2021 Dual Prime (HMO-SNP)

Prospective Member: 1-844-811-6334 (TTY: 711) October 1 – March 31 | 8 am – 8 pm EST | 7 days a week
April 1 – September 30 | 8 am – 8 pm EST | Monday – Friday

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2021 Dual Prime Plan (HMO-SNP)

The 2021 Dual Prime plan (HMO-SNP) is a Medicare Advantage Prescription Drug Plan for those with both Medicare and Medicaid (Maryland Medical Assistance Program) as a Qualified Medicare Beneficiary (QMB) or a Full Benefit Dual Eligible (FBDE). This plan combines your Medical, Hospital and Prescription Drug coverage with extra services and personalized programs focused on improving your health.

To be eligible for the Dual Prime (HMO-SNP) plan, you must also have Medicare Parts A & B and reside in the following Maryland counties: Anne Arundel, Baltimore, Baltimore City, Caroline, Carroll, Cecil, Charles, Dorchester, Howard, Harford, Kent, Montgomery, Prince Georges, Queen Anne’s, and Talbot.

$0 - $32.30 Monthly Plan Premium.
Depending on Medicaid eligibility, you may have lower or $0 cost sharing for Medicare-covered services.
CY 2021 Low Income Subsidy Monthly Premium Summary

How Much You Pay for Covered Services

Benefits	What You Pay with Dual Prime
Monthly Plan Premium	$0 - $32.30 (Depending on your level of extra help)
Maximum Out-of-Pocket	$7,550
Part B Benefits Deductible	$0
Primary Care Physician Visit	$0 or 20% coinsurance**
Specialist Visit	$0 or 20% coinsurance**
Inpatient Hospital Care	Days 1-60: $0 per day Days 61-90: $0 per day Days 91-150: $0 per Lifetime Reserve Day
Emergency Care	$0 or 20% coinsurance**
Durable Medical Equipment	$0 or 20% coinsurance**
Part D Deductible	$0
Prescription Drug Coverage (30-day supply)	For generic drugs (including brand drugs treated as generic), you pay either: $0, $1.30, or $3.70 copay. For all other drugs, you pay either: $0, $4, or $9.20 copay.
Preventive Services	$0 copayment
Routine Podiatry	Medicare Covered Services: $0 Routine Foot Care: 4 visits per year $0 copay
Transportation	$0 copayment for 24 one-way trips per year
Preventive Dental	$0 copayment Oral exams: every 6 months Comprehensive oral exam: every 36 months Prophylaxis: every 6 months Fluoride treatment: every 6 months Palliative treatment: 3 every 12 months Bitewing x-ray: once per 12 months Panoramic x-ray: once every 36 months Vertical bitewing x-ray: once every 36 months Intraoral imaging: once every 36 months
Comprehensive Dental	Coverage limit is $1,000 every year. Member is responsible for all costs over $1,000 annual maximum. $0 copay for the following: Restorative services: 1 restoration per tooth once every 24 months Endodontics: 1 per lifetime, per patient, per tooth Crowns: once per tooth per 60 months Simple Extractions Periodontics: 1 per quadrant of scaling every 36 months Dentures: once every 60 months (not included under $1,000 dental allowance) Denture repairs: once every 12 months Denture relines/rebase: once every 36 months Denture adjustments: 2 per 12 months
Routine Hearing and Hearing Aids	Medicare-covered exam to diagnose and treat hearing and balance issues: $0 copay Routine hearing exam (1 per year): $0 copay 1 fitting and evaluation with 3 follow up visits within the first year from date of initial fitting: $0 copay Our plan pays up to $1,350 every 3 years for hearing aids
Routine Vision	Medicare-covered exam for diagnosis and treatment of diseases and injuries of the eye: $0 copay Routine Eye Exam (1 per year): $0 copay Our plan pays up to $150 annually towards the purchase of eyewear
Over-The-Counter	$90 quarterly allowance through the plan's OTC Catalog
Health & Wellness Program	$0 copay - 1 at-home fitness kit per quarter
Personal Emergency Response System (PERS)	$0 copay - available to select members living with a disability or chronic condition such as COPD, CHF, Diabetes, or ESRD
Meals with Medical Nutrition Therapy	$0 copay - 12 consecutive weeks of meals for members with COPD, CHF, Diabetes, or ESRD. Members will also receive up to 4 medical nutrition therapy sessions
Readmission Prevention	$0 copay - 14 meals per 1-week period for members post-discharge from an inpatient stay. PERS will also be available to select members upon discharge for a defined period of time.
Bathroom Safety Devices	$0 copay for 2 devices each year ordered through the plan's Bathroom Safety Catalog
Healthy Rewards Program	$15 reward cards for completing select preventive services

**If Medicaid status changes from Full Benefit Dual Eligible (FBDE) or Qualified Medicare Beneficiary (QMB), your copays and coinsurances will increase to 20% of the total cost of the service and 25% of the total cost of the Part D drug.

2021 Dual Prime Plan (HMO-SNP)

2021 Enrollment Form