Mount Carmel MediGold Cash Back No Premium MA Only (HMO)
H3668 - 013 - 0
(4.5 / 5)
Mount Carmel MediGold Cash Back No Premium MA Only (HMO) is a Medicare Advantage Plan by MediGold.
This page features plan details for 2024 Mount Carmel MediGold Cash Back No Premium MA Only (HMO) H3668 – 013 – 0 available in Central, Southwest, and Northwest Ohio.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
Locations
Mount Carmel MediGold Cash Back No Premium MA Only (HMO) is offered in the following locations.
Plan Overview
Mount Carmel MediGold Cash Back No Premium MA Only (HMO) offers the following coverage and cost-sharing.
| Insurer: | MediGold |
| Health Plan Deductible: | $0.00 |
| MOOP: | $3,900 In-network |
| Drugs Covered: | No |
Ready to sign up for Mount Carmel MediGold Cash Back No Premium MA Only (HMO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Medicare Part B Give Back Benefit
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
Mount Carmel MediGold Cash Back No Premium MA Only (HMO) qualifies for a monthly Medicare Give Back Benefit of $100.00.
| Premium Reduction: | $100.00 |
Premium Breakdown
Mount Carmel MediGold Cash Back No Premium MA Only (HMO) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $0.00 | $100.00 | $ |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Mount Carmel MediGold Cash Back No Premium MA Only (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $3,900 In-network |
| Yes |
| In-network | No |
| $0-125 copay per visit (Authorization is not required.) (Referral is not required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $30 copay per visit (Authorization is not required.) (Referral is not required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $90 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $35 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $25 copay (Authorization is required.) (Referral is not required.) |
| Lab services | $0 copay (Authorization is required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | $70 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient x-rays | $25 copay (Authorization is not required.) (Referral is not required.) |
| Hearing exam | $30 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| Hearing aids | $599-899 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Restorative services | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Endodontics | 70% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Periodontics | 70% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Extractions | 50% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| Occupational therapy visit | $20 copay (Authorization is not required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $20 copay (Authorization is not required.) (Referral is not required.) |
| $200 copay (Not applicable.) (Not applicable.) |
| $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| Foot exams and treatment | $30 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | $0 copay per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
| $75 per day for days 1 through 7 $0 per day for days 8 through 90 (Authorization is required.) (Referral is not required.) |
| Inpatient hospital – psychiatric | $75 per day for days 1 through 7 $0 per day for days 8 through 90 (Authorization is required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient group therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| Outpatient individual therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| $0 per day for days 1 through 20 $203 per day for days 21 through 56 $0 per day for days 57 through 100 (Authorization is not required.) (Referral is not required.) |
| Monthly Premium | $16.00 |
| Deductible | nan |
| Monthly Premium | $36.00 |
| Deductible | nan |
Ready to sign up for Mount Carmel MediGold Cash Back No Premium MA Only (HMO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Table of Contents
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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