Optima Community Complete (HMO D-SNP)   Print

H2563-004 | Virginia

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.

Highlights

  • Medical, hospital, and prescription benefits
  • Virtual doctor visits: $0 copay
  • Preventive dental: $0 copay
  • Comprehensive dental: $0 copay up to $3000 annual allowable
  • Hearing: Free set of select hearing aids every year
  • Vision: $0 copay and $300 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
    If you are admitted to the hospital within 24 hours, you do not have to pay your cost share for emergency care.

    $0.00
    copay

  • Urgent Care

    each visit
    If you are admitted to the hospital within 24 hours, you do not have to pay your cost share for emergency care.

    $0.00
    copay

  • Lab

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

    $0.00
    copay

  • X-Ray

    For Medicare-covered outpatient X-rays. Cost-sharing for other services may apply.

    $0.00
    copay at PCP office

    $0.00
    copay at all other locations

  • 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

  • Medical Transportation

    Limit of 48 one-way trips for health related services per year at no cost. The appropriate mode of transportation will be selected by the transportation department or vendor.

    $0.00
    copay

    48 one-way trips
    per year

  • *Non-Medical Transportation

    Up to 24 one-way trips (in addition to the standard supplemental benefit) to non-primarily health-related, plan approved locations. Such locations include, but are not limited to, church, grocery store, senior centers, social clubs, support groups, physical fitness facility, and plan-sponsored event.
    *Members with chronic condition(s) that meet certain criteria may be eligible for this special supplemental benefit.

    $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

     

    Fitness center membership, including fitness classes, through SilverSneakersĀ®.

  • Grocery Card

    Eligible members will receive a grocery card with an allowance to be spent each month.
    *Members with chronic condition(s) that meet certain criteria may be eligible for this special supplemental benefit.

    $75.00
    allowance per month

  • Foot Care (Routine Podiatry)

    $0.00
    copay

    8 visits
    Every Year

  • Meals

    $0.00
    copay

    56 meals

  • Over-the-Counter

    On the first day every three months (each quarter) (January, April, July, October), members will receive their allowance to use to purchase OTC items. These can be ordered from the catalog by phone, mail, or online. Amount does not carry forward.

    $350.00
    Every Three Months

  • Personal Emergency Response System

    A Personal Emergency Response 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 quickly, 24 hours a day. Eligible members must have a working landline and/or cellular phone coverage to take part in this benefit. Prior authorization is required.

    $0.00
    copay

  • 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

    • every 12 months

      $0.00
      copay

  • Vision Benefits

     
    •  

      $0.00
      copay

    • $0.00
      copay

    •  

      $0.00
      copay

  • Preventive Dental Coverage

     
    • 2 per 12 months

      $0.00
      copay

    • 2 per 12 months

      $0.00
      copay

    • 2 bitewing x-rays per 12 months and 1 full mouth x-ray every 36 months

      $0.00
      copay

    • 2 per 12 months

      $0.00
      copay

  • Comprehensive
    Dental Coverage

     
    •  

      $3000.00
      per year

    • Amalgam

      $0.00
      copay

    • Anterior and Posterior Composites

      $0.00
      copay

    •  

      $0.00
      copay

    •  

      $0.00
      copay

    •  

      $0.00
      copay

    •  

      $0.00
      copay

    •  

      $0.00
      copay

Optima Community Complete (HMO D-SNP)

Plan Documents