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Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP) - H9706-002-000

$10.80

Monthly Premium

Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP) is a HMO D-SNP Medicare Advantage (Medicare Part C) plan offered by Health Care Service Corporation

Plan ID: H9706-002-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$10.80

Monthly Premium

Texas Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Texas Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price. Speak with a licensed insurance agent to review plans available to you at 1-800-557-6059 (TTY 711,24/7).

Enrollment may be limited to certain times of the year. See why you may be able to enroll.

Compare plans today.

Speak with a licensed insurance agent

1-800-557-6059
|
TTY 711, 24/7

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$10.80
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$0.00
Out-of-pocket maximum$9,350.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Coinsurance for Primary Care Office Visit 0% or 20%
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Coinsurance for Physician Specialist Office Visit 0% or 20%
Prior Authorization Required for Doctor Specialty Visit
Referral Required for Doctor Specialty Visit
Inpatient hospital careIn-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $0
Deductible $1340.00
Prior Authorization Required for Acute Hospital Services
Referral Required for Acute Hospital Services
Urgent care
Urgent Care:
Coinsurance for Urgent Care 0% or 20%
Coinsurance for Medicare Covered Urgent Care waived if you are admitted to hospital
Emergency room visit
Emergency Care:
Coinsurance for Emergency Care 0% or 20%
Ambulance transportationIn-Network:

Ground Ambulance:
Coinsurance for Ground Ambulance Services 0% or 20%

Air Ambulance:
Coinsurance for Air Ambulance Services 0% or 20%
Prior Authorization Required for Air Ambulance

Health Care Services and Medical Supplies

Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP) covers a range of additional benefits. Learn more about Blue Cross Medicare Advantage Dual Care Plus (HMO D-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic servicesIn-Network:

Chiropractic Services:
Coinsurance for Medicare-covered Chiropractic Services 0% or 20%
Prior Authorization Required for Chiropractic Services
Referral Required for Chiropractic Services
Only chiropractic services, related to the subuxation of the spine require authorization.
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare-covered Diabetic Supplies 0% or 20%
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 0% or 20%
Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 0% or 20%
Prior Authorization Required for Durable Medical Equipment
Diagnostic tests, lab and radiology services, and X-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0
Copayment for Medicare-covered Lab Services $0
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
Referral Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Coinsurance for Medicare-covered Diagnostic Radiological Services 0% or 20%
Coinsurance for Medicare-covered Therapeutic Radiological Services 0% or 20%
Coinsurance for Medicare-covered X-Ray Services 0% or 20%
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Referral Required for Home Health Services
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $0
Prior Authorization Required for Psychiatric Hospital Services
Referral Required for Psychiatric Hospital Services
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Coinsurance for Medicare-covered Individual Sessions 0% or 20%
Coinsurance for Medicare-covered Group Sessions 0% or 20%
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 0% or 20%
Prior Authorization Required for Outpatient Hospital Services
Referral Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services $0
Referral Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Coinsurance for Ambulatory Surgical Center Services 0% or 20%
Prior Authorization Required for Ambulatory Surgical Center Services
Referral Required for Ambulatory Surgical Center Services
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Coinsurance for Medicare-covered Individual Sessions 0% or 20%
Coinsurance for Medicare-covered Group Sessions 0% or 20%
Prior Authorization Required for Outpatient Substance Abuse Services
Referral Required for Outpatient Substance Abuse Services
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0
  • Maximum plan benefit of $250.00 every three months for Over-The-Counter (OTC) Items
Maximum Plan Benefit of $250 every three months
$250/qtrly (Note: Unused OTC amounts roll over from quarter to quarter, but do not roll over to the next calendar year. Members may use their pre-loaded card on select OTC item(s) from plan approved catalog and item(s) are shipped to members. Additionally, members may use their pre-loaded card at select retail stores for select OTC items. Only the amount allocated for OTC items may be used on the pre-loaded card. (No cash is exchanged.)
Podiatry servicesIn-Network:

Podiatry Services:
Coinsurance for Medicare-Covered Podiatry Services 0% or 20%
Prior Authorization Required for Podiatry Services
Referral Required for Podiatry Services
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
Copayment for Skilled Nursing Facility Services per Stay $0
Prior Authorization Required for Skilled Nursing Facility Services
Referral Required for Skilled Nursing Facility Services

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Dental careIn-Network:

Medicare Covered Preventive Dental:
Coinsurance for Office Visit 0% or 20%

Non-Medicare Covered Preventive Dental:
Copayment for Non-medicare preventive $0
Copayment for Oral exams $0
  • Maximum 2 visits every year
Copayment for Dental x-rays $0
  • Maximum 1 visit every year
Copayment for Prophylaxis $0
  • Maximum 2 visits every year

Non-Medicare Covered Comprehensive Dental:
Copayment for Non-medicare comprehensive $0
Copayment for Restorative services $0
Copayment for Endodontics $0
Copayment for Periodontics $0
Copayment for Prothodontics, removable $0
Copayment for Maxillofacial prosthetics $0
Copayment for Prothodontics, fixed $0
Copayment for Maxillofacial surgery $0
Copayment for Adjunctive general services $0
Maximum Plan Benefit of $4,000 every year

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage

CoverageDetails
Vision careIn-Network:

Eye Exams:
Coinsurance for Medicare Covered Benefits 0% or 20%
Copayment for Routine Eye Exams $0
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Coinsurance for Medicare-Covered Benefits 0% or 20%
Copayment for Contact Lenses $0
Copayment for Eyeglass Lenses $0
Copayment for Eyeglass Frames $0
Copayment for Upgrades $0
Maximum Plan Benefit of $200 every year

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing careIn-Network:

Hearing Exams:
Coinsurance for Medicare Covered Benefits 0% or 20%
Copayment for Routine Hearing Exams $0
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0

Hearing Aids:
Copayment for Hearing Aids $0
  • Maximum 2 Hearing Aids every year
Maximum Plan Benefit of $2,000 every year

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Preventive services and health/wellness education programsIn-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
    • Tobacco use cessation
    Yearly "Wellness" visit

    When reviewing Texas Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

    You may be able to find plans in your part of Texas that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

    Plan Documents

    Links to plan documents

    Texas Counties Served

    We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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