2023 Wellcare Patriot Giveback Open (PPO)

Wellcare Patriot Giveback Open (PPO) H5965-003 is a 2023 Medicare Advantage Plan or Part-C by Wellcare available to residents in Washington. This plan does not provide extra prescription drug (Part-D) coverage. Wellcare Wellcare Patriot Giveback Open (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $4,000 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $4,000 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 Patriot Giveback Open (PPO) 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 Washington.

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Benefits
Monthly Costs
MOOP
Coverage Area

2023 Wellcare Medicare Advantage Plan Overview

Name:	Wellcare Patriot Giveback Open (PPO)
Plan ID:	H5965 003 0
Provider:	Wellcare
Year:	2023
Type:	Local PPO *
Combined Premium (C+D):	$0/mo
MOOP:	$4,000/yr
Similar Plan:	H5965-002

What type of plan is Wellcare Patriot Giveback Open (PPO)

Wellcare Patriot Giveback Open (PPO) is a Local PPO *. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network, but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

How much does Wellcare Patriot Giveback Open (PPO) cost?

Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Wellcare 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. Wellcare Patriot Giveback Open (PPO) by Wellcare MOOP is $4,000. Once you spend $4,000 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 Wellcare Patriot Giveback Open (PPO) 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

Contact lenses

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

Eyeglass frames

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

Eyeglass lenses

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

Eyeglasses (frames and lenses)

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

Other

Vision	Not covered

Routine eye exam

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

Upgrades

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

Transportation	Not covered
Out-of-Network Skilled Nursing Facility	20% per day for days 1 through 100
In-Network Skilled Nursing Facility	$0 per day for days 1 through 20 $196 per day for days 21 through 50 $0 per day for days 51 through 100

Occupational therapy visit

Out-of-Network Rehabilitation services	40% coinsurance
In-Network Rehabilitation services	$40 copay

Physical therapy and speech and language therapy visit

In-Network Rehabilitation services	$40 copay
Out-of-Network Rehabilitation services	40% coinsurance

Cleaning

Out-of-Network Preventive dental	70% coinsurance
In-Network Preventive dental	$0 copay

Dental x-ray(s)

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	70% coinsurance

Fluoride treatment

Out-of-Network Preventive dental	70% coinsurance
In-Network Preventive dental	$0 copay

Oral exam

Out-of-Network Preventive dental	70% coinsurance
In-Network Preventive dental	$0 copay

In-Network Preventive care	$0 copay
Out-of-Network Preventive care	$0 copay
In-Network Outpatient hospital coverage	$250 copay per visit
Out-of-Network Outpatient hospital coverage	40% coinsurance per visit
In-Network Other health plan deductibles?	No
Optional supplemental benefits	No

Inpatient hospital - psychiatric

Out-of-Network Mental health services	40% per day for days 1 through 90
In-Network Mental health services	$550 per day for days 1 through 3 $0 per day for days 4 through 90

Outpatient group therapy visit

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

Outpatient group therapy visit with a psychiatrist

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

Outpatient individual therapy visit

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

Outpatient individual therapy visit with a psychiatrist

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

Chemotherapy

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

Other Part B drugs

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

Diabetes supplies

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

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

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

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

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

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$8,950 In and Out-of-network $4,000 In-network
In-Network Inpatient hospital coverage	$500 per day for days 1 through 3 $0 per day for days 4 through 90
Out-of-Network Inpatient hospital coverage	20% per day for days 1 through 90

Fitting/evaluation

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

Hearing aids

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

Hearing exam

In-Network Hearing	$50 copay
Out-of-Network Hearing	40% coinsurance

Health plan deductible	$0
In-Network Ground ambulance	$250 copay
Out-of-Network Ground ambulance	$250 copay

Foot exams and treatment

In-Network Foot care (podiatry services)	$50 copay
Out-of-Network Foot care (podiatry services)	40% coinsurance

Routine foot care

In-Network Foot care (podiatry services)	$25 copay
Out-of-Network Foot care (podiatry services)	40% coinsurance

Emergency

Emergency care/Urgent care	$110 copay per visit (always covered)

Urgent care

Emergency care/Urgent care	$30 copay per visit (always covered)

Primary

Out-of-Network Doctor visits	40% coinsurance per visit
In-Network Doctor visits	$20 copay per visit

Specialist

In-Network Doctor visits	$50 copay per visit
Out-of-Network Doctor visits	40% coinsurance per visit

Diagnostic radiology services (e.g., MRI)

In-Network Diagnostic procedures/lab services/imaging	$0-250 copay
Out-of-Network Diagnostic procedures/lab services/imaging	40% coinsurance

Diagnostic tests and procedures

In-Network Diagnostic procedures/lab services/imaging	$0-50 copay
Out-of-Network Diagnostic procedures/lab services/imaging	40% coinsurance

Lab services

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

Outpatient x-rays

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

Diagnostic services

In-Network Comprehensive dental	40% coinsurance
Out-of-Network Comprehensive dental	70% coinsurance

Endodontics

Out-of-Network Comprehensive dental	70% coinsurance
In-Network Comprehensive dental	40% coinsurance

Extractions

Out-of-Network Comprehensive dental	70% coinsurance
In-Network Comprehensive dental	40% coinsurance

Non-routine services

In-Network Comprehensive dental	40% coinsurance
Out-of-Network Comprehensive dental	70% coinsurance

Periodontics

In-Network Comprehensive dental	40% coinsurance
Out-of-Network Comprehensive dental	70% coinsurance

Prosthodontics, other oral/maxillofacial surgery, other services

In-Network Comprehensive dental	40% coinsurance
Out-of-Network Comprehensive dental	70% coinsurance

Restorative services

Out-of-Network Comprehensive dental	70% coinsurance
In-Network Comprehensive dental	40% coinsurance

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 Wellcare Patriot Giveback Open (PPO) requires you to live in that plan’s service area. The service area is listed below:

State:	Washington Medicare
County:	Adams County MA Plans Benton County MA Plans Ferry County MA Plans Franklin County MA Plans Grant County MA Plans King County MA Plans Kitsap County MA Plans Lewis County MA Plans Mason County MA Plans Pierce County MA Plans Snohomish County MA Plans Spokane County MA Plans Stevens County MA Plans Thurston County MA Plans Walla Walla County MA Plans Yakima County MA Plans

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How much does Wellcare Patriot Giveback Open (PPO) cost?

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

How much is Wellcare Patriot Giveback Open (PPO) MOOP?

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Wellcare Patriot Giveback Open (PPO) by Wellcare MOOP is $4,000. Once you spend $4,000 you will pay nothing for Part A or Part B covered services.

What type of plan is Wellcare Patriot Giveback Open (PPO)?

Wellcare Patriot Giveback Open (PPO) is a Local PPO *. A (PPO) is a Medicare plan that has contracts with a network of preferred providers. You do not need to select a primary care physician and you do not need referrals to see other providers in the network.

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.