Cigna TotalCare (HMO D-SNP)
Cigna TotalCare (HMO D-SNP) H4513-055 Plan Details
Cigna TotalCare (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Cigna
Plan ID: H4513-055
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
Cigna TotalCare (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Cigna
Plan ID: H4513-055
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.
Cigna TotalCare (HMO D-SNP) H4513-055 Plan Details
Cigna TotalCare (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Cigna
Plan ID: H4513-055
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
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $5900 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 Prior authorization required |
| Inpatient Hospital Care | 0 or $In-Network: Acute Hospital Services: $150 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Acute Hospital Services In some instances, a readmission policy may apply in which the benefit will continue from original admission. Prior authorization required |
| Urgent Care | Copayment for Urgent Care $0 or $55 Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 2 hours Worldwide Coverage: Copayment for Worldwide Urgent Coverage $0 or $125 Maximum Plan Benefit of $50,000 |
| Emergency Room Visit | Copayment for Emergency Care $0 or $125 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $0 or $125 Copayment for Worldwide Emergency Transportation $0 or $125 Maximum Plan Benefit of $50,000 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $0 or $255 Air Ambulance: Coinsurance for Air Ambulance Services 0% or 20% Prior Authorization Required for Air Ambulance Prior authorization required |
Health Care Services and Medical Supplies
Cigna TotalCare (HMO D-SNP) 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 Prior Authorization Required for Chiropractic Services Prior authorization required |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 0% or 20% |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 0% or 20% Prior Authorization Required for Durable Medical Equipment Prior authorization required |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare-covered Diagnostic Procedures/Tests 0% to 20% Copayment for Medicare-covered Lab Services $0 to $50 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Minimum for EKG. Maximum for all other diagnostic procedures and tests. Outpatient Diag/Therapeutic Rad Services: Coinsurance for Medicare-covered Diagnostic Radiological Services 0% to 20% Coinsurance for Medicare-covered Therapeutic Radiological Services 0% or 20% Coinsurance for Medicare-covered X-Ray Services 0% to 20% Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Prior authorization required |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $0 or $1850 Prior Authorization Required for Psychiatric Hospital Services In some instances, a readmission policy may apply in which the benefit will continue from original admission. Prior authorization required |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $0 Copayment for Medicare-covered Group Sessions $0 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $95 Prior Authorization Required for Outpatient Hospital Services Minimum for any surgical procedures (e.g. polyp removal) during a colorectal screening. Maximum for all other outpatient services not provided in an Ambulatory Surgical Center. Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $0 or $95 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 to $50 Prior Authorization Required for Ambulatory Surgical Center Services Minimum for any surgical procedures (e.g. polyp removal) during a colorectal screening. Maximum for all other Ambulatory Surgical Center (ASC) services. Prior authorization required |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $0 Copayment for Medicare-covered Group Sessions $0 Prior Authorization 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
Catalog orders limited to one per member per month. Exceptions may apply. |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $0 |
| Skilled Nursing Facility Care | 0 or $In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services In some instances, a readmission policy may apply in which the benefit will continue from original admission. Prior authorization required |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental: Copayment for Office Visit $0 Prior Authorization Required for Preventive Dental Comprehensive Dental: Copayment for Non-routine Services $0 Copayment for Diagnostic Services $0 Copayment for Restorative Services $0 Copayment for Endodontics $0 Copayment for Periodontics $0 Copayment for Extractions $0 Maximum Plan Benefit of $2,500 every year 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 Corrective lenses, frames and contacts are covered once per year. The plan will not cover both corrective lenses/frames and contacts in the same benefit year. |
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 $0 or $399 to $1800
|
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 |
