Vantage DUAL PLUS (HMO-POS D-SNP) By Vantage Health Plan

Vantage DUAL PLUS (HMO-POS D-SNP) H2722 003 0 is a 2023 Medicare Advantage Special Needs Plan plan by Vantage Health Plan. This plan from Vantage Health Plan 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 Vantage Health Plan and not Original Medicare. All Medicare SNPs also provide Medicare additional Part-D drug coverage. Vantage DUAL PLUS (HMO-POS D-SNP) H2722-003 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.

2023 Medicare Special Needs Plan Details

The Vantage DUAL PLUS (HMO-POS D-SNP) H2722-003 is available to residents to Medicare eligible seniors in Arkansas. All Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. Vantage DUAL PLUS (HMO-POS 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 Vantage DUAL PLUS (HMO-POS D-SNP) cost?

Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Vantage Health Plan 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. Vantage DUAL PLUS (HMO-POS D-SNP) has a monthly drug premium of $31.90 and a $505.00 drug deductible. This Vantage Health Plan plan offers a $31.90 Part-D Basic Premium that is 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 Vantage Health Plan 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 $31.90. 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.

Vantage Health Plan 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 Vantage Health Plan 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 Vantage DUAL PLUS (HMO-POS D-SNP) medicare insurance offers a $0 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $8.00 for 75% low-income subsidy $15.90 for 50% and $23.90 for 25%.

H2722-003 Formulary and Drug Coverage

Vantage DUAL PLUS (HMO-POS 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.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	NA	15%
Tier 2	NA	15%
Tier 3	NA	15%
Tier 4	NA	15%
Tier 5	NA	15%

The complete Vantage DUAL PLUS (HMO-POS D-SNP) H2722-003 Formulary
*Initial Coverage Phase and 30 day supply

2023 Summary of Benefits

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

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

---

Eyeglass frames

Out-of-Network Vision	$0 copay
In-Network Vision	$0 copay

---

Eyeglass lenses

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

---

Eyeglasses (frames and lenses)

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

---

Other

Vision	Not covered

---

Routine eye exam

Out-of-Network Vision	50% coinsurance
In-Network Vision	$0 copay

---

Upgrades

In-Network Vision	$0 copay
Out-of-Network Vision	$0 copay

---

In-Network Transportation	$0 copay
Out-of-Network Skilled Nursing Facility	50% per stay
In-Network Skilled Nursing Facility	In 2023 the amounts for each benefit period are $0 or: $0 copay for days 1 through 20 $200 copay per day for days 21 through 100

---

Occupational therapy visit

In-Network Rehabilitation services	0% or 20% coinsurance
Out-of-Network Rehabilitation services	50% coinsurance

---

Physical therapy and speech and language therapy visit

In-Network Rehabilitation services	0% or 20% coinsurance
Out-of-Network Rehabilitation services	50% coinsurance

---

Cleaning

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

---

Dental x-ray(s)

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

---

Fluoride treatment

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

---

Oral exam

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

---

Out-of-Network Preventive care	50% coinsurance
In-Network Preventive care	$0 copay
In-Network Outpatient hospital coverage	0% or 20% coinsurance per visit
Out-of-Network Outpatient hospital coverage	50% coinsurance per visit
In-Network Other health plan deductibles?	No
Optional supplemental benefits	No

---

Inpatient hospital - psychiatric

In-Network Mental health services	In 2023 the amounts for each benefit period are $0 or: $1,600 deductible for days 1 through 60 $400 copay per day for days 61 through 90
Out-of-Network Mental health services	50% per stay

---

Outpatient group therapy visit

Out-of-Network Mental health services	50% coinsurance
In-Network Mental health services	0% or 20% coinsurance

---

Outpatient group therapy visit with a psychiatrist

Out-of-Network Mental health services	50% coinsurance
In-Network Mental health services	0% or 20% coinsurance

---

Outpatient individual therapy visit

In-Network Mental health services	0% or 20% coinsurance
Out-of-Network Mental health services	50% coinsurance

---

Outpatient individual therapy visit with a psychiatrist

In-Network Mental health services	0% or 20% coinsurance
Out-of-Network Mental health services	50% coinsurance

---

Chemotherapy

In-Network Medicare Part B drugs	0% or 20% coinsurance
Out-of-Network Medicare Part B drugs	50% coinsurance

---

Other Part B drugs

In-Network Medicare Part B drugs	0% or 20% coinsurance
Out-of-Network Medicare Part B drugs	50% coinsurance

---

Diabetes supplies

Out-of-Network Medical equipment/supplies	50% coinsurance per item
In-Network Medical equipment/supplies	0% or 0-20% coinsurance per item

---

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

Out-of-Network Medical equipment/supplies	50% coinsurance per item
In-Network Medical equipment/supplies	0% or 20% coinsurance per item

---

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

Out-of-Network Medical equipment/supplies	50% coinsurance per item
In-Network Medical equipment/supplies	0% or 20% coinsurance per item

---

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$7,550 In-network
Out-of-Network Inpatient hospital coverage	50% per stay
In-Network Inpatient hospital coverage	In 2023 the amounts for each benefit period are $0 or: $1,600 deductible for days 1 through 60 $400 copay per day for days 61 through 90

---

Fitting/evaluation

In-Network Hearing	$0 copay
Out-of-Network Hearing	$0 copay

---

Hearing aids

In-Network Hearing	$0 copay
Out-of-Network Hearing	$0 copay

---

Hearing exam

In-Network Hearing	0% or 20% coinsurance
Out-of-Network Hearing	50% coinsurance

---

Health plan deductible	$0 or $500 Out-of-network
Out-of-Network Ground ambulance	50% coinsurance
In-Network Ground ambulance	0% or 20% coinsurance

---

Foot exams and treatment

In-Network Foot care (podiatry services)	0% or 20% coinsurance
Out-of-Network Foot care (podiatry services)	50% coinsurance

---

Routine foot care

Foot care (podiatry services)	Not covered

---

Emergency

Emergency care/Urgent care	$0 or $90 copay per visit (always covered)

---

Urgent care

Emergency care/Urgent care	$0 or $60 copay per visit (always covered)

---

Primary

In-Network Doctor visits	0% or 20% coinsurance per visit
Out-of-Network Doctor visits	50% coinsurance per visit

---

Specialist

In-Network Doctor visits	0% or 20% coinsurance per visit
Out-of-Network Doctor visits	50% coinsurance per visit

---

Diagnostic radiology services (e.g., MRI)

Out-of-Network Diagnostic procedures/lab services/imaging	50% coinsurance
In-Network Diagnostic procedures/lab services/imaging	0% or 20% coinsurance

---

Diagnostic tests and procedures

Out-of-Network Diagnostic procedures/lab services/imaging	50% coinsurance
In-Network Diagnostic procedures/lab services/imaging	0% or 20-25% coinsurance

---

Lab services

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

---

Outpatient x-rays

In-Network Diagnostic procedures/lab services/imaging	0% or 20% coinsurance
Out-of-Network Diagnostic procedures/lab services/imaging	50% coinsurance

---

Diagnostic services

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

---

Endodontics

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

---

Extractions

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

---

Non-routine services

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

---

Periodontics

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

---

Prosthodontics, other oral/maxillofacial surgery, other services

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

---

Restorative services

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

---

In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?	Yes, contact plan for further details

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 Vantage DUAL PLUS (HMO-POS D-SNP) requires you to live in that plan’s service area. The service area is listed below:

Source: CMS.

Plans as of Oct 1, 2022.

Last updated on December 03, 2022

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.