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Cigna TotalCare (HMO D-SNP) - H4513-060-004

4.5 out of 5 stars* for plan year 2025

$0.00

Monthly Premium

Cigna TotalCare (HMO D-SNP) is a HMO D-SNP Medicare Advantage (Medicare Part C) plan offered by Cigna

Plan ID: H4513-060-004

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

$0.00

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.

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$0.00
Out-of-pocket maximum$3,450.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $0
Prior Authorization Required for Doctor Specialty Visit
Referral Required for Doctor Specialty Visit
Inpatient hospital care0 or $In-Network:

Acute Hospital Services:
$190 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
In some instances, a readmission policy may apply in which the benefit will continue from original admission.
Urgent care
Urgent Care:
Copayment for Urgent Care $0 or $20
Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 2 hours

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $0 or $140
Maximum Plan Benefit of $50,000
Emergency room visit
Emergency Care:
Copayment for Emergency Care $0 or $140
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $0 or $140
Copayment for Worldwide Emergency Transportation $0 or $140
Maximum Plan Benefit of $50,000
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

Cigna TotalCare (HMO D-SNP) covers a range of additional benefits. Learn more about Cigna TotalCare (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:
Copayment for Medicare-covered Chiropractic Services $0
Prior Authorization Required for Chiropractic Services
Referral Required for Chiropractic Services
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0
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 to $50
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
Referral Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0
Copayment for Medicare-covered Therapeutic Radiological Services $0
Copayment for Medicare-covered X-Ray Services $0
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Mental health inpatient care0 or $In-Network:

Psychiatric Hospital Services:
$190 per day for days 1 to 5
$0 per day for days 6 to 90
Prior Authorization Required for Psychiatric Hospital Services
In some instances, a readmission policy may apply in which the benefit will continue from original admission.
Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 0% to 20%
Prior Authorization Required for Outpatient Hospital Services
Referral Required for Outpatient Hospital Services
Minimum for any surgical procedures (e.g. polyp removal) during a colorectal screening. Maximum for all other outpatient services not provided in an Ambulatory Surgical Center.

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

Ambulatory Surgical Center Services:
Coinsurance for Ambulatory Surgical Center Services 0% to 20%
Prior Authorization Required for Ambulatory Surgical Center Services
Referral Required for Ambulatory Surgical Center Services
Minimum for any surgical procedures (e.g. polyp removal) during a colorectal screening. Maximum for all other Ambulatory Surgical Center (ASC) services.
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0
Prior Authorization 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
Catalog orders limited to one per member per month. Exceptions may apply.
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $0
Referral Required for Podiatry Services
Skilled Nursing Facility (SNF) care0 or $0 or $In-Network:

Skilled Nursing Facility Services:
$20 per day for days 1 to 20
$214 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
In some instances, a readmission policy may apply in which the benefit will continue from original admission.

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:

Preventive Dental:
Copayment for Office Visit $0
Prior Authorization Required for Preventive Dental

Comprehensive Dental:
Copayment for Non-routine Services $0
  • Maximum 4 visits every year
Copayment for Diagnostic Services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Restorative Services $0
Copayment for Endodontics $0
  • Maximum 2 visits every year
Copayment for Periodontics $0
  • Maximum 2 visits every year
Copayment for Extractions $0
Maximum Plan Benefit of $20,000 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:
Copayment for Medicare Covered Benefits $0
Copayment for Routine Eye Exams $0
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0
Copayment for Contact Lenses $0
Copayment for Eyeglasses (lenses and frames) $0
  • Maximum 1 Pair every year
Copayment for Eyeglass Lenses $0
  • Maximum 1 Pair every year
Copayment for Eyeglass Frames $0
  • Maximum 1 Pair every year
Copayment for Upgrades $0
Maximum Plan Benefit of $275 every year
Corrective lenses, frames and contacts are covered once per year. The plan will not cover both corrective lenses/frames and contacts in the same benefit 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:
Copayment for Medicare Covered Benefits $0
Copayment for Routine Hearing Exams $0
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0
  • Maximum 1 visit every year
Referral Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $0 or $399 to $1800
  • Maximum 2 Hearing Aids 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 1-888-876-5731 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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