Wellcare Dual Access Open (PPO D-SNP) By Wellcare

Wellcare Dual Access Open (PPO D-SNP) H5965 004 0 is a 2023 Medicare Advantage Special Needs Plan plan by Wellcare. This plan from Wellcare 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 Wellcare and not Original Medicare. All Medicare SNPs also provide Medicare additional Part-D drug coverage. Wellcare Dual Access Open (PPO D-SNP) H5965-004 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 Wellcare Dual Access Open (PPO D-SNP) H5965-004 is available to residents to Medicare eligible seniors in Washington. All Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. Wellcare Dual Access Open (PPO D-SNP) 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 Dual Access Open (PPO D-SNP) cost?

Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Wellcare 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. Wellcare Dual Access Open (PPO D-SNP) has a monthly drug premium of $21.40 and a $505.00 drug deductible. This Wellcare plan offers a $21.40 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 Wellcare 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 $21.40. 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.

Wellcare 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 Wellcare 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 Wellcare Dual Access Open (PPO D-SNP) medicare insurance offers a $0 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $5.30 for 75% low-income subsidy $10.70 for 50% and $16.00 for 25%.

H5965-004 Formulary and Drug Coverage

Wellcare Dual Access Open (PPO 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	$0

The complete Wellcare Dual Access Open (PPO D-SNP) H5965-004 Formulary
*Initial Coverage Phase and 30 day supply

2023 Summary of Benefits

The benefit information provided is a summary of what Wellcare Dual Access Open (PPO D-SNP) 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

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

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Eyeglass frames

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

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Eyeglass lenses

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

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Eyeglasses (frames and lenses)

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

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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

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

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Out-of-Network Transportation	75% coinsurance
In-Network Transportation	$0 copay
In-Network Skilled Nursing Facility	$0 copay
Out-of-Network Skilled Nursing Facility	$0 per day for days 1 through 20 $196 per day for days 21 through 100

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Occupational therapy visit

Out-of-Network Rehabilitation services	40% coinsurance
In-Network Rehabilitation services	$0 copay

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Physical therapy and speech and language therapy visit

Out-of-Network Rehabilitation services	40% coinsurance
In-Network Rehabilitation services	$0 copay

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Cleaning

Out-of-Network Preventive dental	50% coinsurance
In-Network Preventive dental	$0 copay

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Dental x-ray(s)

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	50% coinsurance

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Fluoride treatment

Out-of-Network Preventive dental	50% coinsurance
In-Network Preventive dental	$0 copay

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Oral exam

In-Network Preventive dental	$0 copay
Out-of-Network Preventive dental	50% coinsurance

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In-Network Preventive care	$0 copay
Out-of-Network Preventive care	$0 copay
In-Network Outpatient hospital coverage	$0 copay
Out-of-Network Outpatient hospital coverage	40% coinsurance 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	$1,660 per stay
In-Network Mental health services	$0 copay

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Outpatient group therapy visit

In-Network Mental health services	$0 copay
Out-of-Network Mental health services	40% coinsurance

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Outpatient group therapy visit with a psychiatrist

In-Network Mental health services	$0 copay
Out-of-Network Mental health services	40% coinsurance

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Outpatient individual therapy visit

Out-of-Network Mental health services	40% coinsurance
In-Network Mental health services	$0 copay

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Outpatient individual therapy visit with a psychiatrist

In-Network Mental health services	$0 copay
Out-of-Network Mental health services	40% coinsurance

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Chemotherapy

In-Network Medicare Part B drugs	$0 copay
Out-of-Network Medicare Part B drugs	20% coinsurance

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Other Part B drugs

Out-of-Network Medicare Part B drugs	20% coinsurance
In-Network Medicare Part B drugs	$0 copay

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Diabetes supplies

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

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

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

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

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

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Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$12,450 In and Out-of-network $8,300 In-network
In-Network Inpatient hospital coverage	$0 copay
Out-of-Network Inpatient hospital coverage	$2,050 per stay

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Fitting/evaluation

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

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Hearing aids

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

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Hearing exam

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

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Health plan deductible	$0
In-Network Ground ambulance	$0 copay
Out-of-Network Ground ambulance	20% coinsurance

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Foot exams and treatment

In-Network Foot care (podiatry services)	$0 copay
Out-of-Network Foot care (podiatry services)	$0 copay or 40% coinsurance

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Routine foot care

Out-of-Network Foot care (podiatry services)	$0 copay or 40% coinsurance
In-Network Foot care (podiatry services)	$0 copay

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Emergency

Emergency care/Urgent care	$0 copay

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Urgent care

Emergency care/Urgent care	$0 copay

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Primary

Out-of-Network Doctor visits	40% coinsurance per visit
In-Network Doctor visits	$0 copay

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Specialist

In-Network Doctor visits	$0 copay
Out-of-Network Doctor visits	40% coinsurance per visit

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Diagnostic radiology services (e.g., MRI)

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

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Diagnostic tests and procedures

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

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Lab services

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

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Outpatient x-rays

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

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Diagnostic services

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

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Endodontics

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

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Extractions

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

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Non-routine services

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

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Periodontics

In-Network Comprehensive dental	$0 copay
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	$0 copay

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Restorative services

In-Network Comprehensive dental	$0 copay
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 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 Wellcare Dual Access Open (PPO 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.