Conventional Plan for 2013

Samaritan Advantage Conventional Plan HMO for 2013

The Samaritan Advantage Conventional Plan HMO offers you some of the most generous Medicare medical benefits available in Corvallis, Albany, Lebanon, Sweet Home, Newport, Lincoln City and other cities in Linn, Benton and Lincoln Counties, Oregon.

Below you will find coverage information for Samaritan Advantage Conventional Plan HMO. These materials are important documents that describe your health insurance benefits in detail.

2013 Summary of Benefits
Conventional Plan (PDF) CMS Approved

2013 Evidence of Coverage 
Conventional Plan (PDF) CMS Approved

CONVENTIONAL PLAN HMO
$72 month		 2013 BENEFIT HIGHLIGHTS
Hospitalization Out-of-pocket limit: $1,750/year
$175/day for days 1-5
$0/day for days 6-90
Doctor office visits Primary care visit: $10 co-pay
Specialist visit: $20 co-pay
Emergency care

Worldwide coverage: $50 co-pay
$0 co-pay if you are admitted to the hospital within 12 hours
$100 co-pay for ambulance
Urgent Care Anywhere in the U.S.: $25 co-pay
Routine physical exams $0 co-pay
Skilled nursing facility care Days 1-120 in a facility: $40 co-pay
Chiropractic services Acupuncture $20 co-pay for manual manipulation of the spine to correct subluxation
$25 co-pay for up to 5 routine chiropractic visits per year
$20 co-pay per acupuncture visit; up to 15 visits per year
Vision services Treatment of eye conditions & diseases: $20 co-pay
Routine eye exam: $20 co-pay for each; limited to 1 exam every 2 years
Eyewear: up to $125 for every 2 years
Preventive and diagnostic services $0 co-pay for:
Medicare-covered bone mass measurements, colorectal screening, flu and pneumonia vaccines
Mammograms
Pap smears
Pelvic exams
Prostate cancer screening
Diagnostic tests
Lab services
Outpatient Prescription Drugs NO.
Only available with the Premier and Premier Plan Plus HMO Plans.
Dental Benefit NO.
Only available with the Premier Plan Plus HMO.
Hearing Aids Benefit NO.
Only available with the Premier Plan Plus HMO.
Out-of-pocket maximum for durable medical equipment NO.
Only available with the Premier Plan Plus HMO.

What are my rights as a member?
As a member of Samaritan Advantage Health Plan HMO you have the right to make a complaint if you have concerns or problems related to your coverage or care or ask us to cover a specific medical service. Read What are my rights as a member? for additional information.

Last modified: October 24, 2012
H3811_MA4001_2012A CMS Approved October 24, 2012

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Tell your Samaritan story | Contact Us | Terms of Use | Patient privacy
Samaritan Advantage Health Plan HMO is a coordinated care plan with a Medicare Advantage Contract and a contract with the Oregon Medicaid program. Individuals must have both Part A and Part B to enroll. Members may enroll in the Conventional, Premier, and Premier Plus plans only during specific times of the year. You must continue to pay your Medicare Part A and Part B premiums. You must receive all routine care from plan providers. Benefits, formulary, pharmacy network, premium, and/or co-payments/coinsurance may change on January 1 of each year. The benefit information provided is a brief summary, not a complete description of benefits. Limitations, co-payments and restrictions may apply. Other providers are available in our network. For more information, contact Samaritan Advantage Health Plan.

Other Medicare Links: By clicking on any of the following links, you will be leaving the Samaritan Health Plan website.
Centers for Medicare and Medicaid Services (CMS) at www.cms.hhs.gov Medicare at www.medicare.gov | The Office of the Medicare Ombudsman (OMO) at www.medicare.gov/navigation/help-and-support/ombudsman.aspx for assistance with complaints, grievances, and information requests | Medicare Complaint Form at www.medicare.gov/MedicareComplaintForm/home.aspx to submit feedback about your Medicare health plan or prescription drug plan directly to Medicare using this form | Social Security Administration (SSA) at www.ssa.gov
© 2012 Samaritan Health Services