2024 Health Net Seniority Plus Group #5800SP
Basics
Lifetime maximum
No maximum
Plan Year
2024
Offered To
Medicare Retirees
Body/Description
This plan pays benefits when you receive care from your Seniority Plus primary doctor and when your doctor refers you to a hospital or specialist in the Health Net network. Most covered expenses are paid at 100%. You must choose a Primary Care Physician (PCP) from the network to coordinate all your services.
You will pay a copay for certain services.
You do not get benefits from this plan or from Medicare if you receive Non-emergency care outside the network. Emergency care and urgent care is covered world wide by Health Net. When you enroll in this plan, you assign your Medicare benefits to Health Net and they will administer all benefits and process claims according to the plan.
Coinsurance
100% after applicable co-pays, unless otherwise noted
Office co-pay
$25 co-pay
Deductible
No deductible
Benefit Type
Medical
Annual maximum
$3,400 per individual
X-rays
100%
Maternity Hospital Stay
100%
Baby's First Exam
Not covered
Birthing Centers
100%
Midwives
100%
If the midwife is part of your covered medical group
If the midwife is part of your covered medical group
Prenatal Visits
$25 co-pay
Doctor Delivery Charge
100%
Reproductive Health
100%
Mental Health
MHN must approve substance abuse care.
INPATIENT CARE
100%
OUTPATIENT CARE
[no visit limit]
$25 co-pay per visit
INPATIENT CARE
100%
OUTPATIENT CARE
[no visit limit]
$25 co-pay per visit
Autism
NA
Substance Abuse
MHN must approve substance abuse care.
INPATIENT CARE
100%
OUTPATIENT CARE
[no visit limit]
$25 co-pay per visit
INPATIENT CARE
100%
OUTPATIENT CARE
[no visit limit]
$25 co-pay per visit
Acupuncture
Medicare covered: $20 copay per visit (up to 12 visits within 90 days, limited to treatment of chronic low back pain.
Routine services: $15 copay, limited to 20 visits - must use American Specialty Health (ASH) providers
Routine services: $15 copay, limited to 20 visits - must use American Specialty Health (ASH) providers
Allergy Tests
100% Office co-pay may apply
Allergy Treatment
100%
Office co-pay may apply
Office co-pay may apply
Alternative Medicine
Not covered
Ambulance charges
$50 co-pay
CT Scans
100%
Chiropractors
$20 co-pay
Coverage is limited to manual manipulation of the spine to correct subluxation. You pay the full cost of routine care. Limited to Medicare allowable coverage. Discount program available.
Coverage is limited to manual manipulation of the spine to correct subluxation. You pay the full cost of routine care. Limited to Medicare allowable coverage. Discount program available.
Christian Science Practitioners
Not covered
Cosmetic Surgery
Not covered
Dental Treatment
Coverage limited to certain conditions only. Contact Health Net for more information.
Emergency Room
$65 co-pay (waived if admitted)
Urgent Care
$25 co-pay
Hearing Care
$25 co-pay for exams
Two standard hearing aids are covered every 12 months, up to a max benefit of $1,000.
Discount program available.
Two standard hearing aids are covered every 12 months, up to a max benefit of $1,000.
Discount program available.
Home Health Care
100%
Hospice Care
100% Covered by Medicare
$25 co-pay for initial evaluation only.
$25 co-pay for initial evaluation only.
Hospital Stay
100%
Infertility Treatment
Not covered
Laboratory Charges
100%
Magnetic resonance imaging - MRI
100%
Durable Medical Equipment
100%
Occupational Therapy
100%
Organ Transplants
100%
Skilled Nursing
100% up to 100 days per Medicare benefit period when preauthorized
Physical Therapy
100%
Surgery : Physician Services
INPATIENT
100%
OUTPATIENT
100% in Surgical Facility or $25 office visit co-pay may apply for surgery performed in a physician's office.
100%
OUTPATIENT
100% in Surgical Facility or $25 office visit co-pay may apply for surgery performed in a physician's office.
Surgery : Facility Charges
INPATIENT
100%
OUTPATIENT
$25 co-pay
100%
OUTPATIENT
$25 co-pay
Speech Therapy
NA
Tubal Ligation
NA
Vasectomy
100%
X-rays
100%
Pharmacy (Retail)
Prescription drug coverage is provided by Health Net. $10 Tier I; $30 Tier II (formulary brand); $75 Tier III (non-preferred brand).
Up to a 30-day supply
Up to a 30-day supply
Mail order drug program
Prescription drug coverage is provided by Health Net. $20 Tier I; $60 Tier II (formulary brand); $150 Tier III
Up to a 90-day supply
Up to a 90-day supply
Birth Control Pills
Included in Prescription Drug benefit
Physical exams for adults
100%
According to plan's periodic health evaluation schedule.
According to plan's periodic health evaluation schedule.
Physical exams for children
100%
Pap smears
100%
Mammograms
100%
Immunizations
100%
When office visit not required; foreign travel/occupational services: 80%
When office visit not required; foreign travel/occupational services: 80%
Prostate Specific Antigen test - PSA
100%
Well-woman visits
100%
Vision care
$25 co-pay for exams
One pair glasses/contacts every 24 months. Health Net Vision pays the first $100. You pay 80% of the remaining balance for frames, 85% for conventional contact lenses and 100% for disposable contact lenses if applicable. See the EOC for more details.
One pair glasses/contacts every 24 months. Health Net Vision pays the first $100. You pay 80% of the remaining balance for frames, 85% for conventional contact lenses and 100% for disposable contact lenses if applicable. See the EOC for more details.
Transgender Services
Benefits are included for all medically necessary and authorized services related to Transsexual/Transgender Surgery.
Travel and Lodging
Contact the plan for details
Benefit Perks
See Health Net Seniority Plus Silver & Fit exercise program flyer on Cardinal at Work or call 800-275-4737