Two Medicare Advantage HMO plan examples

*Note- Below are hypothetical examples only of what some benefits may look like in an HMO plan:

	Plan ABC	Plan XYZ
Medicare Advantage HMO Plans	$0/mo.	$34/mo.
Office primary care physician copay	$0	$0
Specialist copay	$30	$45
Max-out-of-pocket limit per year	$4,500	$5,500
Hospital Inpatient cost share (Days 1 – 6)	$195/day	$250/day
Hospital Inpatient cost share (Days 7 – 90)	$0/day	$0/day
Doctor visits copay	$0	$0
Specialist visit copay	$30	$45
Skilled Nursing Facility copay In-Network (Days 1 – 20)	$0	$0
Skilled Nursing Facility copay In-Network (Days 21 – 100)	$178/day	$178/day
Outpatient surgery at Outpatient Hospital	$195	$250
Outpatient surgery at Ambulatory Surgical Center	$145	$200
Emergency room copay	$90	$90
Preferred Urgent Care copay	$30	$30
Non-preferred Urgent Care copay	$40	$40
Diagnostic mammography	$30-$50	$45-$50
Lab services copay	$0	$0
Diagnostic tests and procedures copay	$0-$100	$0-$50
Outpatient X-rays	$0-$100	$0-$50
Medicare-covered foot care (podiatry) – copay	$30	$45
Medicare-covered chiropractic services – copay	$20	$20
Physical, occupational and speech therapy – copay	$30	$30
Cardiac rehabilitation – copay	$30	$30
Pulmonary rehabilitation – copay	$30	$30
Optional Supplemental Dental Plan with $2000 calendar year max benefit	$38/mo.	N/A
Routine foot care (up to 12 visits)	$0	$0
Over-the-counter (OTC) mail order allowance every quarter (3 months)	$90	$75

The main difference between these two HMO plans is the $34 plan includes greater comprehensive dental coverage including dentures and root canals, where the $0 plan has routine dental, i.e. cleanings, x-rays and exams. *Note: Both plans have additional covered items not detailed in illustration including routine vision and hearing coverage.

Below is an “example only” of how a drug plan may look showing costs
at a Preferred and Standard pharmacy

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