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2020 basic ma plan

2020 ADDITIONAL INFORMATION

2020 Plans - Basic MA

2020 PrimeTime Health Plan Basic-MA Only (HMO-POS) Eligibility Requirements: 
With PrimeTime Health Plan Basic-MA Only (HMO-POS) there are no deductibles to pay. Instead, your cost-sharing consists of co-payments or co-insurances for the services that you receive.

You are eligible for membership in our plan as long as:

• You live in our service area
(Carroll, Columbiana, Harrison, Holmes, Mahoning, Medina, Portage, Stark, Summit, Trumbull, Tuscarawas, and Wayne Counties)

• --and-- you have both Medicare Part A and Medicare Part B
(When you enroll in a Medicare Advantage Plan, you continue to pay your Medicare Part B premium.)

• --and--you do not have End-Stage Renal Disease (ESRD), with limited exceptions, such as if you develop ESRD when you are already a member of a plan that we offer, or you were a member of a different plan that was terminated.

PrimeTime Health Plan BASIC-MA OnlY (HMO-POS)

  • Plan Premium
  • $0 per month*
  • Primary Care Physician
  • $0 copay for each Medicare-covered primary care doctor visit
  • Specialist
  • $40 copay for each Medicare-covered specialist visit
  • Urgent Care (Inside United States)
  • $65 copay for Medicare-covered urgently-needed-care visits
  • Urgent Care (Outside United States)
  • $85 copay for Medicare-covered urgently-needed-care visits
  • Emergency Care (Worldwide Coverage)
  • $85 copay for Medicare-covered emergency room visits
  • Inpatient Hospital Coverage
  • $275 copay per day, days 1 – 6; then $0 copay per day for Medicare-covered hospital stays
  • Outpatient Surgery (Ambulatory/Outpatient Surgery)
  • 25% of the cost for each Medicare-covered surgical service, annual out-of-pocket maximum cost of $1,200
  • Home Delivered Meal Benefit
  • $0 copay; Benefit is limited to 5 days, up to 10 meals, and following an inpatient hospital stay at a network facility, with a doctor’s order, and in our service area with a contracted provider.
  • Ambulance Services
  • $200 copay for Medicare-covered ambulance benefits
  • Durable Medical Equipment
  • 20% of the cost for Medicare-covered durable medical equipment
  • Diabetic Testing Supplies (test strips, lancets, certain glucometers) 0% of cost for Medicare-covered diabetic testing supplies
  • Diabetic Supplies 20% of the cost for Medicare-covered diabetic supplies
  • Diagnostic Tests and Procedures
  • $100 copay for Medicare-covered general diagnostic tests and radiology services (not including x-rays)
  • Diagnostic Radiology Services (MRI/CT/PET/Thallium Scans)
  • $250 copay for Medicare-covered complex diagnostic radiology services (not including X-rays)
  • Outpatient X-rays
  • $100 copay for Medicare-covered X-ray services
  • Lab Services
  • $35 copay for Medicare-covered lab services
  • Radiation Therapy
  • 20% of the cost for Medicare-covered therapeutic radiology services
  • Part B Prescription and Chemotherapy Drugs
  • 20% of the cost for Medicare-covered Part B prescription and chemotherapy drugs
  • Part D Prescription Drug Coverage
  • This plan does not include Part D Prescription Drug Coverage
  • Preventive Services
  • $0 copay for all preventive services covered under Original Medicare at zero cost sharing.
  • Health & Wellness Education Programs
  • • Tele-monitoring Services – Enrollees diagnosed with any of the conditions below may be eligible:
      ○ Heart Failure
      ○ Diabetes
      ○ Chronic Obstructive Pulmonary Disease (COPD)
      ○ Behavioral Health Conditions
    • Stroke Prevention Program – offered to members who have health conditions that put them at higher risk for stroke.
    • In-Home Safety Assessment -evaluates your home for potential safety concerns. For example: proper lighting, fall hazards,and grab bars. The benefit is available in our service area with the plan's contracted network.
    • 24 Hour Nursing Hotline (330) 363-7600 or 1-800-686-9373

    • The Silver&Fit® Exercise & Healthy Aging Program –offers members access to a fitness center membership at a participating fitness center or select YMCA at no additional cost.
  • Vision
  • In-network: You pay a $40 copay for a Medicare covered medical exam.  Exam to diagnose and treat diseases and conditions of the eye (including annual diabetic retinopathy exam). Eyeglasses or contact lenses after cataract surgery - You pay 20% of the cost.

    Reimbursement for non-Medicare covered services up to a maximum of $300 annually combined with non-Medicare covered dental. For routine vision services, you may use any qualified vision provider.
  • Dental
  • In-network: You pay a $40 copay for a Medicare covered medical exam.

    Reimbursement for non-Medicare covered dental services up to a maximum of $300 annually combined with non-Medicare covered vision. For routine dental services, you may use any qualified dental provider.
  • Hearing Services
  • In-network $0 copay for Medicare covered Medical Exam to diagnose and treat hearing and balance issues. Routine exam - you pay $40 copay (one routine hearing exam every three (3) years)
  • Amplifon Hearing Healthcare Program
  • Amplifon Information:

    You pay a copayment of $595, $695, or $895 per hearing aid depending on the brand and model selected. 2 hearing aids every 3 years.  Call 1-866-921-2299 to access Amplifon's discounted hearing aid rates.  Hearing aid copays do not count towards your out-of-pocket limit.
  • Out of Pocket Maximum (per calendar year)
  • $3,400

    For coverage details and additional co-payments/co-insurance, please see the Summary of Benefits. Conditions and limitations may apply.

    You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week; The Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778; or Your State Medicaid Office. 

    You must receive your care from a network provider. 

    In most cases, care you receive from an out-of-network provider (a provider who is not part of plan’s network) will not be covered. There are four exceptions:

    • The plan covers emergency care or urgently needed services that you get from an out-of-network provider.

    • If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider with our prior approval. In this situation with our approval, you will pay the same as you would pay if you got the care from a network provider.

    • The plan covers kidney dialysis services that you get at a Medicare-certified dialysis facility when you are temporarily outside the plan’s service area.

    • Our plan offers a point-of-service (POS) option for lab services, and non-Medicare covered dental and vision services. For lab services, members may use the Medicare provider of their choice and services will be paid in-network. Molecular Diagnostics/Genetic testing requires prior authorization. For non-Medicare covered dental and vision services, members may use the provider of their choice and services will be reimbursed up to the plan annual maximum allowed.


    ELIGIBILITY AND ENROLLMENT in BASIC-MA

    To be eligible for our HMO-POS PLAN Options:

    • Must have Medicare Part A & B
    • Must reside in one of the following counties within Ohio
      • Stark
      • Carroll
      • Columbiana
      • Holmes
      • Harrison
      • Mahoning
      • Medina
      • Portage
      • Summit
      • Trumbull
      • Tuscarawas
      • Wayne

    • Only pre-existing ESRD not eligible to join PrimeTime Health Plan
    • Members may enroll in the plan only during specific times of the year. Contact PrimeTime Health Plan for more information

    2020 Enrollment Forms
    HMO-POS Enrollment Form
    Electronic Funds Transfer (EFT) Form

    ENROLLMENT OPTIONS FOR PRIMETIME HEALTH PLAN

    THIS IS AN ACTUAL ENROLLMENT REQUEST. FILLING OUT THE FORM AND CLICKING “SUBMIT MY ENROLLMENT” WILL BEGIN THE PROCESS TO FORMALLY ENROLL YOU INTO THE PRIMETIME HEALTH PLAN OF YOUR CHOICE.

    ONLINE

    Beginning October 15, 2019, you can complete a secure online enrollment application by continuing with the green button below. I am aware that I am Enrolling in the PrimeTime Health Plan Basic- MA Only (HMO-POS)

    • $0 Monthly Premium
    • $0 Annual Deductible
    • $3,400 Annual Out-of-Pocket Max

    By completing this enrollment form, you are sending an actual enrollment election to PrimeTime Health Plan.

    You will get an enrollment packet in the mail from PrimeTime Health Plan within seven to ten calendar days of enrolling online.

    For more information, contact PrimeTime Health Plan on our Contact Us Page.

    Continue to Basic - MA Online Enrollment on 10-15-2019

    IN PERSON

    You can visit us during our office hours Monday through Friday from 8:00 a.m. to 4:30 p.m. to drop off your completed enrollment application. Additionally, a PrimeTime Health Plan staff person is available to meet with you to discuss your plan options. You can complete an enrollment application during this appointment or take one with you to fill out and return. To schedule an appointment, please call 330-363-7407 or 1-800-577-5084. TTY users call 330-363-7460 or 1-800-617-7446. Our call center is available Monday through Friday from 8:00 a.m. to 8:00 p.m. (October 1 – March 31st, we are available 7 days a week, 8:00 a.m. to 8:00 p.m.).

    PrimeTime Health Plan
    214 Dartmouth Ave SW
    Canton, Ohio 44706

    Download your PDF Here

    BY MAIL

    You can also choose to print and complete an enrollment application. When completed, mail the enrollment application to our office at:

    PrimeTime Health Plan
    214 Dartmouth Ave SW
    Canton, Ohio 44706

    Download your PDF Here
    Return to All Plan Descriptions

    CONTACT INFORMATION

    If you have questions or require language assistance, please call Customer Service at 330-363-7407 or 1-800-577-5084. For people who are hearing impaired, please call our TTY line at 330-363-7460 or 1-800-617-7446. Interpreter services are provided free of charge to you. A customer service representative is available to assist you Monday through Friday from 8:00 a.m. to 8:00 p.m. (October 1st – March 31st, we are available 7 days a week, 8:00 a.m. to 8:00 p.m.)

    Last updated: 10/15/2019