Plan Details
Providence Medicare Dual Plus (HMO D-SNP)
Overview
|
Monthly Premium |
$0 |
|
Annual Deductible |
$0 per year |
|
Maximum Out-of-Pocket |
$8,850 In-network |
*These amounts depend on your level of Medicaid eligibility. Providence Medicare Dual Plus (HMO D-SNP) is available to you if you have Medicare Part A and B, you have full Oregon Health Plan (OHP) Medicaid benefits, and you live in Clackamas, Multnomah, or Washington County. You must continue to pay your Medicare Part B premium. The Part B premium is covered for full dual enrollees who are eligible for Providence Medicare Dual Plus (HMO D-SNP). Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
Important information about this plan
This plan is available in Clackamas, Multnomah, and Washington Counties in Oregon.
Does not include any Part B premium you may have to pay. You must continue to pay your Medicare Part B premium.
- Multi-language Interpreter Services (PDF)
We have free interpreter services to answer any questions you may have about our health or drug plan. - Find out if you qualify for Extra Help with your premiums
- Medical appeals, determination, and grievance processes
For more information about Providence Medicare Advantage Plans, please contact the sales team.
This information is available in a different format, including audio CDs. If you need plan information in another format, please call Customer Service at 503-574-8000 or 1-800-603-2340 (TTY: 711). Service is available between 8 a.m. and 8 p.m. (Pacific Time), seven days a week.
Important note about these benefits
Providence Medicare Dual Plus (HMO D-SNP) is available to you if you have Medicare Part A and B, you have full Oregon Health Plan (OHP) Medicaid benefits, and you live in Clackamas, Multnomah, or Washington County. You must continue to pay your Medicare Part B premium. The Part B premium is covered for full dual enrollees who are eligible for Providence Medicare Dual Plus (HMO D-SNP). Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
Benefit Summary
-
Benefits
Dual Plus (HMO D-SNP) Medicaid OHP Inpatient Hospital Coverage1
$0 or $1,632 deductible for each benefit period
$0 copayment for days 1-60
$0 or $408 copayment each day for days 61-90
$0 copayment for each lifetime reserve day 91 and beyond$0 copay for Medicaid-covered services Outpatient Hospital Coverage1 0% or 20% of the total cost $0 copay for Medicaid-covered services Ambulatory Surgery Center1 0% or 20% of the total cost $0 copay for Medicaid-covered services Primary Care Provider visit 0% or 20% of the total cost $0 copay for Medicaid-covered services Specialist visit 0% or 20% of the total cost $0 copay for Medicaid-covered services Preventive Care You pay nothing $0 copay for Medicaid-covered services Emergency Care 0% or 20% of the total cost, up to $100 $0 copay for Medicaid-covered services Urgently Needed Services 0% or 20% of the total cost, up to $55 $0 copay for Medicaid-covered services -
Diagnostic Services + Labs & Imaging1
Dual Plus (HMO D-SNP) Medicaid OHP Diagnostic radiology services (e.g. MRI, ultrasounds, CT Scans) 0% or 20% of the total cost $0 copay for Medicaid-covered services Therapeutic radiology services 0% or 20% of the total cost $0 copay for Medicaid-covered services Outpatient x-rays 0% or 20% of the total cost $0 copay for Medicaid-covered services Diagnostic test and procedures 0% or 20% of the total cost $0 copay for Medicaid-covered services Lab services $0 copay $0 copay for Medicaid-covered services -
Hearing Services
Dual Plus (HMO D-SNP) Medicaid OHP Medicare-covered 0% or 20% of the total cost $0 copay for Medicaid-covered services -
Dental Services
Dual Plus (HMO D-SNP) Medicaid OHP Medicare-covered 0% or 20% of the total cost $0 copay for Medicaid-covered services Flex Dental Card $1,700 allowance per calendar year for any dental services of your choosing $0 copay for Medicaid-covered services -
Vision Services
Dual Plus (HMO D-SNP) Medicaid OHP Medicare-covered 0% or 20% of the total cost per exam
0% or 20% of the total cost for glaucoma screening$0 copayment for Medicaid-covered services; once every 24 months for adults age 21 or older Routine exam There is no coinsurance or copayment for one routine vision exam (including refraction) per calendar year $0 copayment for Medicaid-covered services; once every 24 months for adults age 21 or older Medicare-Covered Eyewear 0% or 20% of the total cost for one pair of Medicare-covered eyeglasses or contact lenses after each cataract surgery $0 copayment for Medicaid-covered services; only for specific medical conditions Routine eyeglasses or contact lenses Allowance of up to $250 per calendar year for any combination of routine prescription eyewear $0 copayment for Medicaid-covered services; only for specific medical conditions -
Mental Health Services1
Dual Plus (HMO D-SNP) Medicaid OHP Inpatient visit
$0 or $1,632 deductible for each benefit period
$0 copayment for days 1-60
$0 or $408 copayment each day for days 61-90
$0 or $816 copayment per each "lifetime reserve day" for days 91-190
You pay for all costs beyond lifetime reserve days$0 copay for Medicaid-covered services Outpatient individual and group therapy visit 0% or 20% of the total cost $0 copay for Medicaid-covered services -
Skilled Nursing Facility1
Dual Plus (HMO D-SNP) Medicaid OHP Skilled Nursing Facility
$0 copayment for days 1-20
$204 copayment each day for days 21-100$0 copay for Medicaid-covered services. Medicaid covers up to 20 days in a SNF. -
Physical Therapy1
Dual Plus (HMO D-SNP) Medicaid OHP Physical Therapy 0% or 20% of the total cost $0 copay for Medicaid-covered services -
Ambulance1
Dual Plus (HMO D-SNP) Medicaid OHP Ambulance 0% or 20% of the total cost $0 copay for Medicaid-covered services -
Transportation
Dual Plus (HMO D-SNP) Medicaid OHP Transportation: (This plan includes non-medical transportation) $0 copay for 36 one-way trips (max of 25 miles each way) $0 copay for Medicaid-covered services; non-emergency medical transportation to covered appointments -
Medicare Part B Drugs1
Dual Plus (HMO D-SNP) Medicaid OHP Medicare Part B Drugs 0% or 20% of the total cost
(Insulin cost share up to $35 per month)$0 copay for Medicaid-covered services -
Meal Delivery Program
Dual Plus (HMO D-SNP) Medicaid OHP Meal Delivery Program
(post-discharge only)$0 copay for 2 meals per day for 28 days, following a qualifying inpatient hospitalization Not covered -
Flex Card
Dual Plus (HMO D-SNP) Medicaid OHP Over-the-Counter Items
Food and Produce$400 allowance every three months (retail card, catalog, online, mail, and telephonic ordering). You can also use your card to buy eligible healthy food items like produce, dairy products, meats and more.
Unspent dollars will rollover from quarter to quarter, then expire at the end of the 2024 calendar year.Not covered -
Personal Emergency Response System
Dual Plus (HMO D-SNP) Medicaid OHP Personal Emergency Response System (PERS) $0 copay Not covered -
Wellness Program
Dual Plus (HMO D-SNP) Medicaid OHP Wellness Program $0 copay for monthly gym membership with participating fitness clubs Not covered
Prescription Drugs
-
Prescription Drug Deductible
Yearly Deductible
Because there is no deductible for the plan, this payment stage does not apply to you. If you receive “Extra Help” to pay your prescription drugs, this payment stage does not apply to you.
Initial Coverage
Because there is no Initial Coverage Limit for this plan, this stage does not apply to you.
-
For Generic Drugs
You Pay:
(including brand drugs treated as generic)$0 copay -
For All Other Drugs
You Pay:
(You may get your drugs at network retail pharmacies and mail order pharmacies)
$0 copay If you reside in a long-term care facility, you pay the same as at a standard retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy.
You may get drugs from a standard in-network pharmacy, but may pay more than you pay at a preferred in-network pharmacy. -
Coverage Gap
Because there is no coverage gap for this plan, this payment stage does not apply to you.
-
Catastrophic Coverage
If it happens, we've got you covered.
This payment stage does not apply to you.
-
Participating Pharmacies
With over a million nationwide, we've got a pharmacy that's close to your home.
Explore our provider and pharmacy directory to search for a participating in-network pharmacy near you. To learn more about our formularies or more about our prescription drug coverage click here.
Important Message About What You Pay for Insulin - You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on.
We want you to get the most for your money. Whether your goals include better health and fitness or you just need a little extra assistance, our Medicare Advantage Plans include all these added features:
Medicare extras
-
Health and wellness classes
You deserve to live your best life. We offer a host of classes that will broaden and enhance your horizons on your road to True Health.
Learn more -
Health Coaching
It’s time to team up. Whether you'd like to increase your activity level, reduce stress, improve your eating habits, lose weight, quit tobacco or just feel better every day, a Providence health coach can help. We’re here to remove barriers, support your efforts, motivate you when you need a nudge and be a resource on your journey to a healthier, happier you.
Learn more -
OnePass™
Finding a fitness routine that meets your needs just got easier with your new fitness program through One Pass™. Explore over 26,000 gyms and boutique fitness studios with the ability to change locations anytime. You also have access to live virtual classes and social activities within local communities.
Learn more
Care options
-
Nurse Advice Line
Access to care 24/7.
Health issues don’t fit neatly into a 9 to 5 schedule — and neither should your access to health information. Providence Medicare Advantage Plans members can call Nurse Advice Line around the clock to ask questions about their health.
Learn more -
ExpressCare Virtual – Free*
Getting the care you need, when you need it.
Talk with a provider from anywhere using your tablet, smartphone, or computer. This is a great option for prescriptions and treatment that doesn’t require hands on care. Available nationwide.
Learn more
Not available in California. -
ExpressCare Clinics – Free*
Same day in-person treatment.
When you need to see someone and your regular care provider is not available. With many convenient locations (some in your local Walgreens), it’s easy to find a clinic near you.
Learn more
Not available in California.*ExpressCare Clinic visits are free with most Providence health plans. Ancillary services, such as laboratory tests, may apply additional cost-shares.
-
Primary Care – $
Your primary healthcare partner.
Primary care providers develop a relationship with you and know your health history. Visit them for check-ups, managing chronic conditions, and specialist referrals.
Learn more -
Urgent Care – Free
When you need help right away.
Urgent care is where you turn when you know you need help and can’t wait for an appointment. This is best for minor injuries, cuts, burns, pains, and sprains.
Learn more -
Emergency Care – $$$$
When you think you may be in danger.
Use emergency care for suspected heart attack, stroke, severe abdominal pain, poisoning, choking, loss of consciousness, and uncontrolled bleeding.
Learn moreIf you ever think your life or well-being could be in serious danger, call 911 immediately.