Medicare Advantage Plan HMO H3407_001

El Paso Health Medicare Advantage Dual (HMO D-SNP)

$0.00
Monthly Premium
$8,500
Maximum out-of-pocket
How to Enroll
Premium & Deductibles
In-Network
Monthly Plan Premium
$0
Medical Deductible
$0
Maximum Out-of-Pocket
$8,500
Pharmacy (Part D) Deductible
$0
The out-of-pocket maximum is the maximum amount that you will be required to pay a year for deductibles, copayments, and coinsurance on covered services.
Covered Doctor Copays
In-Network
Primary Care Copay
$0 copay
Specialist copay
$0 copay
The cost of your medicine depends on where you buy it, how much you get and whether it is a generic, brand or specialty drug. For more details, see the pharmacy chart in the Summary of Benefits.
Initial Coverage Stage
Copays will depend on the level of LIS the Member qualifies for.
Group 1
$1.60 - $4.90 copay
Group 2
$4.80 - $12.15 copay
Hospital & Urgent Care
In-Network
Inpatient Hospital Care
$0 copay per day for day 1 to 90
Our plan also covers 60 “lifetime reserved days.” These are "extra” days that we cover. If your hospital stay is longer than 90 days, you can use these extra days. But once you have used up these extra 60 days, your inpatient hospital coverage will be limited to 90 days.
Outpatient Hospital Care
$0 copay
Ambulatory Surgical Center (ASC) Service
$0 copay
Emergency Care
$0 copay
Urgent Care
$0 copay
Urgently needed services are provided to treat a non-emergency, unforeseen medical illness, injury or condition that requires immediate medical attention.
Labs & X-Rays
In-Network
Cost share may vary depending on the service and where service is provided.
Diagnostic Procedures/Tests
$0 copay
Lab Services
$0 copay
Diagnostic Radiological Services
$0 copay
X-Ray Services
$0 copay

Primary Benefits

Mental Health Services
In-Network
Inpatient Care at a Psychiatric Facility
$0 copay per day for day 1 to 190
Your plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital.
Outpatient Mental Group Therapy
$0 copay
Outpatient Mental Individual Therapy Visit
$0 copay
Dental Benefits
In-Network
Medicare-covered dental services
$0 copay
Routine Dental
In-Network
Oral exam(s) and Cleanings(s) every year
$0 copay
Dental X-ray(s) every year
$0 copay
Fluoride treatment(s) every year
$0 copay
Comprehensive Dental Services
In-Network
Diagnostic Services
$0 copay
Oral/Maxillofacial surgery
$0 copay
Extractions and Fillings
$0 copay
Implants and Dentures
$0 copay
Maximum benefit
$3,500
Vision Benefits
In-Network
Additional vision benefits may be available with or without a separate monthly premium. For more information see the Summary of Benefits.
Medicare-covered Vision Services
$0 copay
Diabetic Eye Exam
$0 copay
Glaucoma Screening
$0 copay
Eyewear (Post Cataract Surgery)
$0 copay
Routine Vision
In-Network
Routine Exam up to 1 per year
$0 copay
Contact lenses or eyeglasses-lenses and frames up to 1 pair(s) per year
$0 copay
Fitting for eyeglasses-lenses and frames up to 1 per year
$0 copay
Refraction up to 1 per year
$0 copay
Max benefit: contact lenses or eyeglasses-lenses and frames, fitting for eyeglasses-lenses and frames
$400 maximum benefit coverage amount per year
Hearing Benefits
In-Network
Additional hearing benefits may be available with a separate monthly premium. For more information see the Summary of Benefits.
Medicare-covered Hearing Services
$0 copay
Routine Hearing
In-Network
Routine Hearing Exam up to 1 per year
$0 copay
Hearing aid once every 2 years
$0 copay
Benefit Maximum:
Hearing aid device every two (2) years
$2,000 copay
Preventative Benefits
In-Network
In-network: $0 for the following preventive services when you see an in-network provider:

Abdominal aortic aneurysm screening
Colorectal cancer screenings (Colonoscopy, Fecal occult blood test, Flexible sigmoidoscopy)
Sexually transmitted infections screenings and counseling
Alcohol misuse counseling
Depression screenings
Tobacco use cessation counseling (counseling for people with no sign of tobacco related disease)
Bone mass measurement
Diabetes screenings
Flu shots
Breast cancer screening (mammogram)
HIV screenings
Hepatitis B shots
Cardiovascular disease (behavioral screenings)
Medical nutrition therapy services
Pneumococcal shots
Cardiovascular screenings
Obesity screening and counseling
“Welcome to Medicare” Preventive visit (one time)
Cervical and vaginal cancer screening
Pap smears and pelvic exams (women)
Yearly “Wellness” visit

2025 Supplemental Benefits

The Benefit Flyer explains the benefits available to El Paso Health Members. You can download a digital copy to your device using the link on the right. If you prefer a printed copy, just call the number below Monday thru Friday, between 8:00 a.m. and 8:00 p.m.

There’s no obligation to join.

1-833-742-3125 TTY 711
Use your El Paso Health card at any YMCA and get access to all facilities and classes.
Get ten (10) visits annually for routine podiatry care.

Full list of Podiatry Coverage
Cutting or removing corns and calluses.
Trimming, cutting or clipping nails.
Hygienic or other preventive maintenance, like clearing and soaking of the feet.
Full list of Vision Coverage
$0 co-pay

Routine Vision Services:
Routine vision exam - 1 routine eye exam every year.
Routine eye wear (lenses and frames).
Eyeglasses or contact lenses.

This plan covers up to $400 for eyeglasses or contact lenses every year.
One Personal Emergency Response System Device.
Common Uses
Feeling disoriented
Lost
Fallen and can't get up
Shortness of breath

How to get a PERS Device
Contact Member Services to request the PERS Device.
Call us toll free 1-833-742-3125.
$2,000 towards fitting/evaluation of aids and hearing devices every two (2) years.

Full List of Hearing Coverage
$0 co-pay

Routine Hearing Services:
This plan covers 1 hearing exam and hearing aid fitting/evaluation every year. $2,000 maximum plan benefit for hearing aids every two (2) years.
It is always recommended that you talk to your PCP first before you get care from a Specialist.
Get up to fourteen (14) healthy meals delivered to your home after being discharged from a hospital or nursing facility.

How to get a meal delivered
Contact Member Services if you have been discharged from a hospital or nursing facility.

Call us toll free 1-833-742-3125.
Access to a 24-hour, seven days a week bilingual (English/Spanish) medical advice line staffed by nurses and pharmacists.

How to Call the 24-Hour Nurse Line
On the back of your El Paso Health Member card, you will find the 24-hour Nurse line.
Qualifying members receive a $60 monthly allowance for the assistance of paying any of the following utilities:

Gas
Water
Electricity
Rent

How to Get Utility Bill Assistance
The OTC Visa Card can be used to pay the utility bill from the list above.
To qualify for these services you will need to have one of the following chronic conditions listed below:

Chronic alcohol and other drug dependence; autoimmune disorders; cancer, excluding pre-cancer; cardiovascular; chronic heart failure; dementia; diabetes mellitus; end-stage liver disease; end-stage renal disease requiring dialysis; severe hematologic disorders; HIV/AIDS; chronic lung disorders; chronic and disabling mental health conditions; neurologic disorders; stroke

Call us toll free 1-833-742-3125.
Receive 96 one-way non-emergent medical visit transportation services every year.

Common Uses
Routine Doctor Visits
Blood work or test visits
Dialysis
Medication Pickup
Surgery Appointments
Dental and Vision

How to get a Ride
Contact Member Services for any transportation request. All request require a 48-hour notice in advance.Call us toll free 1-833-742-3125.
Qualifying members receive $250 every quarter for approved healthy foods such as: fruits & vegetables, meat, juice, milk, cheese, eggs, yogurt, bread and much more!

How does it work
Every three months, qualifying members will receive an additional $250 dollars to their OTC Visa card, and it can be used to buy approved nutritional food at your local Walmart.

How to join the Healthy Eats Program
To qualify for these services you will need to have one of the following chronic conditions listed below:

Chronic alcohol and other drug dependence; autoimmune disorders; cancer, excluding pre-cancer; cardiovascular; chronic heart failure; dementia; diabetes mellitus; end-stage liver disease; end-stage renal disease requiring dialysis; severe hematologic disorders; HIV/AIDS; chronic lung disorders; chronic and disabling mental health conditions; neurologic disorders; stroke

Call us toll free 1-833-742-3125.
Receive up to $300 each quarter for eligible over-the-counter and hygiene product purchases. Allowance renews every quarter.

List of Qualifying OTC Items

Check your OTC Balance

How to get an OTC Card
Contact Member Services if you have not received your OTC Card. Call us toll free 1-833-742-3125.

Lost or stolen OTC Card
Contact Member Services for any lost or stolen OTC Cards.

Local Retailers
Albertsons, Walmart, CVS, Walgreens, Family Dollar, Dollar General

2026 Supplemental Benefits

Eligible members with a qualifying chronic condition can receive a $450 quarterly allowance to help cover the cost of healthy food or essential utilities like gas, water, electricity, or rent. This benefit supports better health by easing financial stress and making it easier to maintain a stable, nutritious lifestyle.
Members get a monthly membership to any local YMCA facility or Planet Fitness center. Members must call Member Service and specify the fitness center they prefer. Members who choose any Planet Fitness will receive a monthly premium (black card) membership to any local Planet Fitness center.
With up to $200 each quarter for eligible over-the-counter and hygiene products, this benefit helps members afford everyday health essentials like pain relievers, cold medicine, and personal care items. The allowance renews every quarter, making it easier to manage health needs year-round without extra out-of-pocket costs.
With 96 one-way non-emergent medical transportation services each year, members can get to important healthcare appointments without worrying about how they’ll get there. This benefit supports access to routine doctor visits, lab tests, dialysis, and more—helping you stay on top of your health.
A Personal Emergency Response System (PERS) device provides quick, one-touch access to emergency assistance, helping members stay safe and independent at home or on the go. Whether you've fallen, feel disoriented, or are experiencing shortness of breath, help is always within reach.

Plan Documents

Summary of Benefits (CMS Accepted 09/16/2024)
View deductibles, copays, and more.
Provider Directory
Search the Provider Directory on El Paso Health's non-Medicare website or view and download the pdf below.
Pharmacy Directory
View our network of Pharmacies
Enrollment Form (CMS Approved 09/05/2024)
Complete enrollment by filling out this form.
Printable Prescription Drug List
View our Comprehensive Formulary
Evidence of Coverage (CMS Accepted 10/05/2024)
See what's covered, and what you pay as a member of this plan.
CMS Rating (CMS Accepted 09/18/2024)
A CMS Star Rating is a 1–5 scale used by Medicare to measure the quality and performance of D-SNP plan.
Annual Notice of Change (CMS Approved 09/10/2024)
View our 2025 plan benefit changes.
Summary of Benefits (CMS Approved 08/03/2025)
View deductibles, copays, and more.
Provider Directory
Search the Provider Directory on El Paso Health's non-Medicare website or view and download the pdf below.
Pharmacy Directory
View our network of Pharmacies
Enrollment Form (CMS Accepted 07/21/2025)
Complete enrollment by filling out this form.
Printable Prescription Drug List
View our Comprehensive Formulary
CMS Rating (CMS Accepted 09/18/2024)
A CMS Star Rating is a 1–5 scale used by Medicare to measure the quality and performance of D-SNP plan.
Annual Notice of Change (CMS Accepted 08/23/2025)
View our 2026 plan benefit changes.
Evidence of Coverage (Disclaimer– Coming Soon)
See what's covered, and what you pay as a member of this plan.
How to Enroll

Licensed sales agents are here to answer your questions.

Find a plan that best suits your needs in just one phone call.
1-833-742-3125
TTY 711, 24/7
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