| Dual Plus (HMO D-SNP) | Medicaid OHP | |
|---|---|---|
| Inpatient Hospital Coverage1 | $0 copay | $0 copay for Medicaid-covered services |
| Outpatient Hospital Coverage1 | $0 copay | $0 copay for Medicaid-covered services |
| Ambulatory Surgery Center1 | $0 copay | $0 copay for Medicaid-covered services |
| Primary Care Provider visit | $0 copay | $0 copay for Medicaid-covered services |
| Specialist visit | $0 copay | $0 copay for Medicaid-covered services |
| Preventive Care | $0 copay | $0 copay for Medicaid-covered services |
| Emergency Care | $0 copay | $0 copay for Medicaid-covered services |
| Urgently Needed Services | $0 copay | $0 copay for Medicaid-covered services |
Plan Details
Providence Medicare Dual Plus (HMO D-SNP)
Overview
|
Monthly Premium |
$0 |
|
Annual Deductible |
$0 per year |
|
Maximum Out-of-Pocket |
$9,350 In-network |
Additional Benefits
$1,900 Flex Dental Card
$150 every three months for OTC and groceries, plus an additional $250 every three months for groceries if you qualify*
$0 eye exam and $250 for glasses
36 one-way rides for non-medical transportation
$0 gym membership
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.
*This benefit is part of a special supplemental program for the chronically ill. Members with diabetes mellitus, chronic and disabling mental health conditions, cardiovascular disorders, chronic lung disorders, neurologic disorders, and other eligible conditions not listed may qualify to receive this benefit. Eligibility for this benefit cannot be guaranteed based solely on your condition. All applicable eligibility requirements must be met before the benefit is provided. For more details, please contact us at 1-833-949-0263 (TTY: 711), 8 a.m. to 5 p.m. (Pacific Time) Monday - Friday.
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
-
Diagnostic Services + Labs & Imaging1
Dual Plus (HMO D-SNP) Medicaid OHP Diagnostic radiology services (e.g. MRI, ultrasounds, CT Scans) $0 copay $0 copay for Medicaid-covered services Therapeutic radiology services $0 copay $0 copay for Medicaid-covered services Outpatient x-rays $0 copay $0 copay for Medicaid-covered services Diagnostic test and procedures $0 copay $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 copay $0 copay for Medicaid-covered services -
Dental Services
Dual Plus (HMO D-SNP) Medicaid OHP Medicare-covered $0 copay $0 copay for Medicaid-covered services Flex Dental Card $1,900 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 copay $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 copay $0 copay for Medicaid-covered services -
Skilled Nursing Facility1
Dual Plus (HMO D-SNP) Medicaid OHP Skilled Nursing Facility $0 copay $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 copay $0 copay for Medicaid-covered services -
Ambulance1
Dual Plus (HMO D-SNP) Medicaid OHP Ambulance $0 copay $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 copay $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$150 every three months for OTC and groceries
*Additional $250 every three months for groceries if you qualify
Use your card to buy eligible healthy food items and over-the-counter items. (Retail card, catalog, online ordering, and telephonic ordering.)
Unspent dollars will rollover from quarter to quarter then expire on December 31, 2025 at 11:59 p.m.
*This benefit is part of a special supplemental program for the chronically ill. Members with diabetes mellitus, chronic and disabling mental health conditions, cardiovascular disorders, chronic lung disorders, neurologic disorders, and other eligible conditions not listed may qualify to receive this benefit. Eligibility for this benefit cannot be guaranteed based solely on your condition. All applicable eligibility requirements must be met before the benefit is provided. For more details, please contact us at 1-833-949-0263 (TTY: 711), 8 a.m. to 5 p.m. (Pacific Time) Monday - Friday.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 memberships with participating fitness clubs Not covered
1Services may require prior authorization.
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.
-
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. -
Participating Pharmacies
With thousands of pharmacies 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.
The Formulary and/or pharmacy network may change at any time. You will receive notice when necessary.
Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you. Call Customer Service for more information.
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.
Get the right care, at the right time, at the right place. Learn about the types of medical care available to members.
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24/7 Nurse Advice Line - Free
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 the 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
Not available in California.
*ExpressCare Virtual visits are free with most plans.
Learn more -
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.
Not available in California.
Learn more
*ExpressCare Clinic visits are free with most plans. Ancillary services, such as laboratory tests, may apply additional cost-shares.
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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 - $$
When you need help right away.
Urgent care is where you turn when you know you need help and can’t wait for an appointment. This is best for minor injuries, cuts, burns, pains, and sprains.
Learn more -
Emergency Care - $$$$
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 more
If you ever think your life or well-being could be in serious danger, call 911 immediately.
Page current as of: 10/1/2024