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Central Health San Mateo Medicare Plan (HMO) - H5649-018-000
$0.00
Monthly Premium
Central Health San Mateo Medicare Plan (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Molina Healthcare, Inc.,
Plan ID: H5649-018-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
California 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 California Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $6,750.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $25 Prior Authorization Required for Doctor Specialty Visit Referral Required for Doctor Specialty Visit |
| Inpatient hospital care | In-Network: Acute Hospital Services: $310 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Acute Hospital Services Referral Required for Acute Hospital Services |
| Urgent care | Urgent Care: Copayment for Urgent Care $0 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $125 Maximum Plan Benefit of $50,000 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $0 to $125 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $125 Copayment for Worldwide Emergency Transportation $125 Maximum Plan Benefit of $50,000 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $0 to $300 Minimum cost share for transfer from OON hospital to an INN hospital, maximum cost share for all other ambulance services. Air Ambulance: Coinsurance for Air Ambulance Services 20% Prior Authorization Required for Air Ambulance |
Health Care Services and Medical Supplies
Central Health San Mateo Medicare Plan (HMO) covers a range of additional benefits. Learn more about Central Health San Mateo Medicare Plan (HMO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $0 Prior Authorization Required for Chiropractic Services Referral Required for Chiropractic Services |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20% Prior Authorization Required for Durable Medical Equipment 0% Coinsurance:CanesCommodesCrutchesWalkersAttachments20% Coinsurance:All Other Medicare-covered DME |
| Diagnostic tests, lab and radiology services, and X-rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $15 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 Minimum cost share for diagnostic colonoscopies, maximum cost share for all other diagnostic procedures and tests. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 to $250 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $25 |
| Home health care | In-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 care | In-Network: Psychiatric Hospital Services: $310 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services Referral Required for Psychiatric Hospital Services |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $250 Prior Authorization Required for Outpatient Hospital Services Referral Required for Outpatient Hospital Services Minimum amount for diagnostic DEXA scans and diagnostic colonoscopies in an outpatient setting. Maximum amount for all other services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $0 to $250 Minimum amount for diagnostic mammograms, DEXA scans, and colonoscopies in an outpatient setting. Maximum amount for all other services. Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $150 Prior Authorization Required for Ambulatory Surgical Center Services Referral Required for Ambulatory Surgical Center Services Minimum amount for diagnostic mammograms, DEXA scans, and colonoscopies in an ASC setting. Maximum amount for all other services. |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $5 Copayment for Medicare-covered Group Sessions $5 Prior Authorization Required for Outpatient Substance Abuse Services Referral Required for Outpatient Substance Abuse Services |
| Over-the-counter items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0 OTC benefit includes access to a health and wellness herbal catalog |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $20 Prior Authorization Required for Podiatry Services Referral Required for Podiatry Services |
| Skilled Nursing Facility (SNF) care | In-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.
| Coverage | Details |
|---|---|
| Dental care | In-Network: Medicare Covered Preventive Dental: Copayment for Office Visit $0 Prior Authorization Required for Medicare Covered Preventive Dental Non-Medicare Covered Preventive Dental: Copayment for Non-medicare preventive $0 Copayment for Oral exams $0 to $17 Copayment for Dental x-rays $0 to $41
Copayment for Prophylaxis $0
Copayment for Other preventive services $0 Non-Medicare Covered Comprehensive Dental: Copayment for Non-medicare comprehensive $0 Copayment for Restorative services $0 to $424 Copayment for Endodontics $0 Copayment for Periodontics $0 Copayment for Prothodontics, removable $0 to $220 Copayment for Implant services $0 to $2160 Copayment for Prothodontics, fixed $75 to $295 Copayment for Maxillofacial surgery $0 to $237 Copayment for Adjunctive general services $0 to $166 |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Copayment for Contact Lenses $0 Copayment for Eyeglasses (lenses and frames) $0
Maximum Plan Benefit of $150 every year Referral Required for Eyewear |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0 Copayment for Routine Hearing Exams $0
Referral Required for Hearing Exams Hearing Aids: Maximum Plan Allowance 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.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | In-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:
Yearly "Wellness" visit |
When reviewing California 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 California 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 |
California Counties Served
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