Central Health Classic Care Plan I (HMO)
Central Health Classic Care Plan I (HMO) H5649-027 Plan Details
Central Health Classic Care Plan I (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Molina Healthcare, Inc.,
Plan ID: H5649-027
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
Central Health Classic Care Plan I (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Molina Healthcare, Inc.,
Plan ID: H5649-027
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
California Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $999 Out-of-Network: N/A |
| Initial Coverage Limit | $2000 |
| Catastrophic Coverage Limit | $2,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0 Prior Authorization Required for Doctor Specialty Visit Referral Required for Doctor Specialty Visit Prior authorization required |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $0 Prior Authorization Required for Acute Hospital Services Referral Required for Acute Hospital Services Prior authorization required |
| Urgent Care | Copayment for Urgent Care $0 Worldwide Coverage: Copayment for Worldwide Urgent Coverage $140 Maximum Plan Benefit of $50,000 |
| Emergency Room Visit | Copayment for Emergency Care $0 to $140 Worldwide Coverage: Copayment for Worldwide Emergency Coverage $140 Copayment for Worldwide Emergency Transportation $140 Maximum Plan Benefit of $50,000 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $0 to $150 Minimum cost share for transfer from OON hospital to an INN hospital, maximum cost share for all other ambulance services. Air Ambulance: Coinsurance for Air Ambulance Services 20% Prior Authorization Required for Air Ambulance Prior authorization required |
Health Care Services and Medical Supplies
Central Health Classic Care Plan I (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Copayment for Medicare-covered Chiropractic Services $0 Copayment for Routine Care $0
Referral Required for Chiropractic Services Prior authorization required |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0 |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 0% to 20% Prior Authorization Required for Durable Medical Equipment Minimum coinsurance for items $100 or less, maximum coinsurance for items greater than $100. Prior authorization required |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0 Copayment for Medicare-covered Lab Services $0 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Referral Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0 Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Referral Required for Home Health Services Prior authorization required |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $150 per day for days 1 to 6 $0 per day for days 7 to 60 $329 per day for days 61 to 90 Prior Authorization Required for Psychiatric Hospital Services Referral Required for Psychiatric Hospital Services Prior authorization required |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $100 Prior Authorization Required for Outpatient Hospital Services Referral Required for Outpatient Hospital Services Minimum amount for diagnostic DEXA scans and diagnostic colonoscopies in an outpatient setting. Maximum amount for all other services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $0 to $100 Prior Authorization Required for Outpatient Observation Services Referral Required for Outpatient Observation Services Minimum amount for diagnostic DEXA scans and diagnostic colonoscopies in an outpatient setting. Maximum amount for all other services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 Prior Authorization Required for Ambulatory Surgical Center Services Referral Required for Ambulatory Surgical Center Services Prior authorization required |
| Outpatient Substance Abuse Care | In-Network: Coinsurance for Medicare-covered Individual Sessions 20% Coinsurance for Medicare-covered Group Sessions 20% Prior Authorization Required for Outpatient Substance Abuse Services Referral Required for Outpatient Substance Abuse Services Prior authorization required |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0 |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $0 Prior Authorization Required for Podiatry Services Referral Required for Podiatry Services Prior authorization required |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: Copayment for Skilled Nursing Facility Services per Stay $0 Prior Authorization Required for Skilled Nursing Facility Services Referral Required for Skilled Nursing Facility Services Prior authorization required |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Medicare Covered Preventive Dental: Copayment for Office Visit $0 Prior Authorization Required for Medicare Covered Preventive Dental Non-Medicare Covered Preventive Dental: Copayment for Non-medicare preventive $0 Copayment for Oral exams $0
Copayment for Prophylaxis $0
Non-Medicare Covered Comprehensive Dental: Copayment for Non-medicare comprehensive $0 Copayment for Restorative services $25 to $400 Copayment for Endodontics $25 to $720 Copayment for Periodontics $0 to $780 Copayment for Prothodontics, removable $0 to $600 Copayment for Implant services $45 to $2160 Copayment for Prothodontics, fixed $0 to $840 Copayment for Maxillofacial surgery $0 to $380 Copayment for Adjunctive general services $0 to $300 Prior authorization required |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Copayment for Contact Lenses $0 Copayment for Eyeglasses (lenses and frames) $0
Maximum Plan Benefit of $300 every year Referral Required for Eyewear |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0 Copayment for Routine Hearing Exams $0
Hearing Aids: Copayment for Hearing Aids $49 to $1549
|
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit |
