Council on Aging Answers 2017 - 90

COUNCIL ON AGING - SOUTHERN CALIFORNIA

Medicare Advantage Plans Comparison Chart
INTER VALLEY HEALTH PLAN INTER VALLEY HEALTH PLAN
Inter Valley Health Plan
Inter Valley Health Plan
Value Preferred Choice
OC Preferred
H0545-014
H0545-013

KAISER PERMANENTE

Kaiser Permanente
Senior Advantage
L.A., Orange Co.
H0524-003

SCAN HEALTH PLAN
SCAN Classic
H5425-007

TELEPHONE NUMBERS
AND WEBSITE

New enrollment:
800-500-7018
Current Members:
800-251-8191
ivhp.com

New enrollment:
800-777-1238
Current Members:
800-443-0815
kp.org/medicare

New enrollment:
800-915-7226
Current Members:
800-559-3500
scanhealthplan.com

PLAN TYPE

MA-PD (HMO)

MA-PD (HMO)
Medi-Medi option offered

MA-PD (HMO)

TOTAL MONTHLY PREMIUM
& ANNUAL DEDUCTIBLES

$0 monthly premium

$36.20 monthly premium
$400 drug plan deductible

$0 monthly premium

SIZE OF NETWORK
OUT OF POCKET MAXIMUM
DOCTOR/SPECIALIST VISIT

6501-7000 providers
$2,000 In-Network
$0/$0 each visit

6001-6500 providers
$5,900 In-Network
20%/20% of cost each visit

6001-6500 providers
$4,400 In-Network
$10/$10 each visit

4001-4500 providers
$2,900 In-Network
$0/$0 each visit

IN-PATIENT HOSPITALIZATION

$0 copay. Unlimited days each benefit
period.

Contact plan for details.

Days 1-7: $240/day, Days 8-90: $0/day.
$0/day after 90 days. Unlimited days
each benefit period.

$0 copay. Unlimited days each benefit
period.

SKILLED NURSING FACILITY

Days 1-20: $0/day, Days 21-100: $50/day. Days 1-20: $0/day, Days 21-100: $161/day. Days 1-20: $0/day, Days 21-100: $50/day. Days 1-20: $0/day, Days 21-100: $50/day.
100 days each benefit period.
100 days each benefit period.
100 days each benefit period.
100 days each benefit period.

AMBULANCE

$165 each service

20% of cost each service

$200 each service

$175 each service

CHEMOTHERAPY DRUGS

20% of cost for Part B chemotherapy
drugs

$0-$45 copay for Part B chemotherapy
drugs

20% of cost for Part B chemotherapy
drugs

CHIROPRACTIC

$0 for subluxation manipulation

$10 for subluxation manipulation

$0 for subluxation manipulation

DIABETES

$0 for monitoring supplies. $0 for selfmanagement training. 10% of cost for
therapeutic shoes or inserts.

20% of cost for monitoring supplies

$0 for monitoring supplies. $0 for selfmanagement training. 20% of cost for
therapeutic shoes or inserts.

$0 for monitoring supplies. $0 for selfmanagement training. $0 for therapeutic
shoes or inserts.

DIAGNOSTIC TESTS, LAB &
RADIOLOGY SERVICES,
AND X-RAYS

20% of cost for diagnostic radiology
$60 for diagnostic radiology services. $0
services. 20% of cost for diagnostic tests
for diagnostic tests and procedures. $0
and procedures. 20% of cost for lab
for lab services. $0 each x-ray.
services. 20% of cost each x-ray.
$15 for therapeutic radiology services.

$155 for diagnostic radiology services.
$30 for diagnostic tests and procedures.
$30 each lab service. $40 each x-ray. $0
for therapeutic radiology services.

$50 for diagnostic radiology services. $0
for diagnostic tests and procedures. $0
for lab services. $0 each x-ray. $50 for
therapeutic radiology services.

DURABLE MEDICAL EQUIPMENT

10% of cost of Medicare- covered items

20% of cost of Medicare- covered items

0-20% of cost of Medicare-covered items

EMERGENCY ROOM VISIT
OUTPATIENT HOSPITAL SERVICES
OUTPATIENT REHAB SERVICES
TRANSPORTATION

20% of cost of Medicare- covered items

$75 each visit, waived if admitted within
$75 each visit
24 hours.
$0 each visit
Contact plan for details.
$0 each cardiac visit.
$10 each all other visits.
Not covered

$210 each visit

$75 each visit, waived if admitted
immediately.
$0-$75 each visit

20% of cost each visit

$10 each visit

$0 each visit

$0 copay

Not covered

$0 copay

Not covered*

$0 for limited dental

$10 for diagnostic exam. $10 for routine
hearing exam.**

$0 for diagnostic exam. $0 for routine
hearing exam. $0 for hearing aid fitting
or evaluation. $0 for hearing aid. Plan
pays up to $699-$999 for hearing aids.

$75 each visit

DENTAL SERVICES
(SEE NOTES FOR *)

Not covered

$0 for cleaning. $0 for x-rays. $0 for
oral exam.

HEARING SERVICES
(SEE NOTES FOR **)

$0 for diagnostic exam. $0 for routine
hearing exam. $0 for hearing aid fitting
or evaluation. Plan pays up to $250 for
hearing aids.

$0 for routine hearing exam. Plan pays
up to $1,500 for hearing aids.

VISION SERVICES
(SEE NOTES FOR ***)

$0 for diagnostic exam. $0 for routine eye
exam. $0 for eyeglasses. $0 for eyeglass
$0 for routine eye exam. Plan pays up to
frames. $0 for eyeglass lenses. $0 for
$175 for eyeglasses.
eyewear after cataract surgery. Plan pays
up to $175 for eyewear.

$0 for diagnostic exam. $0 for routine
$10 for diagnostic exam. $10 for
eye exam. $30 for contact lenses. $30 for
routine eye exam. $0 for eyewear after
eyeglasses. $30 for eyeglass lenses. $0 for
cataract surgery. Plan pays up to $40 for
eyewear after cataract surgery. Plan pays
eyewear.***
up to $175 for contacts or frames.

Confused by Medicare? Call the Council on Aging - Southern California HICAP experts at (800) 434-0222
90

Answers Guide 2017

THE INFORMATION ON THESE CHARTS IS SUBJECT TO CHANGE. Contact the plan to verify information.

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http://www.ivhp.com http://www.ivhp.com http://www.kp.org/medicare http://www.scanhealthplan.com

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