Benefits A
What is the copay for a specialist office visit?
$0 copay for in person and telehealth services.
Is there a copay for a podiatry visit?
$45 copay
Is the covid vaccine covered on the policy?
Yes, with no coinsurance, copay or deductible.
What is the benefit for urgent care?
No copay or coinsurance.
Does a member have a copay for a visit to the chiropractor?
$20 copay for Medicare covered chiropractic services.
Is there a copay when a member goes to the ER?
$110 copay, ER copay is waived if admitted within 24 hours. If you receive emergency care at an out-of-network hospital and need inpatient care after your emergency condition is stabilized, you must have your inpatient care at the out-of-network hospital authorized by the plan and your cost is the cost sharing you would pay at a network hospital.
What is the out of pocket max on the plan?
$4500
How much gets put on the over the counter card and how often?
$40 every 3 months.
No - Member can go to any provider within the state of NC that is in network with Troy Medicare.
Is there a copay for an inpatient hospital stay? Does it require prior authorization?
$310 copay per day for days 1-5, $0 copay after day 5. (Per benefit period) PA required since inpatient
Is there a copay for an MRI, if so, what is it?
$50 copay
What is the out of network benefit for an office visit?
No out of network benefits
What is the benefit for radiation therapy?
20% coinsurance.
What are the home health benefits?
There is no copay or coinsurance for home health. PA is needed after 14 visits.
What is the benefit for an X-Ray billed professionally?
$10 copay
Is there a copay for acupuncture?
$45 copay for Medicare covered acupuncture.
Does the patient have any dental benefits? If so, what are they?
There is no copayment or coinsurance for preventive or comprehensive dental services. The plan will pay up to $1,000 for preventive and comprehensive dental services combined. (The EOC shows each service broke down that we cover)
What is the benefit for outpatient dialysis?
20% coinsurance for dialysis services.
What kind of routine vision coverage does the member have?
$50 allowance towards routine eye exam once per year, $150 allowance towards eyewear (eyeglasses and contacts) once per year.
Does the member have a hearing aid benefit?
$750 allowance for routine hearing exams, fitting, and evaluations for hearing aids, and hearing aids every 2 years.
What is the benefit for ambulance services?
$255 copay for ground ambulance and 20% coinsurance for medicare covered air ambulance services.
What is the benefit for oxygen equipment?
20% Coinsurance per item. After the 36-month rental period, you pay no more rental fees, although the supplier still owns the equipment. You keep the equipment for up to 24 additional months. If your medical need continues past the 5-year period, a new 36-month payment period and 5-year supplier obligation period starts. If prior to enrolling in Troy Medicare (HMO) you had made 36 months of rental payment for oxygen equipment coverage, you will start a new 36-month cycle and pay full cost sharing for oxygen equipment coverage.
What is the benefit for a low dose lung screening?
There is no coinsurance, copayment, or deductible for the Medicare covered counseling and shared decision-making visit or for the LDCT.
Does Troy Medicare cover hospice?
When you enroll in a Medicare-certified hospice program, your hospice services and your Part A and Part B services related to your terminal prognosis are paid for by Original Medicare, not Troy Medicare (HMO). There is no copayment or coinsurance for a hospice consultation.
What is the benefit for inpatient skilled nursing (SNF) and does it need a prior authorization?
$0 copay for days 1-20, $178 copay for days 21-100. A "benefit period" starts the day you go into a hospital or SNF. It ends when you go for 60 consecutive days without hospital or skilled nursing care. PA is required.