Medical Associates Clinic Health Plan of Wisconsin
Medical Associates SmartPlan (Cost)
Medicare plan ID H5256-001-000 · 2026 benefits. Every benefit the plan filed with Medicare, from the same data as the comparison grid. Other years: 2026 · 2027
| Benefit | Medical Associates SmartPlan (Cost) |
|---|---|
| Plan details | |
| Star rating (2026) Medicare's yearly quality rating, from 1 to 5 stars, covering care, member experience, complaints and customer service. A plan too new to be measured has no rating, which is not the same as a low one. | Not yet rated |
| Plan type How the plan handles doctors and referrals. An HMO generally covers only in-network care and may require referrals; a PPO covers out-of-network care, usually at a higher cost; a PFFS plan pays providers who agree to its terms. Compare Medicare Advantage plan types ↗ | Cost plan |
| Special needs plan A Special Needs Plan enrolls only people in a particular group: those with both Medicare and Medicaid (D-SNP), those living in an institution [or needing the same level of care that a facility offers] (I-SNP), or those with certain chronic conditions (C-SNP). You must qualify to join. Special Needs Plans ↗ | No |
| Carrier The insurance company that sells the plan and pays the claims. | Medical Associates Clinic Health Plan of Wisconsin |
| Medical benefits What the plan charges for the care Medicare covers. | |
| Monthly plan premium | $150/mo |
| Maximum out-of-pocket The most you can pay in a year for in-network medical care. Once you reach it, the plan pays the whole cost of covered services for the rest of the year. It does not include your premiums or what you spend at the pharmacy. Every Medicare Advantage plan must have one; Original Medicare does not. Medicare costs ↗ | n/a |
| Medical deductible What you pay for covered medical care each year before the plan starts paying its share. Many Medicare Advantage plans have none, and some charge Medicare's own deductible instead of setting their own. A deductible can apply to some services and not others. Medicare costs ↗ | $0 |
| Primary Care Physician Services An office visit with the doctor you see for everyday care and who often coordinates your other care. Doctor and provider services ↗ | $0Out of network: Original Medicare's cost sharing |
| Physician Specialist Services An office visit with a doctor who treats one area of medicine -- a cardiologist, dermatologist or surgeon. Some plans require a referral from your primary care doctor first. Doctor and provider services ↗ | $0Out of network: Original Medicare's cost sharing |
| Inpatient Hospital-Acute Services A stay in a hospital after a doctor formally admits you. Medicare Advantage plans usually charge a daily amount for the first several days rather than one deductible. Being 'under observation' is outpatient care and is charged differently. Inpatient hospital care ↗ | $0Out of network: Original Medicare's cost sharing |
| Skilled Nursing Facility Services Short-term skilled care in a nursing facility after a hospital stay -- nursing, physical therapy, wound care. It is not long-term care: Medicare covers up to 100 days per benefit period, and plans usually charge nothing for the first 20 days. Skilled nursing facility care ↗ | $0Out of network: Original Medicare's cost sharing |
| Ambulance Services An ambulance to the nearest hospital that can treat you, when travelling any other way would endanger your health. Ground and air ambulance are filed separately. Medicare does not cover an ambulance for convenience. Ambulance services ↗ | $0Out of network: Original Medicare's cost sharing |
| Emergency Services A visit to an emergency room for a condition a reasonable person would think serious. Plans charge the same whether the hospital is in or out of network, and the charge is usually waived if you are admitted. Emergency department services ↗ | $0 |
| Urgently Needed Services Care you need right away for an unexpected illness or injury that is not an emergency -- an urgent care center rather than an emergency room. Urgently needed care ↗ | $0 |
| Outpatient Hospital Services Care you get at a hospital without being admitted: same-day procedures, tests, and time spent under observation. An observation stay is outpatient care even though you sleep at the hospital. Outpatient hospital services ↗ | $0Out of network: Original Medicare's cost sharing |
| Ambulatory Surgical Center (ASC) Services Surgery at a center that does same-day procedures rather than at a hospital. It usually costs less than the same operation in a hospital outpatient department. Ambulatory surgical centers ↗ | $0Out of network: Original Medicare's cost sharing |
| Physical Therapy and Speech-Language Pathology Services Therapy to restore movement, strength or speech after an illness, injury or surgery, whether at a clinic or at home. Physical therapy ↗ | $0Out of network: Original Medicare's cost sharing |
| Outpatient Diagnostic/Therapeutic Radiological Services Imaging a doctor orders -- X-rays, CT scans, MRIs, ultrasound -- and radiation treatment. Each kind is filed separately, so the prices can differ. Diagnostic non-laboratory tests ↗ | $0Out of network: Original Medicare's cost sharing |
| Medicare Part B Prescription Drugs Drugs given to you by a health professional rather than picked up at a pharmacy: infusions and injections in a clinic, chemotherapy, insulin used in a pump, nebulizer medicine. These are Part B drugs, so they are not part of the pharmacy benefit below. Outpatient prescription drugs ↗ | Not listedOut of network: Original Medicare's cost sharing |
| Durable Medical Equipment (DME) Equipment a doctor prescribes for use at home -- walkers, wheelchairs, hospital beds, oxygen, CPAP machines. Medicare pays 80% after the Part B deductible; plans set their own share. Durable medical equipment ↗ | $0Out of network: Original Medicare's cost sharing |
| Home Health Services Part-time skilled nursing, physical therapy or speech therapy at home when you are homebound and a doctor orders it. Medicare covers it in full; it is not help with cooking, cleaning or bathing alone. Home health services ↗ | $0Out of network: Original Medicare's cost sharing |
| Medicare Dental Services Dental work Medicare itself covers, which is only dental care that is part of another covered treatment -- for example an examination before heart valve surgery or a jaw reconstruction after an injury. Dental services ↗ | $0Out of network: Original Medicare's cost sharing |
| Chiropractic Services Manual manipulation of the spine by a chiropractor to correct a subluxation. Medicare does not cover other chiropractic services such as massage or X-rays ordered by the chiropractor. Chiropractic services ↗ | $0Out of network: Original Medicare's cost sharing |
| Occupational Therapy Services Therapy that helps you regain the ability to do daily tasks such as dressing, cooking or bathing after an illness or injury. Occupational therapy ↗ | $0Out of network: Original Medicare's cost sharing |
| Mental Health Specialty Services Counseling and therapy for mental health, individually or in a group, with a psychiatrist, psychologist, clinical social worker or counsellor. Outpatient mental health care ↗ | $0Out of network: Original Medicare's cost sharing |
| Podiatry Services Treatment of foot injuries and diseases, such as hammer toe or heel spurs, and foot care for people with diabetes-related nerve damage. Routine care such as toenail cutting is covered only in those cases. Foot care ↗ | 4 routine foot care visits every year · $0Out of network: Original Medicare's cost sharing |
| Other Health Care Professional Visits to health professionals other than doctors -- nurse practitioners, physician assistants, clinical nurse specialists. Doctor and provider services ↗ | $0Out of network: Original Medicare's cost sharing |
| Psychiatric Services Visits with a psychiatrist or other doctor for mental health care, individually or in a group. Outpatient mental health care ↗ | $0Out of network: Original Medicare's cost sharing |
| Additional Telehealth Benefits Care from a doctor by video or phone instead of in person. Plans can offer more telehealth than Original Medicare covers, and may charge less for it than for an office visit. Telehealth ↗ | Not listedOut of network: Original Medicare's cost sharing |
| Opioid Treatment Program Services Treatment for opioid use disorder at a certified program: medication such as methadone or buprenorphine, counseling and testing. Medicare covers it with no cost sharing at an opioid treatment program. Opioid use disorder treatment ↗ | $0Out of network: Original Medicare's cost sharing |
| Inpatient Hospital Psychiatric Services A hospital stay for mental health care. Medicare limits psychiatric hospital care to 190 days in a lifetime. Inpatient mental health care ↗ | $0Out of network: Original Medicare's cost sharing |
| Cardiac and Pulmonary Rehabilitation Services Supervised exercise and education after a heart attack, heart surgery, or for a lung condition, and supervised exercise therapy for peripheral artery disease. Each is filed separately, so the prices can differ. Cardiac rehabilitation ↗ | $0Out of network: Original Medicare's cost sharing |
| Partial Hospitalization Program Intensive day treatment for mental health at a hospital or community mental health center, without staying overnight. Partial hospitalization ↗ | Not listedOut of network: Original Medicare's cost sharing |
| Intensive Outpatient Services Intensive outpatient mental health or substance use treatment, less intensive than partial hospitalization. Outpatient mental health care ↗ | $0Out of network: Original Medicare's cost sharing |
| Outpatient Diagnostic Procedures/Tests/Lab Services Blood tests, urine tests and other diagnostic tests a doctor orders. Lab services and other diagnostic procedures are filed separately, so their prices can differ. Diagnostic laboratory tests ↗ | $0Out of network: Original Medicare's cost sharing |
| Outpatient Substance Abuse services Outpatient treatment for alcohol or drug use, individually or in a group, including counseling and medication management. Outpatient mental health care ↗ | $0Out of network: Original Medicare's cost sharing |
| Outpatient Blood Services Blood you receive as an outpatient. Medicare and plans may not pay for the first pints in a year unless they are donated. Blood ↗ | $0Out of network: Original Medicare's cost sharing |
| Prosthetics/Medical Supplies Devices that replace a body part or function -- artificial limbs, braces, ostomy and surgical supplies. Prosthetic devices ↗ | $0Out of network: Original Medicare's cost sharing |
| Diabetic Supplies and Services Test strips, lancets, blood sugar monitors and control solution, plus therapeutic shoes or inserts for people with diabetes-related foot problems. Insulin taken by syringe comes under the pharmacy benefit, not here. Blood sugar test strips ↗ | $0Out of network: Original Medicare's cost sharing |
| Renal Dialysis Dialysis for kidney failure at a center or at home, including training for home dialysis and the equipment it needs. Dialysis services and supplies ↗ | $0Out of network: Original Medicare's cost sharing |
| Annual Physical Exam A yearly head-to-toe physical. Medicare covers a yearly wellness visit, which is a planning conversation rather than an examination, so a full physical is an extra the plan adds. Yearly wellness visits ↗ | $0Out of network: Original Medicare's cost sharing |
| Kidney Disease Education Services Classes that teach people with advanced kidney disease how to manage it and choose a treatment. Medicare covers up to six sessions. Kidney disease education ↗ | $0Out of network: Original Medicare's cost sharing |
| Other Medicare-covered Preventive Services Screenings and checks Medicare covers to catch problems early -- glaucoma screening, diabetes self-management training, an EKG after a welcome visit. Medicare covers most preventive services in full. Preventive and screening services ↗ | $0Out of network: Original Medicare's cost sharing |
| Pharmacy benefits (Part D) What the plan charges for prescriptions you fill at a pharmacy. None of these plans includes drug coverage. | |
| Extra benefits Medicare does not cover Dental, vision, hearing and other extras the plan adds on top. | |
| Preventive dental Check-ups, cleanings, X-rays and fluoride. Original Medicare covers none of this, so it is an extra the plan adds, usually with a yearly limit. Dental services ↗ | Not listed |
| Comprehensive Dental Services Fillings, crowns, root canals, extractions, dentures and other repair work. Original Medicare covers none of this; plans that offer it usually pay a share up to a yearly limit. Dental services ↗ | Not listed |
| Eye Exams An eye examination. Medicare covers eye exams only for specific conditions -- glaucoma, diabetic retinopathy, macular degeneration -- so a routine exam for glasses is an extra the plan adds. Eye exams (routine) ↗ | 1 routine eye exam every year · Routine eye exams: $0 |
| Eyewear Glasses and contact lenses. Medicare pays for one pair only after cataract surgery, so everything else is an extra the plan adds, usually as an allowance every year or two. Eyeglasses and contact lenses ↗ | Not covered |
| Prescription Hearing Aids Hearing aids and the fitting appointments for them. Original Medicare covers neither, so this is entirely the plan's own benefit, usually with a limit per ear every few years. Hearing aids ↗ | Not covered |
| Over-The-Counter (OTC) Items An allowance for health items bought without a prescription -- pain relievers, first aid supplies, toothpaste. Original Medicare covers none of this; it is an extra the plan adds, usually as a fixed amount each month or quarter. Compare Medicare Advantage plan types ↗ | Not listed |
| Benefit packages for some members Extra benefits or lower costs the plan offers to some members only, usually those with a particular condition -- CMS calls this uniformity flexibility, and it ran the VBID model on the same idea. Everything else in this grid applies to every member; these do not, so check the plan's rules before counting on one. Compare Medicare Advantage plan types ↗ | None |
| Worldwide Emergency/Urgent Coverage Emergency and urgent care while travelling outside the United States, which Original Medicare almost never covers. Plans that offer it usually cap what they pay in a year. Travel outside the U.S. ↗ | $0 |
| Transportation Services Rides to medical appointments that are not emergencies. Original Medicare does not cover this. What differs between plans is the number of trips, not the price: almost every plan offering it charges nothing a ride, and then allows anywhere from 6 one-way trips a year to unlimited. Rides normally have to be booked days ahead, and some plans need the plan's approval first. Ambulance services ↗ | Not covered |
| Acupuncture Acupuncture. Medicare covers it only for chronic low back pain, up to 12 visits in 90 days; a plan may add more as an extra benefit. Acupuncture ↗ | Not covered |
| Meals Prepared meals delivered, usually for a short time after a hospital stay. Original Medicare does not cover meals. Medicare's plan data records when a plan provides meals, not how many; the plan's Evidence of Coverage gives the number of meals and for how long. Compare Medicare Advantage plan types ↗ | Not covered |
| Other benefit 1 (the plan names it) An extra benefit the plan defines and names itself, filed under a numbered slot. Each plan's cell shows the plan's own name for it; the plan's Evidence of Coverage describes it in full. Compare Medicare Advantage plan types ↗ | Not listed |
| Other benefit 2 (the plan names it) An extra benefit the plan defines and names itself, filed under a numbered slot. Each plan's cell shows the plan's own name for it; the plan's Evidence of Coverage describes it in full. Compare Medicare Advantage plan types ↗ | Not listed |
| Other benefit 3 (the plan names it) An extra benefit the plan defines and names itself, filed under a numbered slot. Each plan's cell shows the plan's own name for it; the plan's Evidence of Coverage describes it in full. Compare Medicare Advantage plan types ↗ | Not listed |
| Other extra benefits Extras beyond Medicare that the plan chooses from a list CMS keeps -- a fitness membership, a nurse line, safety devices in the home, help quitting smoking and others. Each one the plan includes is checked; the plan's Evidence of Coverage says how much of each you get. Compare Medicare Advantage plan types ↗ | Not covered |
| Hearing Exams A hearing examination. Medicare covers one ordered by a doctor to diagnose a medical problem; a routine test for fitting hearing aids is an extra the plan adds. Hearing and balance exams ↗ | Not covered |
| OTC Hearing Aids Hearing aids you can buy without a prescription for mild to moderate hearing loss. Hearing aids ↗ | Not listed |
| Special Supplemental Benefits for the Chronically Ill Non-medical extras -- food, transportation, home repairs and similar -- some plans offer only to members with a qualifying chronic illness. Not everyone in the plan can use them, even where the grid shows a figure. | |
| Who can use these | You must qualify. The plan decides who may use each benefit.Special Supplemental Benefits for the Chronically Ill are offered only to members with a qualifying condition, such as chronic heart failure, cardiovascular disorders, diabetes, cancer or end-stage liver disease. Other conditions may qualify, and a condition may qualify for one of these benefits and not another. Having the condition does not by itself entitle you to the benefit: the plan decides, against its own rules. Ask the plan before you join on the strength of one of these. |
| Food and Produce A benefit for members with a chronic illness that is not primarily health care. A plan may offer it only to members who have a qualifying condition, a high risk of hospital admission, and who need it -- so it is not available to everyone in the plan. Special Needs Plans ↗ | Not listed |
| Meals (beyond limited basis) A benefit for members with a chronic illness that is not primarily health care. A plan may offer it only to members who have a qualifying condition, a high risk of hospital admission, and who need it -- so it is not available to everyone in the plan. Special Needs Plans ↗ | Not listed |
| Pest Control A benefit for members with a chronic illness that is not primarily health care. A plan may offer it only to members who have a qualifying condition, a high risk of hospital admission, and who need it -- so it is not available to everyone in the plan. Special Needs Plans ↗ | Not listed |
| Transportation for Non-Medical Needs A benefit for members with a chronic illness that is not primarily health care. A plan may offer it only to members who have a qualifying condition, a high risk of hospital admission, and who need it -- so it is not available to everyone in the plan. Special Needs Plans ↗ | Not listed |
| Indoor Air Quality Equipment and Services A benefit for members with a chronic illness that is not primarily health care. A plan may offer it only to members who have a qualifying condition, a high risk of hospital admission, and who need it -- so it is not available to everyone in the plan. Special Needs Plans ↗ | Not listed |
| Social Needs Benefit A benefit for members with a chronic illness that is not primarily health care. A plan may offer it only to members who have a qualifying condition, a high risk of hospital admission, and who need it -- so it is not available to everyone in the plan. Special Needs Plans ↗ | Not listed |
| Complementary Therapies A benefit for members with a chronic illness that is not primarily health care. A plan may offer it only to members who have a qualifying condition, a high risk of hospital admission, and who need it -- so it is not available to everyone in the plan. Special Needs Plans ↗ | Not listed |
| Services Supporting Self-Direction A benefit for members with a chronic illness that is not primarily health care. A plan may offer it only to members who have a qualifying condition, a high risk of hospital admission, and who need it -- so it is not available to everyone in the plan. Special Needs Plans ↗ | Not listed |
| Structural Home Modifications A benefit for members with a chronic illness that is not primarily health care. A plan may offer it only to members who have a qualifying condition, a high risk of hospital admission, and who need it -- so it is not available to everyone in the plan. Special Needs Plans ↗ | Not listed |
| General Supports for Living A benefit for members with a chronic illness that is not primarily health care. A plan may offer it only to members who have a qualifying condition, a high risk of hospital admission, and who need it -- so it is not available to everyone in the plan. Special Needs Plans ↗ | Not listed |
Add your drugs on the plan list to see how this plan covers them. Figures are what the plan filed with Medicare for 2026; check the plan's Evidence of Coverage before you enroll.