The Peoples Health Complete Care LA-5 (HMO-POS C-SNP) plan offers a wide range of benefits with varying cost-sharing. You can expect no copay for primary care, preventive services, hearing exams, vision exams, and many dental services. There are also no copays for home health services, over-the-counter items, and meal benefits. The plan includes copays for inpatient hospital stays, outpatient services, ambulance services, emergency services, and specialist visits. Additionally, the plan covers prescription hearing aids, eyewear, and offers some dental services, with some services having coinsurance.

Inpatient Hospital

Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, both requiring prior authorization; Inpatient Hospital-Acute has a $95 copay for days 1-10, and no copay for days 11-90, while Inpatient Hospital Psychiatric has the same cost sharing. Additional days for Inpatient Hospital-Acute have no copay, but Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.

Outpatient Services

Outpatient Services include coverage for Outpatient Hospital Services with a copay between $0 and $125, Observation Services with a $125 copay, and Ambulatory Surgical Center (ASC) Services with no copay. Outpatient Substance Abuse Services are covered with a copay between $0 and $25 for individual sessions, and a $15 copay for group sessions, and Outpatient Blood Services are covered with no copay.

Partial Hospitalization

Partial Hospitalization is covered under the Peoples Health Complete Care LA-5 (HMO-POS C-SNP) plan, but requires prior authorization. You will have a $55 copay for this benefit.

Ambulance and Transportation Services

Ambulance and Transportation Services are covered by the Peoples Health Complete Care LA-5 (HMO-POS C-SNP) plan. Ground and Air Ambulance Services have a copay of $145.00. Transportation Services to any health-related location are not covered.

Emergency Services

Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Peoples Health Complete Care LA-5 (HMO-POS C-SNP) plan. Emergency Services have a $140 copay, while Urgently Needed Services have a copay between $0 and $65; both have no coinsurance. Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation have no copay and no coinsurance.

Primary Care

The Peoples Health Complete Care LA-5 (HMO-POS C-SNP) plan covers primary care physician services with no copay. Chiropractic services have a $20 copay, while occupational therapy services have a copay between $0 and $10. Physician specialist services and physical therapy/speech-language pathology services have a copay between $0 and $10. Mental health and psychiatric services, and other health care professional services have varying copays. Opioid treatment program services have no copay. Additional telehealth benefits are covered with no copay. Podiatry services are not covered, and routine chiropractic care is not covered.

Preventive Services

Preventive Services include coverage for Medicare-covered preventive services, annual physical exams with no copay, and additional preventive services including Fitness Benefit, Home and Bathroom Safety Devices, and Modifications with no copay. Some services such as health education, in-home safety assessments, and counseling services are not covered.

Hearing Services

Hearing exams are covered with no copay, and routine hearing exams are covered once per year with no copay, but fitting/evaluation for hearing aids are not covered. Prescription hearing aids are covered, with copays between $199 and $1249, and OTC hearing aids are covered with a copay between $99 and $829.

Vision Services

Vision Services includes coverage for eye exams with no copay, and routine eye exams with no copay for one exam per year. Eyewear is covered with no copay for contact lenses, and eyeglass frames, while eyeglass lenses have a copay of $0-$153. Eyeglasses (lenses and frames) and upgrades are not covered.

Dental Services

The Peoples Health Complete Care LA-5 (HMO-POS C-SNP) plan covers dental services, including Medicare dental services with 20% coinsurance. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatments, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, maxillofacial prosthetics, oral and maxillofacial surgery are covered with no copay, while prosthodontics (removable and fixed) have 0-50% coinsurance. However, implant services and orthodontics are not covered.

Home Infusion bundled Services

Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is a coinsurance between 0% and 20%.

Dialysis Services

Dialysis Services are covered, but require prior authorization. You will pay a coinsurance of 20% for these services.

Medical Equipment

Medical Equipment benefits are covered, including Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment with a copay for Medicare-covered diabetic supplies and therapeutic shoes/inserts. Durable Medical Equipment for use outside the home is not covered.

Diagnostic and Radiological Services

Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests with a $25 copay and Lab Services with no copay. Diagnostic Radiological Services have a maximum copay of $150, while Therapeutic Radiological Services have a 20% coinsurance, and Outpatient X-Ray Services have a $15 copay.

Home Health Services

Home Health Services are covered by the Peoples Health Complete Care LA-5 (HMO-POS C-SNP) plan with no copay and no coinsurance, however, additional hours of care and personal care services are not covered.

Cardiac Rehabilitation Services

Cardiac Rehabilitation Services are covered, but the plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services. Prior authorization is required, and the copay information is available within the plan details.

Skilled Nursing Facility (SNF)

Skilled Nursing Facility (SNF) services are covered by the Peoples Health Complete Care LA-5 (HMO-POS C-SNP) plan, but require prior authorization. There is no copay for days 1-20, and a $203 copay for days 21-100.

Other Services

Other Services includes coverage for Over-the-Counter (OTC) Items and a Meal Benefit with no copay. Acupuncture, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.