Compare 2014 Medicare Health Plans
Home Medicare Plans Oregon Klamath County
Monday, November 24, 2014

ATRIO Special Needs Plan (HMO SNP)
(H3814-007)

by ATRIO Health Plans - Klamath County, OR
  • This plan is a Medicare Special Needs Plan for people with both Medicare and full Medicaid benefits. Contact the plan for details.
  • The plan offers national in-network prescription coverage. This means that you will pay the same amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).
Contact Information

Atrio Health Plans
2270 NW Aviation Dr
Roseburg, OR 97470

Phone: 1-541-672-8620
Toll free: 1-877-672-8620

Website
http://www.atriohp.com

Pharmacy
http://www.atriohp.com

Compare Plan Plan details
Plan Rating3.5 out of 5 stars
Premium and Other Important Information* Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for original Medicare services
** Please consult with your plan about cost sharing when receiving services from out-of-network providers.
$0 monthly plan premium in addition to your monthly Medicare Part B premium.*
In 2012 the annual Part B deductible amount is $0 or $140 .* Contact the plan for services that apply.
$6700 out-of-pocket limit for Medicare-covered services.*

Doctor and Hospital ChoiceYou must go to network doctors specialists and hospitals.
Referral required for network specialists (for certain benefits).

Inpatient Hospital CarePlan covers 90 days each benefit period.
In 2012 the amounts for each benefit period $0 or:
Days 1 - 60: $1 156 deductible*
Days 61 - 90: $289 per day*
Days 91 - 150: $578 per lifetime reserve day*
You will not be charged additional cost sharing for professional services
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.

Inpatient Mental Health CareIn 2012 the amounts for each benefit period $0 or:
Days 1 - 60: $1 156 deductible*
Days 61 - 90: $289 per day*
Days 91 - 150: $578 per lifetime reserve day*
You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.
Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.

Skilled Nursing Facility (SNF)Authorization rules may apply.
Plan covers up to 100 days each benefit period
No prior hospital stay is required.
In 2012 the amounts for each benefit period are: $0 or:
Days 1 - 20: $0 per day*
Days 21 - 100: $144.50 per day*
You will not be charged additional cost sharing for professional services

Home Health CareAuthorization rules may apply.
$0 copay for Medicare-covered home health visits*

HospiceYou must get care from a Medicare-certified hospice. Your plan will pay for a consultative visit before you select hospice.

Doctor Office VisitsAuthorization rules may apply.
$0 or $1 copay for each primary care doctor visit for Medicare-covered benefits.*
0% or 20% of the cost for each in-area network urgent care Medicare-covered visit*
0% or 20% of the cost for each specialist visit for Medicare-covered benefits.*

Chiropractic ServicesAuthorization rules may apply.
0% or 20% of the cost for each Medicare-covered visit*
Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.

Podiatry ServicesAuthorization rules may apply.
0% or 20% of the cost for each Medicare-covered visit*
Medicare-covered podiatry benefits are for medically-necessary foot care.

Outpatient Mental Health CareAuthorization rules may apply.
0% or 20% of the cost for each Medicare-covered individual therapy visit*
0% or 20% of the cost for each Medicare-covered group therapy visit*
0% or 20% of the cost for each Medicare-covered individual therapy visit with a psychiatrist*
0% or 20% of the cost for each Medicare-covered group therapy visit with a psychiatrist*
0% or 20% of the cost for Medicare-covered partial hospitalization program services*

Outpatient Substance Abuse Care0% or 20% of the cost for Medicare-covered individual therapy visits*
0% or 20% of the cost for Medicare-covered group visits*

Outpatient Services/Surgery0% or 20% of the cost for each Medicare-covered ambulatory surgical center visit*
0% or 20% of the cost for each Medicare-covered outpatient hospital facility visit*

Ambulance Services0% or 20% of the cost for Medicare-covered ambulance benefits.*
If you are admitted to the hospital you pay $0 for Medicare-covered ambulance benefits.

Emergency Care0% or 20% of the cost (up to $65) for Medicare-covered emergency room visits*
Not covered outside the U.S. except under limited circumstances. Contact the plan for more details.
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit.

Urgently Needed Care0% or 20% of the cost for Medicare-covered urgently-needed-care visits*
If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the urgently-needed-care visit.

Outpatient Rehabilitation ServicesAuthorization rules may apply.
There may be limits on physical therapy occupational therapy and speech and language pathology services If so there may be exceptions to these limits.
0% or 20% of the cost for Medicare-covered Occupational Therapy visits*
0% or 20% of the cost for Medicare-covered Physical and/or Speech and Language Therapy visits*

Durable Medical EquipmentAuthorization rules may apply.
0% or 20% of the cost for Medicare-covered items*

Prosthetic DevicesAuthorization rules may apply.
0% or 20% of the cost for Medicare-covered items*

Diabetes Programs and Supplies$0 copay for Diabetes self-management training*
0% or 20% of the cost for Diabetes monitoring supplies*
0% or 20% of the cost for Therapeutic shoes or inserts*

Diagnostic Tests X-Rays Lab Services and Radiology ServicesAuthorization rules may apply.
0% of the cost for Medicare-covered lab services*
0% or 20% of the cost for Medicare-covered diagnostic procedures and tests*
0% or 20% of the cost for Medicare-covered X-rays*
0% or 20% of the cost for Medicare-covered diagnostic radiology services (not including X-rays)*
0% or 20% of the cost for Medicare-covered therapeutic radiology services*
If the doctor provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of 0% or 0% to 20% of the cost may apply*

Cardiac and Pulmonary Rehabilitation Services0% or 20% of the cost for Medicare-covered Cardiac Rehabilitation Services*
0% or 20% of the cost for Medicare-covered Intensive Cardiac Rehabilitation Services*
0% or 20% of the cost for Medicare-covered Pulmonary Rehabilitation Services*

Preventive Services and Wellness/Education Programs$0 copay for all preventive services covered under Original Medicare at zero cost sharing:
  • Abdominal Aortic Aneurysm screening
  • Bone Mass Measurement
  • Cardiovascular Screening
  • Cervical and Vaginal Cancer Screening (Pap Test and Pelvic Exam)
  • Colorectal Cancer Screening
  • Diabetes Screening
  • Influenza Vaccine
  • Hepatitis B Vaccine
  • HIV Screening
  • Breast Cancer Screening (Mammogram)
  • Medical Nutrition Therapy Services
  • Personalized Prevention Plan Services (Annual Wellness Visits)
  • Pneumococcal Vaccine
  • Prostate Cancer Screening (Prostate Specific Antigen (PSA) test only)
  • Smoking Cessation (Counseling to stop smoking)
  • Welcome to Medicare Physical Exam (Initial Preventive Physical Exam)
  • HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy. Please contact plan for details.
    This plan does not cover supplemental education/wellness programs.

    Kidney Disease and Conditions0% or 20% of the cost for renal dialysis*
    $0 copay for kidney disease education services*

    Outpatient Prescription Drugs$0 copay for Part B-covered drugs.
    $0 annual deductible for Part B-covered drugs.*
    $0 copay for Part B covered chemotherapy drugs and other Part-B covered drugs.*
    This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.atriohp.com on the web.
    Different out-of-pocket costs may apply for people who
  • have limited incomes
  • live in long term care facilities or
  • have access to Indian/Tribal/Urban (Indian Health Service) providers.
  • The plan offers national in-network prescription coverage (i.e. this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).
    Total yearly drug costs are the total drug costs paid by you the plan and Medicare.
    The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.
    Some drugs have quantity limits.
    Your provider must get prior authorization from ATRIO Special Needs Plan (HMO SNP) for certain drugs.
    The plan will pay for certain over-the-counter drugs as part of its utilization management program. Some over-the-counter drugs are less expensive than prescription drugs and work just as well. Contact the plan for details.
    You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.
    If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount.
    You pay a $0 annual deductible.
    Depending on your income and institutional status you pay the following: For generic drugs (including brand drugs treated as generic) either:
  • A $0 copay or
  • A $1.10 copay or
  • A $2.60 copay For all other drugs either:
  • A $0 copay or
  • A $3.30 copay or
  • A $6.50 copay.
  • You can get drugs the following way(s):
  • one-month (31-day) supply
  • three-month (90-day) supply
  • You can get drugs the following way(s):
  • one-month (31-day) supply
  • You can get drugs the following way(s):
  • one-month (31-day) supply
  • three-month (90-day) supply
  • After your yearly out-of-pocket drug costs reach $4 700 you pay a $0 copay.
    Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from ATRIO Special Needs Plan (HMO SNP).
    You can get drugs the following way:
  • one-month (31-day) supply
  • Depending on your income and institutional status you will be reimbursed by ATRIO Special Needs Plan (HMO SNP) up to the plan's cost of the drug minus the following: For generic drugs purchased out-of-network (including brand drugs treated as generic) either:
  • A $0 copay or
  • A $1.10 copay or
  • A $2.60 copay For all other drugs purchased out-of-network either:
  • A $0 copay or
  • A $3.30 copay or
  • A $6.50 copay.
  • After your yearly out-of-pocket drug costs reach $4 700 you will be reimbursed in full for drugs purchased out-of-network.

    Dental Services$0 copay for Medicare-covered dental benefits*
    In general preventive dental benefits (such as cleaning) not covered.

    Hearing ServicesIn general supplemental routine hearing exams and hearing aids not covered.
  • 0% or 20% of the cost for Medicare-covered diagnostic hearing exams*

  • Vision ServicesNon-Medicare Supplemental eye exams and glasses not covered.
    $0 copay for
  • one pair of eyeglasses or contact lenses after cataract surgery *
  • 0% or 20% of the cost for exams to diagnose and treat diseases and conditions of the eye.*

  • Over-the-Counter ItemsThe plan does not cover Over-the-Counter items.

    TransportationThis plan does not cover supplemental routine transportation.

    AcupunctureThis plan does not cover Acupuncture.

    Premium and Other Important InformationIn 2012 the monthly Part B Standard Premium is $99.90 and the annual Part B deductible amount is $140.
    If a doctor or supplier does not accept assignment their costs are often higher which means you pay more.
    Most people will pay the standard monthly Part B premium. However some people will pay a higher premium because of their yearly income (over $85 000 for singles $170 000 for married couples). For more information about Part B premiums based on income call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048. You may also call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.

    Doctor and Hospital ChoiceYou may go to any doctor specialist or hospital that accepts Medicare.

    Inpatient Hospital CareIn 2012 the amounts for each benefit period are:
    Days 1 - 60: $1 156 deductible
    Days 61 - 90: $289 per day
    Days 91 - 150: $578 per lifetime reserve day
    Call 1-800-MEDICARE (1-800-633-4227) for information about lifetime reserve days.
    Lifetime reserve days can only be used once.
    "A ""benefit period"" starts the day you go into a hospital or skilled nursing facility. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have."

    Inpatient Mental Health CareIn 2012 the amounts for each benefit period are:
    Days 1 - 60: $1 156 deductible
    Days 61 - 90: $289 per day
    Days 91 - 150: $578 per lifetime reserve day
    You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.

    Skilled Nursing Facility (SNF)In 2012 the amounts for each benefit period after at least a 3-day covered hospital stay are:
    Days 1 - 20: $0 per day
    Days 21 - 100: $144.50 per day
    100 days for each benefit period.
    "A ""benefit period"" starts the day you go into a hospital or SNF. It ends when you go for 60 days in a row without hospital or skilled nursing care. If you go into the hospital after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have."

    Home Health Care$0 copay.

    HospiceYou pay part of the cost for outpatient drugs and inpatient respite care.
    You must get care from a Medicare-certified hospice.

    Doctor Office Visits20% coinsurance

    Chiropractic ServicesSupplemental routine care not covered
    20% coinsurance for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part) if you get it from a chiropractor or other qualified providers.

    Podiatry ServicesSupplemental routine care not covered.
    20% coinsurance for medically necessary foot care including care for medical conditions affecting the lower limbs.

    Outpatient Mental Health Care40% coinsurance for most outpatient mental health services
    Specified copayment for outpatient partial hospitalization program services furnished by a hospital or community mental health center (CMHC). Copay cannot exceed the Part A inpatient hospital deductible.
    """Partial hospitalization program"" is a structured program of active outpatient psychiatric treatment that is more intense than the care received in your doctor's or therapist's office and is an alternative to inpatient hospitalization."

    Outpatient Substance Abuse Care20% coinsurance

    Outpatient Services/Surgery20% coinsurance for the doctor's services
    Specified copayment for outpatient hospital facility services Copay cannot exceed the Part A inpatient hospital deductible.
    20% coinsurance for ambulatory surgical center facility services

    Ambulance Services20% coinsurance

    Emergency Care20% coinsurance for the doctor's services
    Specified copayment for outpatient hospital facility emergency services.
    Emergency services copay cannot exceed Part A inpatient hospital deductible for each service provided by the hospital.
    You don't have to pay the emergency room copay if you are admitted to the hospital as an inpatient for the same condition within 3 days of the emergency room visit.
    Not covered outside the U.S. except under limited circumstances.

    Urgently Needed Care20% coinsurance or a set copay
    NOT covered outside the U.S. except under limited circumstances.

    Outpatient Rehabilitation Services20% coinsurance

    Durable Medical Equipment20% coinsurance

    Prosthetic Devices20% coinsurance

    Diabetes Programs and Supplies20% coinsurance for diabetes self-management training
    20% coinsurance for diabetes supplies
    20% coinsurance for diabetic therapeutic shoes or inserts

    Diagnostic Tests X-Rays Lab Services and Radiology Services20% coinsurance for diagnostic tests and x-rays
    $0 copay for Medicare-covered lab services
    Lab Services: Medicare covers medically necessary diagnostic lab services that are ordered by your treating doctor when they are provided by a Clinical Laboratory Improvement Amendments (CLIA) certified laboratory that participates in Medicare. Diagnostic lab services are done to help your doctor diagnose or rule out a suspected illness or condition. Medicare does not cover most supplemental routine screening tests like checking your cholesterol.

    Cardiac and Pulmonary Rehabilitation Services20% coinsurance Cardiac Rehabilitation services 20% coinsurance for Pulmonary Rehabilitation services 20% coinsurance for Intensive Cardiac Rehabilitation services
    This applies to program services provided in a doctor+s office. Specified cost sharing for program services provided by hospital outpatient departments.

    Preventive Services and Wellness/Education ProgramsNo coinsurance copayment or deductible for the following:
  • Abdominal Aortic Aneurysm Screening
  • Bone Mass Measurement. Covered once every 24 months (more often if medically necessary) if you meet certain medical conditions.
  • Cardiovascular Screening
  • Cervical and Vaginal Cancer Screening. Covered once every 2 years. Covered once a year for women with Medicare at high risk.
  • Colorectal Cancer Screening
  • Diabetes Screening
  • Influenza Vaccine
  • Hepatitis B Vaccine for people with Medicare who are at risk
  • HIV Screening. $0 copay for the HIV screening but you generally pay 20% of the Medicare-approved amount for the doctor+s visit. HIV screening is covered for people with Medicare who are pregnant and people at increased risk for the infection including anyone who asks for the test. Medicare covers this test once every 12 months or up to three times during a pregnancy.
  • Breast Cancer Screening (Mammogram). Medicare covers screening mammograms once every 12 months for all women with Medicare age 40 and older. Medicare covers one baseline mammogram for women between ages 35-39.
  • Medical Nutrition Therapy Services Nutrition therapy is for people who have diabetes or kidney disease (but aren+t on dialysis or haven+t had a kidney transplant) when referred by a doctor. These services can be given by a registered dietitian and may include a nutritional assessment and counseling to help you manage your diabetes or kidney disease
  • Personalized Prevention Plan Services (Annual Wellness Visits)
  • Pneumococcal Vaccine. You may only need the Pneumonia vaccine once in your lifetime. Call your doctor for more information.
  • Prostate Cancer Screening + Prostate Specific Antigen (PSA) test only. Covered once a year for all men with Medicare over age 50.
  • Smoking Cessation (counseling to stop smoking). Covered if ordered by your doctor. Includes two counseling attempts within a 12-month period. Each counseling attempt includes up to four face-to-face visits.
  • Welcome to Medicare Physical Exam (initial preventive physical exam) When you join Medicare Part B then you are eligible as follows. During the first 12 months of your new Part B coverage you can get either a Welcome to Medicare Physical Exam or an Annual Wellness Visit. After your first 12 months you can get one Annual Wellness Visit every 12 months.

  • Kidney Disease and Conditions20% coinsurance for renal dialysis
    20% coinsurance for kidney disease education services

    Outpatient Prescription DrugsMost drugs are not covered under Original Medicare. You can add prescription drug coverage to Original Medicare by joining a Medicare Prescription Drug Plan or you can get all your Medicare coverage including prescription drug coverage by joining a Medicare Advantage Plan or a Medicare Cost Plan that offers prescription drug coverage.

    Dental ServicesPreventive dental services (such as cleaning) not covered.

    Hearing ServicesSupplemental routine hearing exams and hearing aids not covered.
    20% coinsurance for diagnostic hearing exams.

    Vision Services20% coinsurance for diagnosis and treatment of diseases and conditions of the eye.
    Supplemental routine eye exams and glasses not covered.
    Medicare pays for one pair of eyeglasses or contact lenses after cataract surgery.
    Annual glaucoma screenings covered for people at risk.

    Over-the-Counter ItemsNot covered.

    TransportationNot covered.

    AcupunctureNot covered.

    Point of ServiceYou may go to any doctor specialist or hospital that accepts Medicare.
    Compare Plan

    Help is available. If you have limited income and resources, you may qualify for help paying your Medicare health care and/or prescription drug coverage costs. For more information, visit socialsecurity.gov, call Social Security at 1-800-772-1213, or apply for help at your State Medical Assistance (Medicaid) office.

    If you have questions about Medicare, visit medicare.gov or call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.