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Provider Partners Pennsylvania Essential Plan (HMO I-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Provider Partners Pennsylvania Essential Plan (HMO I-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Provider Partners Pennsylvania Essential Plan (HMO I-SNP) in 2025, please refer to our full plan details page.
Provider Partners Pennsylvania Essential Plan (HMO I-SNP) is a HMO I-SNP plan offered by Rifkin Managed Care Holding, LLC available for enrollment in 2025 to people living in PA East and West Borders. This plan received an overall rating of 2 out of 5 stars in 2025.
It's important to know that Provider Partners Pennsylvania Essential Plan (HMO I-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Provider Partners Pennsylvania Essential Plan (HMO I-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Provider Partners Pennsylvania Essential Plan (HMO I-SNP).
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 Provider Partners Pennsylvania Essential Plan (HMO I-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $47.30. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $0.90. You must continue to pay paying your reduced 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 $590.00 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 $9350.00 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 Provider Partners Pennsylvania Essential Plan (HMO I-SNP) has a $590 deductible for prescription drugs. After the deductible, you will pay costs for your prescriptions until your total drug costs reach $2000, at which point you enter the next coverage phase. If you qualify for the low-income subsidy, you may pay a reduced premium.
Additional Benefits
The Provider Partners Pennsylvania Essential Plan (HMO I-SNP) offers a range of benefits, including coverage for inpatient and outpatient services, with a 20% coinsurance for many services. The plan also covers primary care, preventive services, hearing, vision, dental, and home health services, with varying cost-sharing structures. This plan also includes additional benefits such as coverage for home infusion bundled services, dialysis, medical equipment, and diagnostic and radiological services. Other notable benefits include coverage for ambulance and transportation services, and emergency services. The plan also offers an Over-the-Counter (OTC) items benefit with a maximum benefit of $50.00 every three months.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered by the Provider Partners Pennsylvania Essential Plan (HMO I-SNP), but additional days, upgrades, and non-Medicare-covered stays are not covered. For both acute and psychiatric care, prior authorization is required, and the plan charges the Medicare-defined cost share for tier 1.
Outpatient Services See details
Outpatient Services are covered by this plan, including outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient Hospital Services and Observation Services have a 20% coinsurance. Ambulatory Surgical Center Services, Individual Sessions for Outpatient Substance Abuse, and Group Sessions for Outpatient Substance Abuse each have a minimum and maximum coinsurance of 20%. Outpatient Blood Services have a 20% coinsurance.
Partial Hospitalization See details
Partial Hospitalization is covered by the Provider Partners Pennsylvania Essential Plan (HMO I-SNP), but requires prior authorization. You will pay 20% coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Provider Partners Pennsylvania Essential Plan (HMO I-SNP), including ground and air ambulance services with a 20% coinsurance. Transportation Services to any health-related location are covered for up to 36 one-way trips per year, but transportation services to plan-approved health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Provider Partners Pennsylvania Essential Plan (HMO I-SNP). Emergency Services and Urgently Needed Services have a 20% coinsurance, and Worldwide Emergency Services is not covered.
Primary Care See details
Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Podiatry Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered, with a 20% coinsurance. Routine Chiropractic Care is not covered.
Preventive Services See details
The Provider Partners Pennsylvania Essential Plan (HMO I-SNP) covers preventive services, including annual physical exams with 20% coinsurance. Kidney Disease Education Services, Glaucoma Screening, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit are covered with 20% coinsurance. However, 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, Fitness Benefit, Enhanced Disease Management, Telemonitoring Services, Remote Access Technologies, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing Services includes coverage for hearing exams with a coinsurance of at most 20%, as well as routine hearing exams, and fitting/evaluation for hearing aids. This plan also covers prescription hearing aids, including inner ear, outer ear, and over the ear aids, with a maximum plan benefit of $2000 every two years. OTC hearing aids are not covered.
Vision Services See details
Vision Services includes coverage for eye exams, routine eye exams with 20% coinsurance, and eyewear, with 20% coinsurance, and a combined maximum of $300 per year for contact lenses, eyeglass lenses, and eyeglass frames. Eyeglass frames and lenses are unlimited, but eyeglasses (lenses and frames) and upgrades are not covered.
Dental Services See details
Dental Services are covered, including Medicare Dental Services with 20% coinsurance. Other Dental Services have a maximum plan benefit coverage of $3,000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but require prior authorization. For Medicare Part B Insulin Drugs, there is a $35 copay and coinsurance between 0% and 20%. Other Medicare Part B drugs, as well as chemotherapy and radiation drugs, have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Provider Partners Pennsylvania Essential Plan (HMO I-SNP). You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance and no copay, along with Prosthetics, Medical Supplies, and Diabetic Equipment, all of which are subject to coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with no copay. For Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services, you pay at most 20% coinsurance.
Home Health Services See details
Home Health Services are covered under the Provider Partners Pennsylvania Essential Plan (HMO I-SNP) with no copay and no coinsurance, but prior authorization 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 Provider Partners Pennsylvania Essential Plan (HMO I-SNP). Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. The plan does not cover additional days beyond Medicare-covered SNF days or non-Medicare-covered SNF stays.
Other Services See details
The Provider Partners Pennsylvania Essential Plan (HMO I-SNP) covers Over-the-Counter (OTC) items with a maximum benefit of $50.00 every three months. Acupuncture, Meal Benefit, 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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