Imperial Courage Plan (HMO)
Medicare Advantage Health Plan Details
Health insurance company offering plan: Imperial Health Plan of California, Inc.
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: $0 copay
Out-of-network: $5 copay
Out-of-network: $0 copay
Emergency Room
$125 copay
Ambulance Coverage
In-network: $150 copay
Out-of-network: $150 copay
Lab, X-Ray, Radiology Coverage
Diagnostic tests & procedures:
In-network: $0 copay
Out-of-network: $0 copay
Lab services:
In-network: $0 copay
Out-of-network: $0 copay
Diagnostic radiology services (e.g., CT, MRI, etc):
In-network: $0 copay
Out-of-network: $0 copay
Outpatient x-rays:
In-network: $0 copay
Out-of-network: $0 copay
Hospital Services
Inpatient hospital coverage:
Tier 1
$150 per day for days 1-5
$0 per day for days 6-90
$0 per stay
Outpatient hospital coverage:
In-network: $200 copay
Out-of-network: $200 copay
Rehabilitation Coverage
Occupational therapy services:
In-network: $10 copay
Out-of-network: $10 copay
Urgent Care Coverage
$125 copay
Skilled Nursing Facility (SNF)
Tier 1
$0 per day for days 1-20
$200 per day for days 21-100
Mental Health Coverage
Outpatient group therapy with a psychiatrist:
In-network: $0 copay
Out-of-network: $0 copay
Outpatient individual therapy with a psychiatrist:
In-network: $0 copay
Out-of-network: $0 copay
Outpatient group therapy visits:
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
Outpatient individual therapy visit:
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
Dental, Vision, Hearing Benefits
Additional Added Benefits
Plan Links
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