SummaCare is one of Ohio’s oldest and most respected regional health insurers. Based in Akron, this carrier has provided quality medical benefits for more than two decades to consumers in the Northern part of the state. More than 60 hospitals and 10,000 additional physicians, specialists, and medical providers help shape the Network for local residents in a 20-county area. Private individual coverage (Under age 65) is offered in Portage, Medina, Stark, and Summit counties.
We provide the lowest available Summacare health plan prices and make it easy for you to enroll in an individual or family policy. After the official Open Enrollment period expires, a special exception is required to purchase Marketplace benefits. For example, if you lose qualified coverage from an employer, or move to a different service area, a qualifying life event will cause an “SEP” exemption to be granted. Lifetime benefits are unlimited, and federal subsidies are offered to reduce the cost of coverage.
Senior Medigap coverage is offered to Medicare-eligible applicants. SummaCare Medicare plans have earned a Four-Star rating from CMS (Centers For Medicare and Medicaid Services). Member experience, service, complaints, reviews, and pricing accuracy are considered. The National Committee for Quality Assurance has also awarded a “commendable” rating for quality and service.
Prices are typically very competitive compared to other larger companies, and service to patients and customers is well-documented. Ethics and compliance are taken seriously, and are rigorously enforced. These rules and guidelines apply not just to employees, but also physicians, providers, hospitals and affiliated vendors. A partial list of SummaCare SCSelect participating network hospitals is shown below:
Akron Children’s
Alliance Community
Aultman
Bellevue
Bucyrus Community
Cleveland Clinic Mercy
Firelands Regional
Fisher-Titus Medical Center
Lake Health
Magruder
Mercy Allen
Mercy Health – Lorain
Mercy Health – Youngstown
Mercy Regional Medical Center
Mercy-Willard
MetroHealth Medical Center
Parma Medical Center
Pomerene
Promedica Memorial
Robinson Memorial
Salem Community
St. Vincent Charity Medical Center
Southwest General Health Center
Summa Health Akron
Summa Health Barberton
Trumbull Memorial
Union Hospital
University Hospitals
Western Reserve
Wooster Community
Under Age 65 Plans
SummaCare actively participates in the Ohio Health Marketplace. Exchange plans are offered to individuals and families. Listed below are the available plans offered in each Metal tier. Policies are not offered in all counties. NOTE: Catastrophic plans are only offered to applicants under age 30, or any person that can prove “financial hardship.” However, it is possible that in 2025, these types of policies may be available to all applicants, regardless of their age. Travel assistance and adult vision exam benefits can be added to plans.
Catastrophic
Value With Three Free PCP Visits – Three free primary-care physician (pcp) visits are provided with no copay, coinsurance, or deductible. Specialist visits, however, must meet deductible. Plan deductible is $9,450 and maximum out-of-pocket expenses are $9,450 with 0% coinsurance. No charge for children’s glasses and eye exam.
Bronze
Bronze 8000 – $8,000 deductible with $9,450 maximum out-of-pocket expenses and 50% coinsurance.
Standard Bronze – $50 and $100 office visit copays. $75 Urgent Care copay. $7,500 deductible with $9,400 maximum out-of-pocket expenses and 50% coinsurance. Generic and preferred non-generic drugs are subject to $10 and $20 copays ($25 and $50 copays for 90-day mail order).
Bronze 9100 With 3 Free PCP Visits – $0 copay for first three pcp office visits and then $30 copay. $9,100 deductible with $9,100 maximum out-of-pocket expenses and 0% coinsurance. $75 Urgent Care copay.
Silver
Silver 5000 40 With 3 Free PCP Visits -$25 copay for pcp visits ($0 copay for first three visits and specialist visits are subject to deductible). $5,000 deductible with $8,500 maximum out-of-pocket expenses and 40% coinsurance. Preferred generic and preferred non-generic drugs are subject to $10 and $20 copays ($25 and $50 copays for 90-day mail order).
Silver 5000 With 3 Free PCP Visits -$10 copay for pcp visits ($0 copay for first three visits and specialist visits are subject to $50 copay). $5,000 deductible with $9,100 maximum out-of-pocket expenses and 30% coinsurance. Preferred generic and preferred non-generic drugs are subject to $15 and $25 copays ($30 and $50 copays for 90-day mail order). Preferred brand drug copays are $50 and $125. $75 Urgent Care copay.
Silver 6000 With 3 Free PCP Visits -$20 pcp office visit copay ($0 copay for first three PCP visits). $6,000 deductible with $7,600 maximum out-of-pocket expenses and 40% coinsurance. Preferred generic and preferred non-generic drugs are subject to $10 and $15 copays ($20 and $30 copays for 90-day mail order).
Standard Silver -$40 and $80 office visit copays. $5,800 deductible with $8,900 maximum out-of-pocket expenses and 40% coinsurance. $60 Urgent Care copay. Generic, preferred brand and non-preferred brand drugs are subject to $20, $40, and $80 copays ($40, $100, and $200 for 90-day mail order).
Silver 6000 -$20 pcp office visit copay. $6,000 deductible with $8,700 maximum out-of-pocket expenses and 40% coinsurance. Preferred generic and generic drugs are subject to $10 and $15 copays ($30 and $45 mail order).
Silver 3500 With 3 Free PCP Visits -$10 copay for pcp visits ($0 copay for first three visits and specialist visits are subject to $60 copay). $3,500 deductible with $9,100 maximum out-of-pocket expenses and 30% coinsurance. Preferred generic and non-preferred generic drugs are subject to $15 and $25 copays ($30 and $50 copays for 90-day mail order). Preferred brand drug copays are $50 and $125. $75 Urgent Care copay.
Gold
Gold 2000 -$0 copay for first three pcp office visits and then $15. $50 copay for specialist visits. $2,000 deductible with $9,100 maximum out-of-pocket expenses and 20% coinsurance. Preferred generic and generic drugs are subject to $15 and $25 copays ($45 and $75 mail order). The preferred brand drug copay is $50 ($150 mail order). The Urgent Care copay is $75. Imaging and diagnostic tests are subject to deductible and coinsurance.
Standard Gold -$30 and $60 office visit copays. $2,000 deductible with $8,700 maximum out-of-pocket expenses and 25% coinsurance. Preferred generic and generic drugs are subject to $15 copays ($45 mail order). The preferred brand and non-preferred brand drug copays are $30 and $60 ($90 and $180 mail order). The Urgent Care copay is $45. Imaging and diagnostic tests are subject to deductible and coinsurance.
Current Prices
The monthly rates illustrated below are shown for several different scenarios. Prices vary, depending on the ages, income, and counties used.
Family of three (40-year-old parents with one child) residing in Summit County with household income of $62,000.
$23 – Bronze 8000
$34 – Standard Bronze
$81 – Bronze 9100
$173 – Bronze 7000 HSA
$249 – Silver 6000
40-year-old residing in Summit County with household income of $34,000.
$30 – Bronze 8000
$35 – Standard Bronze
$53 – Bronze 9100
$88 – Bronze 7000 HSA
$117 – Silver 6000
30-year-old residing in Medina County with household income of $32,000.
$17 – Bronze 8000
$21 – Standard Bronze
$37 – Bronze 9100
$69 – Bronze 7000 HSA
$95 – Silver 6000-73
Family of two (30-year-old married couple) residing in Medina County with household income of $48,000
$33 – Bronze 8000
$40 – Standard Bronze
$72 – Bronze 9100
$135 – Bronze 7000 HSA
$187 – Silver 6000
Family of two (50-year-old married couple) residing in Portage County with household income of $54,000.
$29 – Bronze 8000
$41 – Standard Bronze
$91 – Bronze 9100
$191 – Bronze 7000 HSA
$273 – Silver 6000
Family of four (50-year-old married couple with two children) residing in Portage County with household income of $85,000
$84 – Bronze 8000
$102 – Standard Bronze
$175 – Bronze 9100
$318 – Bronze 7000 HSA
$437 – Silver 6000
Family of two (55-year-old married couple) residing in Stark County with household income of $100,000.
$471 – Bronze 8000
$475 – Standard Bronze
$558 – Bronze 9100
$695 – Bronze 7000 HSA
$809 – Silver 6000
Family of two (62-year-old married couple) residing in Stark County with household income of $67,000.
$121 – Bronze 8000
$143 – Standard Bronze
$233 – Bronze 9100
$410 – Bronze 7000 HSA
$557 – Silver 6000
Prescription Benefits
Most policies have four available tiers of benefits. Tier 1 is the least expensive option and covers most generic and some over-the-counter prescriptions with a copay. Tier 2 includes preferred brand and the most expensive generics. Tier 3 includes non-preferred brand drugs subject to a copay. Tier 4 is reserved for the most expensive drugs and a copay and/or a deductible may apply. Specialty drugs are offered, but are rarely utilized.
A “Formulary” prescription drug list is available. These medications are typically covered, assuming they are medically necessary during approved treatment. Although the list can change, once you have begun receiving a listed drug, it will continue to be covered throughout the calendar year. The entire list can be found here and is offered by both alphabetical and specific medical condition. Note: Some prescriptions may require prior approved authorization. Quantity limits may also apply and utilization management programs may restrict certain drugs.
Step therapy may be utilized if your condition requires costly prescriptions. This process may involve utilizing less expensive (and safe) drugs at the outset of treatment, and advancing (upon physician’s request) to using more expensive, and possibly riskier drugs. Often, successful prior results from specific drugs, will be a reason for quick approval of the identical drug for a similar condition or illness. SummaCare health insurance reviews are available upon request.
Senior Medigap Coverage
Medicare Advantage Options
Previously, there was a name-change on the Medicare Advantage plans. The “Silver” and “Gold” policies were eliminated.” The principal reason was to eliminate confusion some consumers were having since “Silver” and “Gold” are two of the Metal plans available on Exchanges for persons under age 65. Four plans are offered (see below), although policy availability will vary, depending upon your county of residence.
Rates and benefits shown below are for the following counties: Carroll, Columbiana, Cuyahoga, Geauga, Lake, Lorain, Mahoning, Medina, Portage, Stark, Summit, Trumbull, and Wayne. Other counties typically offer 1-3 plans.
Preventative dental and vision benefits are included on all Advantage plans. Delta Dental Of Ohio provides preventative services, which consist of a $0 office visit copay and a $500 yearly maximum benefit. An annual exam, routine cleaning, and bitewing x-ray are included. A Delta Dental directory of providers is available upon request
Extensive health and wellness benefits are also provided along with the mandated required coverage. Benefits include $0 premium for most MA plans, $0 copays for pcp visits and generic drugs, one-one-one service with health coaching, QuitCare for smoking cessation, and preventative dental coverage.
A free membership through SilverSneakers is included on each plan, and Teledoc (Telehealth medical services) allow you to visit with a licensed physician online with the provided app. Additional online tools provide “QuitCare,” a smoking cessation program, along with many additional services. Vision hardware and hearing aid benefits are also included. A $795 copay applies to the hearing aids, and Homelink must provide the products.
Additional benefits include $0 primary care physician (PCP) copays, $0 copays for online or mobile Teladoc visits, home safety devices, coverage for emergency travel, and transportation services, and a large provider network. Each year, new benefits are introduced. Also, after a stay in the hospital, Diabetics with a high A1C level may receive meals delivered to their residence at no charge.
A quarterly allowance is provided for OTC (Over-The-Counter) health-related items. Popular items include: nasal decongestant spray, allergy tablets, Alka-Seltzer, antacid tablets, TUMS, enema, Ex-Lax, Milk Of Magnesia, Pepto-Bismol, athlete’s foot cream, anti-fungal cream, bath mat, night light, raised toilet seat, cough drops, throat lozenges, personal steam inhaler, nasal rinse kit, denture brush, electric tooth brush, diabetic socks, bathroom scale, blood pressure monitor, thermometer, artificial tears drops, cotton swabs, ear wax removal system, eye drops, burn relief spray, cotton balls, first aid kit, insect repellent spray, petroleum jelly, bunion guard, medicated foot powder, hammer toe crest, bunion guard, medicated foot powder, CPAP pillow, humidifier, kitchen scale, pill case, bladder control pad, Aspercreme, heating bag, ice pad, Aleve, Acetaminophen, aspirin, Ibuprofen, lice treatment, hand sanitizer, nicotine gum, nicotine patches, arthritis gloves, arthritis knee sleeve, carpal tunnel brace, compression socks, wrist splint, knee support, vitamins, and wart remover.
All of SummaCare’s plans (Medicare) are rated 4.5 Star from CMS (Centers for Medicare and Medicaid Services). 5 Stars is the highest available rating. Ratings are based on several factors, including responsiveness to member requests, satisfaction of members, and effectiveness of preventing and detecting illness. Rates, copays, and out-of-pocket expenses can vary by county, and not all plans are offered in each county.
Medicare Amber – HMO option with $0 deductible and $0 premium. Non-network benefits not available (unless emergency or Urgent-Care). Maximum out-of-pocket expenses are $3,450 with an inpatient hospital copay is $250 for the first 5 days. The outpatient hospital copay is $250. The ambulatory surgical center and observational services copays are also $250. The primary care physician copay is $0 and the specialist office visit copay is $30. The Urgent Care and ER copays are $40 and $120.
The diagnostic radiology service copay (MRIs) copay is $125. Other copays are $50 for diagnostic tests and procedures, $5 for lab services, $50 for outpatient x-rays, and 20% for radiation treatment. Diagnostic hearing exams are covered with a $0-$20 copay. Additional exams are also subject to a $20 copay. One hearing aid is covered every year years ($395 Tier 1 and $695 Tier 2).
Preventative dental benefits covers two exams each year, two cleanings, and a cleaning and x-ray with a $0 copay through the Delta Dental Of Ohio MA PPO network. A maximum of $2,000 of coverage is included. A diagnostic and routine eye exam is also covered. Medicare-covered lenses and frames up to the approved amount are included. An annual glaucoma screening is included in benefits. A $300 annual allowance for prescription eyewear is included. If cataract surgery is performed, glasses or contacts are provided with a $0 copay.
Mental health benefits have a $250 per day copay for four days. Inpatient services in a psychiatric hospital have a 190-day limit. Outpatient individual and group therapy visit copays are $30. Speech and language, physical, and occupational therapy visit copays are $25 and $30. Ground and air ambulance copays are $200. Six one-way non-emergency trips are also fully-covered. The skilled nursing facility copay is $0 for days 1-20, and $196 for days 21-100. Six annual acupuncture or therapeutic visits are allowed with a $20 copay (chronic back pain included).
Telehealth services (including primary care, substance abuse, and behavioral health) have a $0 copay ($20 for a specialist). 90 hours of “Papa Pals” benefits are included for transportation, companionship, technology assistance, and other Senior services. A visitor/travel benefits applies to covered services for persons that visit Arizona, Florida, and Texas for six consecutive months. “Assist America” provides emergency travel benefits without a deductible, copay, or coinsurance. Fourteen meals are provided (two per day for a week) after a discharge from a hospital for diabetics with high A1C levels. Home safety devices may be provided for certain conditions ($150 annual limit), including knee and hip replacement. HOMELINK is the SummaCare vendor.
Chiropractic and foot care services are covered with $20 and $30 copays. Outpatient substance abuse group and individual visits are subject to a $30 copays (individual and group). Opioid treatment services are fully covered. A $25 or $100 per quarter allowance covers over-the-counter non-prescription items, including cough and cold medicines, first-aid supplies, vitamins, and pain relievers. A $40 copay applies to “partial hospitalization,” a psychiatric treatment program provided as an outpatient benefit.
Additional benefits include SilverSneakers Fitness Program, QuitCare, 24-Hour Nurse Line, and Health Manager (WebMD). BrainHQ also helps customers think and focus more effectively. This online memory fitness program can be utilized on tablets, smartphones, or computers.
Part D prescription drug benefits are not included. An optional supplementary dental plan is available for an additional $35 per month with a $2,000 maximum annual benefit. Basic and major services are covered at 50%.
Medicare Topaz – HMO option with $0 deductible and $0 premium. Non-network benefits not available (unless emergency or Urgent-Care). Maximum out-of-pocket expenses are $3,700 with an inpatient hospital copay is $340 for the first 6 days. The outpatient hospital copay is $310. The primary care physician copay is $0 and the specialist office visit copay is $35. The Urgent Care and ER copays are $30 and $110.
The diagnostic radiology service copay (MRIs) copay is $175. Other copays are $0 and $125 for diagnostic tests and procedures, $0-$10 for lab services, $75-$130 for outpatient x-rays, and 20% for radiation treatment. Diagnostic hearing exams are covered with a $0-$20 copay. Additional exams are also subject to a $0 copay. One hearing aid (per ear) is covered annually, subject to a $395 or $695 (Levels 1 and 2) maximum benefit.
Preventative dental benefits cover an annual exam, cleaning and x-ray with a $0 copay through the Delta Dental Of Ohio MA PPO network. A maximum of $2,000 of coverage is included. A diagnostic and routine eye exam is also covered. Medicare-covered lenses and frames up to the approved amount are included. An annual glaucoma screening is included in benefits. A $230 annual allowance for prescription eyewear is included. If cataract surgery is performed, glasses or contacts are provided with a $0 copay.
Mental health benefits have a $340 per day copay for five days. Inpatient services in a psychiatric hospital have a 190-day limit. Outpatient individual and group therapy visit copays are $35. Speech and language, physical, and occupational therapy visit copays are $35. Ground and air ambulance copays are $290. The skilled nursing facility copay is $0 for days 1-20, and $196 for days 21-100. Six annual acupuncture or therapeutic visits are allowed with a $20 copay (chronic back pain included).
Telehealth services have a $0 copay ($20 for a specialist). 60 hours of “Papa Pals” benefits are included for transportation, companionship, technology assistance, and other Senior services. A visitor/travel benefits applies to covered services for persons that visit Arizona, Florida, and Texas for six consecutive months. “Assist America” provides emergency travel benefits without a deductible, copay, or coinsurance. Fourteen meals are provided (two per day for a week) after a discharge from a hospital for diabetics with high A1C levels. Home safety devices may be provided for certain conditions ($150 annual limit), including knee and hip replacement.
Chiropractic and foot care services are covered with $20 and $35 copays. Outpatient substance abuse group and individual visits are subject to a $35 copays (individual and group). Opioid treatment services are fully covered. A $75 per quarter allowance covers over-the-counter non-prescription items, including cough and cold medicines, first-aid supplies, vitamins, and pain relievers. Additional benefits include SilverSneakers Fitness Program, QuitCare, 24-Hour Nurse Line, and Health Manager (WebMD).
No deductible applies to prescription drugs. 30-day copays are $0 (Tier 1), $9 (Tier 2), $46 (Tier 3), $100 (Tier 4), and 33% (Tier 5). Three month mail-order copays are $0 (Tier 1), $20 (Tier 2), $110 (Tier 3), $300 (Tier 4), and N/A (Tier 5).
Medicare Ruby – HMO option with $0 deductible and $0 premium. Non-network benefits not available (unless emergency or Urgent-Care). Maximum out-of-pocket expenses are $3,600 with an inpatient hospital copay is $270 for the first 6 days. The outpatient hospital copay is $250. The primary care physician copay is $0 and the specialist office visit copay is $40. The Urgent Care and ER copays are $25 and $110.
The diagnostic radiology service copay (MRIs) copay is $150. Other copays are $0 and $125 for diagnostic tests and procedures, $0-$8 for lab services, $0-$110 for outpatient x-rays, and 20% for radiation treatment. Diagnostic hearing exams are covered with a $0-$15 copay. Additional exams are also subject to a $0 copay. One hearing aid is covered every year, subject to a $695 copay (Tier 2) and $395 copay (Tier 1).
Preventative dental benefits cover two yearly exams, cleaning and x-ray with a $0 copay through the Delta Dental Of Ohio MA PPO network. A maximum of $500 of coverage is included. A diagnostic and routine eye exam is also covered. Medicare-covered lenses and frames up to the approved amount are included. An annual glaucoma screening is included in benefits. A $225 annual allowance for prescription eyewear is included. If cataract surgery is performed, glasses or contacts are provided with a $0 copay.
Mental health benefits have a $270 per day copay for five days. Inpatient services in a psychiatric hospital have a 190-day limit. Outpatient individual and group therapy visit copays are $40. Speech and language, physical, and occupational therapy visit copays are $40. Ground and air ambulance copays are $200. The skilled nursing facility copay is $0 for days 1-20, and $196 for days 21-100. Twenty annual acupuncture or therapeutic visits are allowed with a $40 copay (chronic back pain only).
Telehealth services have a $0 copay ($20 for a specialist). 80 hours of “Papa Pals” benefits are included for transportation, companionship, technology assistance, and other Senior services. A visitor/travel benefits applies to covered services for persons that visit Arizona, Florida, and Texas for six consecutive months. “Assist America” provides emergency travel benefits without a deductible, copay, or coinsurance. Fourteen meals are provided (two per day for a week) after a discharge from a hospital for diabetics with high A1C levels. Home safety devices may be provided for certain conditions ($175 annual limit), including knee and hip replacement.
Chiropractic and foot care services are covered with $20 and $40 copays. Outpatient substance abuse group and individual visits are subject to a $40 copays (individual and group). Opioid treatment services are fully covered. A $25 per quarter allowance covers over-the-counter non-prescription items, including cough and cold medicines, first-aid supplies, vitamins, and pain relievers. Additional benefits include SilverSneakers Fitness Program, QuitCare, 24-Hour Nurse Line, and Health Manager (WebMD).
30-day copays are $0 (Tier 1), $8 (Tier 2), $44 (Tier 3), $100 (Tier 4), and 33% (Tier 5). Three month mail-order copays are $0 (Tier 1), $20 (Tier 2), $110 (Tier 3), $300 (Tier 4), and N/A (Tier 5).
An optional supplementary dental plan is available for an additional $28 per month with a $1,500 maximum annual benefit. Basic and major services are covered at 50%.
Medicare Garnet – HMO option with $0 deductible and $29 premium. Non-network benefits not available (unless emergency or Urgent-Care). Maximum out-of-pocket expenses are $3,700 with an inpatient hospital copay is $306 for the first 6 days. The outpatient hospital copay is $275. The primary care physician copay is $0 and the specialist office visit copay is $40. The Urgent Care and ER copays are $30 and $110.
The diagnostic radiology service copay (MRIs) copay is $125. Other copays are $0-$50 for diagnostic tests and procedures, $0-$5 for lab services, $0-$50 for outpatient x-rays, and 20% for radiation treatment. Diagnostic hearing exams are covered with a $0-$15 copay. Additional exams are also subject to a $0 copay. One hearing aid is covered every year, subject to a $695 copay (Tier 2) and $395 copay (Tier 1).
Preventative dental benefits cover two yearly exams, cleaning and x-ray with a $0 copay through the Delta Dental Of Ohio MA PPO network. A maximum of $2,000 of coverage is included. A diagnostic and routine eye exam is also covered. Medicare-covered lenses and frames up to the approved amount are included. An annual glaucoma screening is included in benefits. A $350 annual allowance for prescription eyewear is included. If cataract surgery is performed, glasses or contacts are provided with a $0 copay.
Mental health benefits have a $306 per day copay for five days. Inpatient services in a psychiatric hospital have a 190-day limit. Outpatient individual and group therapy visit copays are $40. Speech and language, physical, and occupational therapy visit copays are $40. Ground and air ambulance copays are $225. The skilled nursing facility copay is $0 for days 1-20, and $196 for days 21-100. Six annual acupuncture or therapeutic visits are allowed with a $10 copay (chronic back pain included).
Telehealth services have a $0 copay ($20 for a specialist). 60 hours of “Papa Pals” benefits are included for transportation, companionship, technology assistance, and other Senior services. A visitor/travel benefits applies to covered services for persons that visit Arizona, Florida, and Texas for six consecutive months. “Assist America” provides emergency travel benefits without a deductible, copay, or coinsurance. Fourteen meals are provided (two per day for a week) after a discharge from a hospital for diabetics with high A1C levels. Home safety devices may be provided for certain conditions ($200 annual limit), including knee and hip replacement.
Chiropractic and foot care services are covered with $20 and $40 copays. Outpatient substance abuse group and individual visits are subject to a $40 copays (individual and group). Opioid treatment services are fully covered. A $100 per quarter allowance covers over-the-counter non-prescription items, including cough and cold medicines, first-aid supplies, vitamins, and pain relievers. Additional benefits include SilverSneakers Fitness Program, QuitCare, 24-Hour Nurse Line, and Health Manager (WebMD).
30-day copays are $0 (Tier 1), $8 (Tier 2), $44 (Tier 3), $100 (Tier 4), and 33% (Tier 5). Three month mail-order copays are $0 (Tier 1), $20 (Tier 2), $110 (Tier 3), $300 (Tier 4), and N/A (Tier 5).
An optional supplementary dental plan is available for an additional $35 per month with a $2,000 maximum annual benefit. Basic and major services are covered at 50%.
Medicare Sapphire – HMO option with $0 deductible and $76 premium. Non-network benefits not available (unless emergency or Urgent-Care). Maximum out-of-pocket expenses are $3,600 with an inpatient hospital copay is $240 for the first 6 days. The outpatient hospital copay is $250. The primary care physician copay is $0 and the specialist office visit copay is $35. The Urgent Care and ER copays are $40 and $90.
The diagnostic radiology service copay (MRIs) copay is $150. Other copays are $0-$99 for diagnostic tests and procedures, $0-$6 for lab services, $0-$99 for outpatient x-rays, and 20% for radiation treatment. Diagnostic hearing exams are covered with a $0-$15 copay. Additional exams are also subject to a $0 copay. One hearing aid is covered every year, subject to a $395 (Tier 1) or $795 (tier 2) copay.
Preventative dental benefits cover two yearly exams, cleaning and x-ray with a $0 copay through the Delta Dental Of Ohio MA PPO network. A maximum of $500 of coverage is included. A diagnostic and routine eye exam is also covered. Medicare-covered lenses and frames up to the approved amount are included. An annual glaucoma screening is included in benefits. A $250 annual allowance for prescription eyewear is included. If cataract surgery is performed, glasses or contacts are provided with a $0 copay.
Mental health benefits have a $240 per day copay for five days. Inpatient services in a psychiatric hospital have a 190-day limit. Outpatient individual and group therapy visit copays are $35. Speech and language, physical, and occupational therapy visit copays are $35. Ground and air ambulance copays are $200. The skilled nursing facility copay is $0 for days 1-20, and $184 for days 21-100. Twenty visits per year ($35 copay) are allowed for chronic lower back pain.
Telehealth services have a $0 copay ($20 for a specialist). 100 hours of “Papa Pals” benefits are included for transportation, companionship, technology assistance, and other Senior services. A visitor/travel benefits applies to covered services for persons that visit Arizona, Florida, and Texas for six consecutive months. “Assist America” provides emergency travel benefits without a deductible, copay, or coinsurance. Fourteen meals are provided (two per day for a week) after a discharge from a hospital for diabetics with high A1C levels. Home safety devices may be provided for certain conditions ($225 annual limit), including knee and hip replacement.
Chiropractic and foot care services are covered with $20 and $35 copays. Outpatient substance abuse group and individual visits are subject to a $35 copays (individual and group). Opioid treatment services are fully covered. A $30 per quarter allowance covers over-the-counter non-prescription items, including cough and cold medicines, first-aid supplies, vitamins, and pain relievers. Additional benefits include SilverSneakers Fitness Program, QuitCare, 24-Hour Nurse Line, and Health Manager (WebMD).
30-day copays are $0 (Tier 1), $8 (Tier 2), $44 (Tier 3), $100 (Tier 4), and 33% (Tier 5). Three month mail-order copays are $0 (Tier 1), $20 (Tier 2), $110 (Tier 3), $300 (Tier 4), and N/A (Tier 5).
An optional supplementary dental plan is available for an additional $28 per month with a $1,500 maximum annual benefit. Basic and major services are covered at 50%.
Medicare Emerald – HMO option with $0 deductible and $180 premium. Non-network benefits not available (unless emergency or Urgent-Care). Maximum out-of-pocket expenses are $3,400 with an inpatient hospital copay is $205 for the first 5 days. The outpatient hospital copay is $175. The primary care physician copay is $0 and the specialist office visit copay is $20. The Urgent Care and ER copays are $40 and $90.
The diagnostic radiology service copay (MRIs) copay is $100. Other copays are $0-$75 for diagnostic tests and procedures, $0-$4 for lab services, $0-$75 for outpatient x-rays, and 20% for radiation treatment. Diagnostic hearing exams are covered with a $0 copay. Additional exams are also subject to a $0 copay. One hearing aid is covered every year, subject to a $395 (Tier 1) or $795 (tier 2) copay.
Preventative dental benefits cover two yearly exams, cleaning and x-ray with a $0 copay through the Delta Dental Of Ohio MA PPO network. A maximum of $500 of coverage is included. A diagnostic and routine eye exam is also covered. Medicare-covered lenses and frames up to the approved amount are included. An annual glaucoma screening is included in benefits. A $275 annual allowance for prescription eyewear is included. If cataract surgery is performed, glasses or contacts are provided with a $0 copay.
Mental health benefits have a $205 per day copay for four days. Inpatient services in a psychiatric hospital have a 190-day limit. Outpatient individual and group therapy visit copays are $20. Speech and language, physical, and occupational therapy visit copays are $20. Ground and air ambulance copays are $200. The skilled nursing facility copay is $0 for days 1-20, and $184 for days 21-100. Twenty visits per year ($10 copay) are allowed for chronic lower back pain.
Telehealth services have a $0 copay ($20 for a specialist). 120 hours of “Papa Pals” benefits are included for transportation, companionship, technology assistance, and other Senior services. A visitor/travel benefits applies to covered services for persons that visit Florida for six consecutive months. “Assist America” provides emergency travel benefits without a deductible, copay, or coinsurance. Fourteen meals are provided (two per day for a week) after a discharge from a hospital for diabetics with high A1C levels. Home safety devices may be provided for certain conditions ($250 annual limit), including knee and hip replacement.
Chiropractic and foot care services are covered with $20 copays. Outpatient substance abuse group and individual visits are subject to a $20 copays (individual and group). Opioid treatment services are fully covered. A $40 per quarter allowance covers over-the-counter non-prescription items, including cough and cold medicines, first-aid supplies, vitamins, and pain relievers. Additional benefits include SilverSneakers Fitness Program, QuitCare, 24-Hour Nurse Line, and Health Manager (WebMD).
30-day copays are $0 (Tier 1), $8 (Tier 2), $39 (Tier 3), $95 (Tier 4), and 33% (Tier 5). Three month mail-order copays are $0 (Tier 1), $20 (Tier 2), $97.50 (Tier 3), $285 (Tier 4), and N/A (Tier 5).
An optional supplementary dental plan is available for an additional $28 per month with a $1,500 maximum annual benefit. Basic and major services are covered at 50%.
Current Estimated SummaCare Medicare Advantage Monthly Rates In Selected Counties:
Allen, Hancock, Huron, Lucas, Putnam, Seneca, Wayne, and Fulton Counties
Amber – $0
Jade With Bene-Flex – $19
Ruby – $43
Sapphire – $76
Ashland and Holmes Counties
Amber – $0
Jade With Bene-Flex – $19
Ruby – $43
Sapphire – $76
Carroll,Cuyahoga, Geauga, Lake, Lorain, Mahoniong, Trumbull, and Columbiana Counties
Amber – $0
Topaz – $0
.Jade With Bene-Flex – $19
Ruby – $43
Sapphire – $76
Emerald – $170
Auglaize, Henry, Mercer, Ottawa, Van Wert, and Defiance Counties
Amber – $0
Sapphire – $76
Ashland, Holmes, Tuscarawas, and Ashtabula Counties
Amber – $0
Jade With Bene-Flex – $19
Ruby – $43
Sapphire – $76
Medina, Stark, Summit, Wayne, and Portage Counties
Amber – $0
Topaz – $0
Jade With Bene-Flex – $19
Garnet – $29
Ruby – $43
Sapphire – $76
Emerald – $170
Small Employer Plans (2-50 Employees)
Group coverage at very competitive rates is also available. Listed below are several of the most popular and budget-friendly policy options for both employer and worker. The three available networks (discussed further below) are SCConnect, SCSelect, and SCPremier. “Healthy You” programs that are available, include wellness services, utilization management, case management, disease management, and pregnancy management.
Commercial PPO plans are accredited by NCQA to 2022. Popular plans are listed below:
Bronze 5750 HSA-19 – 20% coinsurance on office visits and $5,750 deductible.
Bronze 6000-19 – $30 and $60 office visit copays and $6,000 deductible.
Silver 3000-19 – $25 and $50 office visit copays and $3,000 deductible.
Silver 4300-19 – $25 and $50 office visit copays and $4,300 deductible.
Silver 5000-19 – $30 and $60 office visit copays and $6,000 deductible.
Gold 2000-19 – $25 and $45 office visit copays and $2,000 deductible.
Gold 3000-19 – $30 and $50 office visit copays and $3,000 deductible.
Three types of company-provided benefits are available.
Fully insured – SummaCare designs the plan and benefits. Provider networks are offered and the ACA tax is paid by the employer.
Self Funded – Employer creates plan design, deductibles, and copays. ACA fees do not apply.
Chamber Of Commerce Plans – 10 plans are offered. Three available networks and no ACA fees.
Small Group Plan Network Options
SCConnect – Specialized network of doctors, specialists, hospitals, and other providers. Participating hospitals include Mercy Medical Center in Canton, Summa Health System, and Akron Children’s Hospital. Offered to businesses in Medina, Portage, Stark, and Summit Counties.
SCPremier – Biggest network with more than 7,000 physicians and facilities, and affiliated services with PHCS/MultiPlan. Covered hospitals include University Hospitals, Cleveland Clinic, and Summa Health System.
SCSelect – Popular PPO network that includes Summa Health System and University Hospitals. It is also affiliated with Ohio Health Choice.
MEWA
Small businesses that are members of the Greater Akron Chamber of Commerce are eligible for a multiple-employer welfare arrangement (MEWA) plan. Companies with 50 or less employees can offer the coverage. Several different options are offered through brokers, and as a self-funded plan, rates may be less expensive than traditional policies, since medical history and gender can be considered.
These types of policies meet the ACA guidelines for self-funded plans. Ancillary benefits, including dental, vision, and life insurance, may be offered. Essential health benefits are also included.15 plans are offered, including 3 HSA-compatible and 12 PPO options. Two separate pharmacy plans are also available from the self-funded plan. Discounted life coverage is also offered.
Health and wellness programs are included with many services and benefits provided to employees. Several of the value-added perks are listed below.
Health Coaching – individual attention to help prevent serious medical issues.
24-Hour Nurse Line – 24/7 free assistance and advice for patients.
WebMD Health Manager – Several web-based applications are offered.
QuitCare – Smoking cessation program.
Vision Discounts – At EyeMed locations.
Gym Membership Discounts – To promote wellness.
Group Ancillary Products
Dental – Guardian Dental features several plans that provide your workers with a different levels of coverage. Basic preventative and cleanings are covered, along with major services. Billing is separate from the primary healthcare policy, and the network is one of the largest in the Buckeye State.
Voluntary Employee – Various benefits are available with easy online enrollment.
Life And Accidental Death – Lincoln Financial provides guarantee-issue life insurance coverage (2-50 employees) without medical underwriting.No separate waiting period is needed.
Vision – Benefits are provided by EyeMed Vision Care, who features a large countrywide network. Standard eye examinations are subject to only a $10 copay (one per year), and up to $160 towards the purchase of frames is available. Several lens and contact options are offered.
Primary Service Area
If you reside in Northern portion of Ohio, SummaCare is a viable healthcare option that is reputable and affordable. We are always happy to help with any information, comparison or the application process for an individual or family.The 20-County primary service area (Group) consists of the following counties:
Ottawa, Sandusky, Erie, Huron, Ashland, Lorain, Medina, Holmes, Summit, Cuyahoga, Lake, Geauga, Ashtabula, Trumball, Portage, Mahoning, Carroll, Stark, Tuscarawas, and Wayne.
NOTE: For treatment in Ohio, but outside of the main provider network, the Ohio Health Choice (OHC) network should be utilized. Treatment out-of-state should utilize First Health Providers. Provider network information, including physician and hospital lookup can be found here.
Participating Vendors
Cognisight – Medicare in-home assessments
CHP (Cooperative Health Partners) – Assistance with ambulance and non-emergency transportation
EMMI – Helps policyholders when scheduling
eviCore – Oncology services assistance
MedImpact – Reminder notifications for prescriptions
Home Access – At-home tests provided
HomeLink – Hearing aids, durable medical equipment, diabetes testing supplies, and home safety devices are available
Papa – “Papa Pals” provides support and companionship for many routine daily tasks
Past Updates:
Catholic Health Partners had previously agreed to purchase a minority ownership in Summa for approximately $250 Million. However, the transaction is on hold until there is a restructure that satisfies Bishop Richard Lennon of the Catholic Diocese of Cleveland.
The main area of concern is the treatment for sterilizations, abortions and contraceptives. However, an auxiliary tax-exempt company will handle the purchase which satisfy all parties.
SummaCare is participating in the Ohio Exchange, which began Open Enrollment on October 1st (You can view rates by requesting a quote on our website). The cheapest plan offered will be the “Individual Value” policy, which is considered a “catastrophic” option. Thus, it will be offered to applicants under age 30 along with other persons who meet specific eligibility guidelines.
Also offered is a $6,350 deductible Bronze policy, $5,000 deductible Silver policy, and $750 Gold policy. We are not aware of any Platinum options offered at this time.
Open Enrollment starts in less than one week and many new options are available for the Ohio Marketplace. Bronze and Silver plans appear to be their most competitive niche when compared to the carriers offering policies in the Northeastern part of the state.
Proposed rate increases for plans were fairly mild. For example, QHP Qualified Individual plans were 6.22%, QHP Individual plans were 4.98%, QHP Small Group was 1.51%, and QHP Qualified Small Group was 4.78%.
