McLaren Medicare
Summary of Benefits D-SNP

2022 Summary of Benefits

Summary of Benefits D-SNP (downloadable pdf)

happy couple

McLaren Medicare Inspire Duals (HMO D-SNP) H6322, Plan 004

This is a summary of drug and health services covered by McLaren Medicare for January 1, 2022 - December 31, 2022

 

The benefit information provided is a summary of what we cover and what you pay. It does not list every service that we cover or list every limitation or exclusion. To see a complete list of services we cover, please review the Evidence of Coverage on www.mclarenhealthplan.org/medicare.

To join McLaren Medicare Inspire Duals you must be entitled to Medicare Part A, be enrolled in Medicare Part B, eligible for full Medicaid benefits, and live in our service area. Our service area includes the following counties in Michigan: Alcona, Antrim, Arenac, Barry, Bay, Benzie, Berrien, Calhoun, Cass, Charlevoix, Cheboygan, Clare, Clinton, Crawford, Eaton, Emmet, Genesee, Gladwin, Grand Traverse, Gratiot, Hillsdale, Huron, Ingham, Ionia, Iosco, Isabella, Kalamazoo, Kalkaska, Kent, Lake, Lapeer, Leelanau, Livingston, Macomb, Manistee, Mecosta, Midland, Missaukee, Montcalm, Montmorency, Newaygo, Oakland, Ogemaw, Osceola, Oscoda, Otsego, Ottawa, Roscommon, Saginaw, St. Clair, St. Joseph, Sanilac, Shiawassee, Tuscola, Van Buren, Washtenaw, Wayne, and Wexford counties.

McLaren Medicare Inspire Duals

McLaren Medicare Inspire Duals has a network of doctors, hospitals, pharmacies, and other providers. If you use the providers that are not in our network, the plan may not pay for these services.

Out-of-network/noncontracted providers are under no obligation to treat members, except in emergency situations. Please call our member service number or review the Evidence of Coverage for more information, including the cost- sharing that applies to out-of- network services.

map of Michigan medicare coverage area

Monthly Premium, Deductibles, and Coverage Limits

Your Monthly Plan Premium (in addition to your Medicare Part B premium) - There is no monthly premium for this plan.

Deductible - There is no deductible for this plan.

Maximum Out-of-Pocket Responsibility - $0 annually for Medicare-covered services from in-network providers.
This is the most you will pay for copays, coinsurance, and other costs for medical services for the year. This does not include prescription drugs.

Covered Medical Benefits

Inpatient Hospital Coverage - You pay $0 per stay.
Our plan covers unlimited days for an inpatient stay. Prior authorization may be required.

Outpatient Hospital Coverage

  • Outpatient Hospital: $0 copay
  • Ambulatory Surgical Center: $0 copay
  • Observation: $0 copay
  • Prior authorization may be required.

Doctor Visits

  • Primary Care: $0 copay per visit
  • Specialist: $0 copay per visit. Specialist visits require a referral.

Preventive Care

$0 copay

Preventive care includes:

  • abdominal aortic aneurysm screening
  • annual wellness visit
  • bone mass measurement
  • breast cancer screening
  • cardiovascular disease risk reduction visit
  • cardiovascular disease testing
  • cervical and vaginal cancer screening
  • colorectal cancer screening
  • depression screening
  • diabetes screening
  • diabetes self-management training
  • HIV screening
  • immunizations (flu, pneumonia, Hepititis B)
  • medical nutrition therapy
  • obesity screening and therapy to promote sustained weight loss
  • prostate cancer screening exams
  • screening and counseling to reduce alcohol misuse
  • screening for lung cancer
  • screening for STIs and counseling to prevent STIs
  • smoking and tobacco use cessation (counseling)
  • Welcome to Medicare preventive visit

Emergency Care - $0 copay in or out of network

Urgently Needed Services - $0 copay in or out of network

Outpatient Diagnostic Services/Labs/ Imaging

  • Diagnostic radiology service (CT/MRI): $0 copay
  • Lab services: $0 copay
  • Diagnostic tests and procedures: $0 copay
  • Outpatient X-rays: $0 copay
  • Prior authorization and referral may be required. Outpatient X-rays do not require prior authorization or referral.

Hearing Services

  • Hearing exams: $0 copay for a Medicare-covered hearing exam
  • $0 copay for a non-Medicare covered routine hearing exam
  • Hearing aid fitting and evaluation: $0 copay
  • Hearing aids: You will be reimbursed for up to $1,000 per year for hearing aids.

Dental Services

  • In-network preventive dental services are provided by Delta Dental’s Medicare Advantage PPO network dentists. $0 copay for two exams and two cleanings each year
  • $0 copay for one set of bitewing X-rays each year
  • $0 copay for a brush biopsy
  • You have a $1000 limit on all covered dental services.

Vision Services

  • $0 copay for each Medicare-covered exam to diagnose and treat diseases of the eye
  • $0 copay for eyeglasses or contact lenses after cataract surgery
  • $0 copay for glaucoma screening
  • $0 copay for a routine eye exam
  • $0 copay for non-Medicare-covered routine corrective eyeglasses (lenses and frames) or contact lenses. You will be reimbursed up to a maximum of $100 each year.

Mental Health Services - Our plan covers up to 190 days in a lifetime for inpatient care in a psychiatric hospital. Inpatient: $0 copay per stay; our plan covers up to 90 days for an inpatient hospital stay Outpatient therapy (group or individual): $0 copay per session Prior authorization may be required for inpatient mental health services.

Skilled Nursing Facility (SNF) - $0 copay Our plan covers up to 100 days each benefit period in a SNF. A benefit period starts the day you go into a SNF and ends when you go 60 days in a row without SNF care. Prior authorization may be required.

Physical Therapy - $0 copay per visit. Prior authorization and referral may be required.

Ambulance - $0 copay per one-way transport. Prior authorization may be required for Medicare covered non-emergency transport

Transportation Routine - transportation is not covered by Medicare. This benefit is covered when using services through your Medicaid benefit.

Medicare Part B Drugs Chemotherapy and Other Part B Drugs: - $0 copay Home Infusion Drugs: $0 copay Prior authorization may be required.

Medicaid Benefits

Your covered services are paid for first by Medicare and then by Medicaid. The chart below shows you which benefits are covered by Medicare and which benefits are covered by Medicaid. If a benefit is not covered by Medicare, it may be covered by Medicaid depending on your type of Medicaid coverage.

Inpatient Services

Inpatient Services McLaren Medicare Inspired Duals Michigan Medicaid
Inpatient Hospital Care Covered Covered
Inpatient Mental Health Covered Covered
Skilled Nursing Facility (SNF) Covered Covered

If you want to know more about the coverage and costs of Original Medicare, look in your current “Medicare & You” handbook. View it online at http://www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users should call 1-877-486-2048. This document is available in other formats such as Braille, large print or audio.

happy couple on the beach

For more information, please call us at the phone number below or visit us at www.mclarenhealthplan.org/medicare.

Toll-free 1-833-358-2404, TTY users should call 711.

From October 1st to March 31st, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Eastern Time. From April 1st to September 30th, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Eastern Time.

You can see our plan’s provider/pharmacy directory at our website at www.mclarenhealthplan.org/medicare.

McLaren Medicare is a DSNP HMO plan with a Medicare contract and a contract with the State of Michigan Medicaid Program. Enrollment in McLaren Medicare depends on contract renewal.

H6322_SummaryofBenefitsDuals_M