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Essence Advantage (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Essence Advantage (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Essence Advantage (HMO) in 2025, please refer to our full plan details page.
Essence Advantage (HMO) is a HMO plan offered by Lumeris Group Holdings Corporation available for enrollment in 2025 to people living in Little Rock Metropolitan Area. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Essence Advantage (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Essence Advantage (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Essence Advantage (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $295.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3850.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Essence Advantage (HMO) plan has a $295.00 deductible for prescription drugs. After the deductible, you will pay a copay for your prescriptions depending on the drug tier and the pharmacy you use. For example, preferred generic drugs have a $3.00 copay at preferred pharmacies. Once your total drug costs reach $2,000.00, you enter the catastrophic coverage phase where you pay nothing for Part D covered drugs. If you qualify for the low-income subsidy, you will pay $0.00 for your Part D drugs.
Additional Benefits
The Essence Advantage (HMO) plan offers a wide range of benefits with varying costs. Inpatient hospital stays have a copay, but outpatient services, including primary care, have copays that vary by service. Emergency and urgent care services are covered with copays, and ambulance services also have a copay. The plan also covers preventive, hearing, vision, and dental services, each with specific copays or coverage limits. Home health services have no copay. The plan covers home infusion services with a copay for insulin drugs and coinsurance for other drugs. Diagnostic and radiological services are covered with copays or coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services, with a copay of $290 for days 1-5 of Inpatient Hospital-Acute and days 1-7 of Inpatient Hospital Psychiatric, and no copay for days 6-90 and days 8-90 respectively. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a $285 copay, observation services with a $285 copay, ambulatory surgical center (ASC) services with a $245 copay, and outpatient substance abuse services with a copay between $10 and $15 depending on the type of session. Outpatient blood services are also covered.
Partial Hospitalization See details
Essence Advantage (HMO) covers partial hospitalization with a $50 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Essence Advantage (HMO) plan, with a $265 copay for both ground and air ambulance services and no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the Essence Advantage (HMO) plan, with copays of $125, $45, and $125 respectively, and no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Essence Advantage (HMO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $30 copay, physician specialist services with a $30 copay, mental health specialty services with a copay of $15 for individual sessions and $10 for group sessions, physical therapy and speech-language pathology services with a $30 copay, and opioid treatment program services with a minimum copay of $15 and a maximum copay of $15. Routine Chiropractic Care and Podiatry Services are not covered.
Preventive Services See details
The Essence Advantage (HMO) plan covers preventive services, including Medicare-covered services, annual physical exams, and additional preventive services, but requires prior authorization and a doctor referral for the latter. Additional benefits include Fitness Benefit, and Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), which has a copay between $0-$30. The plan does not cover Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services.
Hearing Services See details
Hearing Services include coverage for hearing exams with a $20 copay. Prescription hearing aids are covered up to $1000 every two years, but hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
The Essence Advantage (HMO) plan covers vision services, including eye exams with a $30 copay, and eyewear with a combined maximum benefit of $200 per year. Contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames are covered, with a limit of one pair or set per year, and upgrades are not covered.
Dental Services See details
Essence Advantage (HMO) offers dental services with a $30 copay for Medicare Dental Services, along with coverage for oral exams (2 per year), dental X-rays (1 per year), prophylaxis (cleaning) (2 per year), fluoride treatment (1 per year), and orthodontics, all with no copay. Orthodontic services have a maximum benefit of $750 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay and a coinsurance between 0% and 20%. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are also covered with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Essence Advantage (HMO) plan with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance and Prosthetics/Medical Supplies with 20% coinsurance, while Durable Medical Equipment for use outside the home and Diabetic Supplies are not covered. Diabetic Therapeutic Shoes/Inserts are covered with 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including all diagnostic services and radiological services. Diagnostic Procedures/Tests have a copay between $0 and $30, while Diagnostic Radiological Services have a copay up to $200 and Therapeutic Radiological Services have a 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the Essence Advantage (HMO) plan with no copay and no coinsurance, but a referral is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Essence Advantage (HMO) plan. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Essence Advantage (HMO), but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $188.
Other Services See details
The Essence Advantage (HMO) plan covers Over-the-Counter (OTC) items, with a maximum benefit coverage amount of $40.00 every three months. However, acupuncture, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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