Optima Community Complete (HMO D-SNP)   Print

H2563-004 | Virginia | 2021

Optima Community Complete (HMO D-SNP) is the combination of Original Medicare (Part A and Part B) and Commonwealth Coordinated Care Plus (CCC Plus) Medicaid with all-in-one added benefits and services to help you get the most value from your coverage.

This Medicare Dual Special Needs Plan (D-SNP) provides personalized support to help manage your medical needs. You can rely on a Care Coordinator just for you, a network of high-quality doctors and specialty providers, and virtual visits any time of day, any day of the year through MDLive.

Highlights

  • Medical, hospital, and prescription benefits
  • Virtual doctor visits: $0 copay
  • Preventive dental: $0 copay
  • Comprehensive dental: $0 copay up to $2000 annual allowable
  • Hearing: Free set of select hearing aids every three years
  • Vision: $0 copay and $200 eyewear allowance
  • Over-the-counter product allowance
  • Health-related transportation: $0 copay
  • Foot care (routine podiatry): $0 copay

Plan Details

  • Premium

     

    $0.00
    a month

Medical Coverage

  • Medical Maximum Out-of-Pocket

    This is the most you pay for copays, coinsurance, and other costs for Medicare-covered medical services for the year. Once you reach this limit, you will not have to pay any out-of-pocket costs for the rest of the year.
    This does not include Part D prescription drugs.

    $6700.00
    per year

  • Primary Care Doctor

    each visit

    $0.00
    copay

  • Specialist

    each visit

    $0.00
    copay

  • Emergency Care

    each visit

    $0.00
    copay

  • Urgent Care

    each visit

    $0.00
    copay

  • Lab

    Applies to Medicare-covered lab services. Cost-sharing for other services may apply.

    $0.00
    copay

  • Diagnostic Tests and Procedures

    Prior authorization required for Medicare-covered diagnostic radiological services except ultrasound.

    $0.00
    copay at PCP office

    $0.00
    copay at all other locations

  • Advanced Diagnostic Imaging Procedures

    (e.g., MRI, MRA, CT, CTA, PET scans, etc.)

    $0.00
    copay

  • Therapeutic Radiological Services

     

    $0.00
    copay at Specialist office

    $0.00
    coinsurance at all other locations

  • Partial Hospitalization

    $0.00
    copay

  • Outpatient Hospital Care

    $0.00
    copay

  • Outpatient Group or Individual Therapy with a Psychiatrist

    $0.00
    copay for group sessions

    $0.00
    copay for individual sessions

  • Outpatient Group or Individual Therapy with a Licensed Clinical Psychologist or Licensed Clinical Social Worker

    Prior authorization required for electroconvulsive therapy (ECT) and intensive outpatient program (IOP)

    $0.00
    copay for group sessions

    $0.00
    copay for individual sessions

  • Physical Therapy

    $0.00
    copay

  • Ambulance

    Prior authorization required for elective ambulance transport.

    $0.00
    copay

  • Transportation

    Limit of 24 one-way trips for health related services per year at no cost.

    $0.00
    copay

    24 one-way trips
    per year

  • Medicare Part B Drugs

    $0.00
    copay

  • Annual Physical Exam

    $0.00
    copay

  • Chiropractic, Routine

    $0.00
    copay

    12 visits
    per year

  • Fitness Benefit

     

    Members can be reimbursed up to $400 per calendar year for their fitness benefit. This can be used for expenses related to gym membership, personal training sessions at the gym, and other fitness related classes.

  • Foot Care (Routine Podiatry)

    $0.00
    copay

    8 visits
    Every Year

  • Meals

    $0.00
    copay

    56 meals

  • Over-the-Counter

    On the first business day every three months (each quarter) (January, April, July, October) member will receive their allowance to use to purchase OTC items. These can be ordered through the catalog by phone, mail, or online.

    $150.00
    Every Three Months

  • Personal Emergency Response System

    A Personal Emergency Reponse System (PERS) connects eligible members to help with just a push of a button. Eligible members receive a PERS in-home monitoring device that can get them help quikcly, 24 hours a day. Eligible members must have a working landline and/or cellular phone coverage to take part in this benefit. Prior authorization required.

    $0.00
    copay

  • MDLive Virtual Visits

    Appointments via secure phone or video using your computer or smart phone with a local doctor board certified in internal medicine, family practice, emergency medicine, or pediatrics. These doctors can diagnose, treat, and write prescriptions for routine medical conditions. Appointments are available 24 hours a day/7 days a week/365 days a year.

    $0.00
    copay

  • MDLive Behavioral Health Virtual Visits

    Appointments via secure phone or video using your computer or smart phone with a counselor or psychiatrist. MDLive psychiatrists can send prescriptions to your local, participating pharmacy. Appointments are available 24 hours a day/7 days a week/365 days a year.

    $0.00
    copay

  • Hearing Benefits

     
    • $0.00
      copay

    • 1 per year

      $0.00
      copay

    • 3 per year

      $0.00
      copay

    • every year

      $0.00
      copay

  • Vision Benefits

     
    •  

      $0.00
      copay

    • $0.00
      copay

    •  

      $0.00
      copay

    •  

      $0.00
      copay

  • Dental Coverage

    Included preventive care
    • 2 per year

      $0.00
      copay

    • 2 per year

      $0.00
      copay

    • 1 per year

      $0.00
      copay

    • 2 per year

      $0.00
      copay

Included Dental Coverage

  • Maximum Benefit Coverage

     

    $2,000
    per year

  • Oral Exam

     

    $0.00
    copay

  • Semiannual Cleanings

    2 per year

    $0.00
    copay

  • Bitewing X-rays

    2 per year

    $0.00
    copay

  • Full Mouth X-rays

    1 per 36 months

    $0.00
    copay

  • Fluoride

    2 per year

    $0.00
    copay

  • Fillings

    Amalgam

    $0.00
    copay

  • Fillings

    Anterior and Posterior Composites

    $0.00
    copay

  • Dentures and Bridges

     

    $0.00
    copay

  • Implants

     

    $0.00
    copay

Optima Community Complete (HMO D-SNP)

Plan Documents