 is a 2023 Medicare Advantage Plan or Part-C by Wellcare available to residents in New York. This plan does not provide extra prescription drug (Part-D) coverage. Wellcare Wellcare Advantage Premium Enhanced (PFFS) has a monthly premium of $60.00 and has an in-network maximum out-of-pocket limit of $- (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $- out-of-pocket. This can be an extremely nice safety net.

Wellcare works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Wellcare Advantage Premium Enhanced (PFFS) you still retain Original Medicare. But you will get extra Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Wellcare 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 Wellcare except hospice care. Original Medicare still provides you with hospice care if you sign up for Medicare Advantage in New York.

2023 Wellcare Medicare Advantage Plan Overview

What type of plan is Wellcare Advantage Premium Enhanced (PFFS)

Wellcare Advantage Premium Enhanced (PFFS) is a PFFS *. A Private Fee-For-Service (PFFS) plan is a Medicare Advantage (MA) health plan offered by a contract with the Centers for Medicare & Medicaid Services (CMS) to provide you with benefits. Wellcare (instead of Medicare) will decide on how much it will cover and how much you will pay for the services you get. You may go to any Medicare approved doctor or hospital or any other health care provider that accepts both Medicare and your plans payment. A PFFS plan has no provider network, and you dont need a referral or a primary care physician for any health care or services. PFFS plans are the most flexible but a doctor will make a visit-by-visit decisions on whether to accept your provider.

How much does Wellcare Advantage Premium Enhanced (PFFS) cost?

Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Wellcare charges a $60.00 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.

2023 Summary of Benefits

The benefit information provided is a summary of what Wellcare Advantage Premium Enhanced (PFFS) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Wellcare 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)

Vision	Not covered

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Other

Vision	Not covered

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Routine eye exam

Out-of-Network Vision	40% coinsurance
In-Network Vision	$0 copay

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Upgrades

Vision	Not covered

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Transportation	Not covered
In-Network Skilled Nursing Facility	$0 per day for days 1 through 20 $150 per day for days 21 through 70 $0 per day for days 71 through 100
Out-of-Network Skilled Nursing Facility	$0 per day for days 1 through 20 $200 per day for days 21 through 100

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Occupational therapy visit

In-Network Rehabilitation services	$15 copay
Out-of-Network Rehabilitation services	30% coinsurance

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Physical therapy and speech and language therapy visit

Out-of-Network Rehabilitation services	30% coinsurance
In-Network Rehabilitation services	$15 copay

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Cleaning

Preventive dental	Not covered

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Dental x-ray(s)

Preventive dental	Not covered

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Fluoride treatment

Preventive dental	Not covered

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Oral exam

Preventive dental	Not covered

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In-Network Preventive care	$0 copay
Out-of-Network Preventive care	$0 copay
In-Network Outpatient hospital coverage	$200 copay per visit
Out-of-Network Outpatient hospital coverage	30% coinsurance per visit
In-Network Other health plan deductibles?	No
Optional supplemental benefits	No

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Inpatient hospital - psychiatric

In-Network Mental health services	$500 per stay
Out-of-Network Mental health services	$300 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% coinsurance
In-Network Mental health services	$25 copay

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Outpatient group therapy visit with a psychiatrist

Out-of-Network Mental health services	30% coinsurance
In-Network Mental health services	$25 copay

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Outpatient individual therapy visit

In-Network Mental health services	$25 copay
Out-of-Network Mental health services	30% coinsurance

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Outpatient individual therapy visit with a psychiatrist

In-Network Mental health services	$25 copay
Out-of-Network Mental health services	30% coinsurance

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Chemotherapy

In-Network Medicare Part B drugs	20% coinsurance
Out-of-Network Medicare Part B drugs	30% coinsurance

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Other Part B drugs

Out-of-Network Medicare Part B drugs	30% coinsurance
In-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	30% coinsurance per item

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

Out-of-Network Medical equipment/supplies	30% coinsurance per item
In-Network Medical equipment/supplies	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	30% coinsurance per item

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Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$6,700 In and Out-of-network
In-Network Inpatient hospital coverage	$650 per stay $0 per day for days 91 and beyond
Out-of-Network Inpatient hospital coverage	$388 per day for days 1 through 7 $0 per day for days 8 and beyond

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Fitting/evaluation

Out-of-Network Hearing	40% coinsurance
In-Network Hearing	$0 copay

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Hearing aids - inner ear

Hearing	Not covered

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Hearing aids - outer ear

Hearing	Not covered

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Hearing aids - over the ear

Hearing	Not covered

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Hearing exam

In-Network Hearing	$25 copay
Out-of-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

In-Network Foot care (podiatry services)	$25 copay
Out-of-Network Foot care (podiatry services)	$35 copay

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Routine foot care

Foot care (podiatry services)	Not covered

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Emergency

Emergency care/Urgent care	$95 copay per visit (always covered)

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Urgent care

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

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Primary

In-Network Doctor visits	$0 copay
Out-of-Network Doctor visits	$10 copay per visit

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Specialist

In-Network Doctor visits	$25 copay per visit
Out-of-Network Doctor visits	$35 copay per visit

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Diagnostic radiology services (e.g., MRI)

In-Network Diagnostic procedures/lab services/imaging	$0-200 copay
Out-of-Network Diagnostic procedures/lab services/imaging	30% coinsurance

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Diagnostic tests and procedures

In-Network Diagnostic procedures/lab services/imaging	$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging	30% coinsurance

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Lab services

In-Network Diagnostic procedures/lab services/imaging	$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging	30% coinsurance

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Outpatient x-rays

In-Network Diagnostic procedures/lab services/imaging	$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging	30% coinsurance

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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?	No

Wellcare Advantage Premium Enhanced (PFFS) Reviews

Is Wellcare Advantage Premium Enhanced (PFFS) a good plan? Wellcare Advantage Premium Enhanced (PFFS) received a 3 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 Wellcare Advantage Premium Enhanced Reviews among several different plans.

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with H2816-037 Health Plan

Member Complaints and Changes in Plans Performance

Health Plan Customer Service Rating for Wellcare

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 Wellcare Advantage Premium Enhanced (PFFS) 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.