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



Wellcare Dual Liberty Open (PPO D-SNP) H4699 005 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 Liberty Open (PPO D-SNP) H4699-005 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

Plan Name:Wellcare Dual Liberty Open (PPO D-SNP)
Plan ID:H4699 005 0
Special Needs Type:Dual-Eligible
Provider:Wellcare
Plan Year:2023
Plan Type:Local PPO
Monthly Premium C+D:$22.70
Part C Premium:$0
Part D (Drug) Premium:$22.70
Part D Supplemental Premium$0
Total Part D Premium:$22.70
Drug Deductible:$505.00
Tiers with No Deductible:0
Benchmark:below the regional benchmark
Type of Medicare Health Plan:Defined Standard Benefit
Drug Benefit Type:Basic
Gap Coverage:No
Similar Plan: H4699-003


The Wellcare Dual Liberty Open (PPO D-SNP) H4699-005 is available to residents to Medicare eligible seniors in Rhode Island. All Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. Wellcare Dual Liberty 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 Liberty 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 Liberty Open (PPO D-SNP) has a monthly drug premium of $22.70 and a $505.00 drug deductible. This Wellcare plan offers a $22.70 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 $22.70. 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 Liberty 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 $5.70 for 75% low-income subsidy $11.30 for 50% and $17.00 for 25%.


Full Assistance Premium:$0
75% Assistance Premium:$5.70
50% Assistance Premium:$11.30
25% Assistance Premium:$17.00


H4699-005 Formulary and Drug Coverage

Wellcare Dual Liberty 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 Liberty Open (PPO D-SNP) H4699-005 Formulary
*Initial Coverage Phase and 30 day supply





2023 Summary of Benefits

The benefit information provided is a summary of what Wellcare Dual Liberty 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


Contact lenses


Out-of-Network Vision40% coinsurance
In-Network Vision$0 copay


Eyeglass frames


Out-of-Network Vision40% coinsurance
In-Network Vision$0 copay


Eyeglass lenses


Out-of-Network Vision40% coinsurance
In-Network Vision$0 copay


Eyeglasses (frames and lenses)


In-Network Vision$0 copay
Out-of-Network Vision40% coinsurance


Other


VisionNot covered


Routine eye exam


Out-of-Network Vision40% coinsurance
In-Network Vision$0 copay


Upgrades


Out-of-Network Vision40% coinsurance
In-Network Vision$0 copay



In-Network Transportation$0 copay
Out-of-Network Transportation75% coinsurance
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


Occupational therapy visit


In-Network Rehabilitation services$0 copay
Out-of-Network Rehabilitation services40% coinsurance


Physical therapy and speech and language therapy visit


In-Network Rehabilitation services$0 copay
Out-of-Network Rehabilitation services40% coinsurance


Cleaning


In-Network Preventive dental$0 copay
Out-of-Network Preventive dental50% coinsurance


Dental x-ray(s)


In-Network Preventive dental$0 copay
Out-of-Network Preventive dental50% coinsurance


Fluoride treatment


In-Network Preventive dental$0 copay
Out-of-Network Preventive dental50% coinsurance


Oral exam


Out-of-Network Preventive dental50% coinsurance
In-Network Preventive dental$0 copay



In-Network Preventive care$0 copay
Out-of-Network Preventive care$0 copay
Out-of-Network Outpatient hospital coverage40% coinsurance per visit
In-Network Outpatient hospital coverage$0 copay
In-Network Other health plan deductibles?No
Optional supplemental benefitsNo


Inpatient hospital - psychiatric


Out-of-Network Mental health services$1,660 per stay
In-Network Mental health services$0 copay


Outpatient group therapy visit


Out-of-Network Mental health services40% coinsurance
In-Network Mental health services$0 copay


Outpatient group therapy visit with a psychiatrist


Out-of-Network Mental health services40% coinsurance
In-Network Mental health services$0 copay


Outpatient individual therapy visit


Out-of-Network Mental health services40% coinsurance
In-Network Mental health services$0 copay


Outpatient individual therapy visit with a psychiatrist


In-Network Mental health services$0 copay
Out-of-Network Mental health services40% coinsurance


Chemotherapy


Out-of-Network Medicare Part B drugs40% coinsurance
In-Network Medicare Part B drugs$0 copay


Other Part B drugs


Out-of-Network Medicare Part B drugs40% coinsurance
In-Network Medicare Part B drugs$0 copay


Diabetes supplies


Out-of-Network Medical equipment/supplies20% coinsurance per item
In-Network Medical equipment/supplies$0 copay


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


In-Network Medical equipment/supplies$0 copay
Out-of-Network Medical equipment/supplies20% coinsurance per item


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


In-Network Medical equipment/supplies$0 copay
Out-of-Network Medical equipment/supplies20% coinsurance per item



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


Fitting/evaluation


In-Network Hearing$0 copay
Out-of-Network Hearing40% coinsurance


Hearing aids


In-Network Hearing$0 copay
Out-of-Network Hearing40% coinsurance


Hearing exam


In-Network Hearing$0 copay
Out-of-Network Hearing40% coinsurance



Health plan deductible$0
In-Network Ground ambulance$0 copay
Out-of-Network Ground ambulance20% coinsurance


Foot exams and treatment


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


Routine foot care


Foot care (podiatry services)Not covered


Emergency


Emergency care/Urgent care$0 copay


Urgent care


Emergency care/Urgent care$0 copay


Primary


Out-of-Network Doctor visits40% coinsurance per visit
In-Network Doctor visits$0 copay


Specialist


In-Network Doctor visits$0 copay
Out-of-Network Doctor visits40% coinsurance per visit


Diagnostic radiology services (e.g., MRI)


Out-of-Network Diagnostic procedures/lab services/imaging40% coinsurance
In-Network Diagnostic procedures/lab services/imaging$0 copay


Diagnostic tests and procedures


In-Network Diagnostic procedures/lab services/imaging$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging40% coinsurance


Lab services


In-Network Diagnostic procedures/lab services/imaging$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging40% coinsurance


Outpatient x-rays


Out-of-Network Diagnostic procedures/lab services/imaging40% coinsurance
In-Network Diagnostic procedures/lab services/imaging$0 copay


Diagnostic services


In-Network Comprehensive dental$0 copay
Out-of-Network Comprehensive dental50% coinsurance


Endodontics


In-Network Comprehensive dental$0 copay
Out-of-Network Comprehensive dental50% coinsurance


Extractions


In-Network Comprehensive dental$0 copay
Out-of-Network Comprehensive dental50% coinsurance


Non-routine services


In-Network Comprehensive dental$0 copay
Out-of-Network Comprehensive dental50% coinsurance


Periodontics


In-Network Comprehensive dental$0 copay
Out-of-Network Comprehensive dental50% coinsurance


Prosthodontics, other oral/maxillofacial surgery, other services


In-Network Comprehensive dental$0 copay
Out-of-Network Comprehensive dental50% coinsurance


Restorative services


In-Network Comprehensive dental$0 copay
Out-of-Network Comprehensive dental50% 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 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 Liberty Open (PPO D-SNP) requires you to live in that plan’s service area. The service area is listed below:

State: Medicare Rhode Island
County:SNP in Bristol

SNP in Kent

SNP in Newport

SNP in Providence

SNP in Washington





Source: CMS.

Plans as of Oct 1, 2022.

Last updated on

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.

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