Longevity Health Plan (PPO I-SNP)
Medicare Advantage Health Plan Details
Institutional Special Needs Plans (I-SNP)
Health insurance company offering plan: Longevity Health Plan
- Rx
- Vision
- Hearing
General Plan Details
Additional Benefits
Doctor & Hospital Coverage
Out-of-network: 30% coinsurance
Out-of-network: 30% coinsurance
Out-of-network: 30% coinsurance
Emergency Room
$115 copay
Ambulance Coverage
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
Lab, X-Ray, Radiology Coverage
Diagnostic tests & procedures:
In-network: 20% coinsurance
Out-of-network: 30% coinsurance
Lab services:
In-network: $0 copay
Out-of-network: 30% coinsurance
Diagnostic radiology services (e.g., CT, MRI, etc):
In-network: 20% coinsurance
Out-of-network: 30% coinsurance
Outpatient x-rays:
In-network: 20% coinsurance
Out-of-network: 30% coinsurance
Hospital Services
Inpatient hospital coverage:
In-network:
Tier 1
$1300 per stay
Out-of-network:
$1300 per stay
Outpatient hospital coverage:
In-network: 20% coinsurance
Out-of-network: 30% coinsurance
Rehabilitation Coverage
Occupational therapy services:
In-network: $0 copay
Out-of-network: 30% coinsurance
Urgent Care Coverage
$115 copay
Skilled Nursing Facility (SNF)
In-network:
$0 copay
Out-of-network:
30% per day for days 1-999
30% per stay
Mental Health Coverage
Outpatient group therapy with a psychiatrist:
In-network: 20% coinsurance
Out-of-network: 30% coinsurance
Outpatient individual therapy with a psychiatrist:
In-network: 20% coinsurance
Out-of-network: 30% coinsurance
Outpatient group therapy visits:
In-network: 20% coinsurance
Out-of-network: 30% coinsurance
Outpatient individual therapy visit:
In-network: 20% coinsurance
Out-of-network: 30% coinsurance
Dental, Vision, Hearing Benefits
Vision Benefits
Routine eye exams:
In-network: $0 copay
Out-of-network: 30% coinsurance
Contact Lenses:
In-network: $0 copay
Out-of-network: 30% coinsurance
Eyeglasses:
In-network: $0 copay
Out-of-network: 30% coinsurance
Hearing Benefits
Hearing exam:
In-network: $0 copay
Out-of-network: 30% coinsurance
Fitting/evaluation:
In-network: $0 copay
Out-of-network: 30% coinsurance
Hearing aids - prescription:
In-network: $0 copay
Out-of-network: 30% coinsurance
Hearing aids - over the counter:
In-network: $0 copay
Out-of-network: 30% coinsurance
Additional Added Benefits
Plan Links
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