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Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) H5932 001 0 is a 2023 Medicare Advantage Special Needs Plan plan by Highmark Wholecare Medicare Assured. This plan from Highmark Wholecare Medicare Assured works with Medicare to give you significant coverage beyond original Medicare. If you decide to sign up you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Highmark Wholecare Medicare Assured and not Original Medicare. All Medicare SNPs also provide Medicare additional Part-D drug coverage.
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) H5932-001 is a Dual Eligible Special Needs Plan (D-SNP). A Dual Eligible SNP is for beneficiaries who are eligible for both Medicare and Medicaid. If you have Medicare and get help from Medicaid you can join any Medicare SNP you qualify for or switch plans at any time.
The Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) H5932-001 is available to residents to
Medicare eligible seniors in Pennsylvania.
All Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage.
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) 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 PCP will serve as your personal doctor to provide all of your basic healthcare services. If you need special care for a physician specialist, your primary care physician will make the arrangements and tell you where you can go in the network. You will need your PCPs okay, called a referral. Without getting a referral or services received from out-of-network providers are not typically covered by the plan.
How much does Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) cost?
Part-C Premium
A monthly premium is the fee you pay to the plan in exchange for coverage. Highmark Wholecare Medicare Assured charges a $0 Part-C 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.
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. Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) has a monthly drug premium of $41.10 and a $505.00 drug deductible. This Highmark Wholecare Medicare Assured plan offers a $41.10 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 Highmark Wholecare Medicare Assured above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $41.10. 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.
Highmark Wholecare Medicare Assured 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 additional coverage. This Highmark Wholecare Medicare Assured plan does not offer additional coverage through the gap.
Extra Help Premium Assistance
The Low Income Subsidy (LIS) Extra Helps people with Medicare pay for prescription drugs and lowers the costs of Medicare prescription drug coverage. Income limits are based on the Federal Poverty Level (FPL), which changes every year in February or March. The 2022 income limit is $1,719 ($2,309 for couples) per month. Depending on your income level you may be eligible for a full 75%, 50%, 25% premium assistance. The Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) medicare insurance offers a $0 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $10.30 for 75% low-income subsidy $20.60 for 50% and $30.80 for 25%.
Full Assistance Premium:
$0
75% Assistance Premium:
$10.30
50% Assistance Premium:
$20.60
25% Assistance Premium:
$30.80
H5932-001 Formulary and Drug Coverage
Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) 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 Special Needs Plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.
The benefit information provided is a summary of what Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Highmark Wholecare Medicare Assured 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.
Physical therapy and speech and language therapy visit
Rehabilitation services
$0 copay
Cleaning
Preventive dental
$0 copay
Dental x-ray(s)
Preventive dental
$0 copay
Fluoride treatment
Preventive dental
Not covered
Oral exam
Preventive dental
$0 copay
Preventive care
$0 copay
Outpatient hospital coverage
$0 copay
In-Network Other health plan deductibles?
No
Optional supplemental benefits
No
Inpatient hospital - psychiatric
Mental health services
$0 copay
Outpatient group therapy visit
Mental health services
$0 copay
Outpatient group therapy visit with a psychiatrist
Mental health services
$0 copay
Outpatient individual therapy visit
Mental health services
$0 copay
Outpatient individual therapy visit with a psychiatrist
Mental health services
$0 copay
Chemotherapy
Medicare Part B drugs
$0 copay
Other Part B drugs
Medicare Part B drugs
$0 copay
Diabetes supplies
Medical equipment/supplies
$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)
Medical equipment/supplies
$0 copay
Prosthetics (e.g., braces, artificial limbs)
Medical equipment/supplies
$0 copay
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$8,300 In-network
Inpatient hospital coverage
$0 copay
Fitting/evaluation
Hearing
$0 copay
Hearing aids
Hearing
$0 copay
Hearing exam
Hearing
$0 copay
Health plan deductible
$0
Ground ambulance
$0 copay
Foot exams and treatment
Foot care (podiatry services)
$0 copay
Routine foot care
Foot care (podiatry services)
$0 copay
Emergency
Emergency care/Urgent care
$0 copay
Urgent care
Emergency care/Urgent care
$0 copay
Primary
Doctor visits
$0 copay
Specialist
Doctor visits
$0 copay
Diagnostic radiology services (e.g., MRI)
Diagnostic procedures/lab services/imaging
$0 copay
Diagnostic tests and procedures
Diagnostic procedures/lab services/imaging
$0 copay
Lab services
Diagnostic procedures/lab services/imaging
$0 copay
Outpatient x-rays
Diagnostic procedures/lab services/imaging
$0 copay
Diagnostic services
Comprehensive dental
$0 copay
Endodontics
Comprehensive dental
$0 copay
Extractions
Comprehensive dental
$0 copay
Non-routine services
Comprehensive dental
Not covered
Periodontics
Comprehensive dental
$0 copay
Prosthodontics, other oral/maxillofacial surgery, other services
Comprehensive dental
$0 copay
Restorative services
Comprehensive dental
$0 copay
In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
No
CMS Star Ratings
Is Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) a good plan? Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) received 4 overall star rating from the CMS. The CMS uses a Star Rating System to measure how well Medicare Special Needs 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 Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) performance among several different plans.
2022 Overall Rating
Part C Summary Rating
Part-D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing
Staying Healthy, Screening, Testing, & Vaccines
Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Monitoring Physical Activity
Managing Chronic And Long Term Care for Older Adults
Total Rating
SNP Care Management
Medication Review
Pain Assessment
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Controlling Blood Pressure
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Statin Therapy
Member Experience with H5932-001 Health Plan
Total Experience Rating
Getting Needed Care
Getting Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination
Member Complaints and Changes in Plans Performance
Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement
Health Plan Customer Service Rating for Highmark Wholecare Medicare Assured
Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language
Drug Plan Customer Service Ratings
Total Rating
Call Center, TTY, Foreign Language
Ratings For Member Complaints and Changes in the Drug Plans Performance
Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Drug Plan Quality Improvement
Member Experience with the Drug Plan
Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs
Drug Safety and Accuracy of Drug Pricing
Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes
Coverage Area
(Click county or state to compare all available Advantage plans)
The availability of Medicare Special Need 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 Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) requires you to live in that plan’s service area. The service area is listed below:
Notes: Data are subject to change. All contracts for 2023 have not been finalized. For 2023, enhanced alternative plans may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part Part D benefit.
Includes 2023 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.
Site Search:
MedicareHelp.org is a privately-owned Non-governmental agency. The government website can be found at HealthCare.gov.
Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.
Every year, Medicare evaluates plans based on a 5-star rating system.
