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Provider Partners North Carolina Essential Plan (HMO I-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Provider Partners North Carolina 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 North Carolina Essential Plan (HMO I-SNP) in 2026, please refer to our full plan details page.
Provider Partners North Carolina 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 Select North Carolina Counties. The overall rating for this plan is not yet available for 2026.
It's important to know that Provider Partners North Carolina 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 North Carolina 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 North Carolina 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 North Carolina Essential Plan (HMO I-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $36.20. 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 $615.00 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 $9250.00 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 North Carolina Essential Plan (HMO I-SNP) requires an annual prescription drug deductible of $615. This means you will need to pay this amount out of pocket for your covered medications before the plan begins to share the costs. Specific drug coverage tier details, including individual copays and coinsurance percentages, are not available for this plan. To determine how your specific medications are covered and estimate your total costs, you should consult the plan's comprehensive formulary.
Additional Benefits
The Provider Partners North Carolina Essential Plan (HMO I-SNP) offers comprehensive medical coverage where most outpatient, primary care, specialist, and emergency services feature no copay and a 20% coinsurance. Essential services like home health, home infusion, and Medicare-covered preventive services are fully covered with no copay and no coinsurance. For inpatient hospital stays and skilled nursing facility care, members face no coinsurance, though Medicare-defined cost shares and copays do apply. In addition to medical care, the plan provides robust dental, vision, and hearing benefits, including preventive and comprehensive dental services with no copay or coinsurance up to a $3,000 annual limit. Members also enjoy no copays for vision and hearing exams, a $300 eyewear allowance, up to $2,000 every two years for prescription hearing aids, and a $180 quarterly allowance for over-the-counter items. To ensure easy access to care, the plan covers up to 48 one-way trips per year to health-related locations with no copay and no coinsurance.
Inpatient Hospital See details
Inpatient hospital services are partially covered by the Provider Partners North Carolina Essential Plan (HMO I-SNP) with no copay and no coinsurance, though prior authorization is required and Medicare-defined cost shares apply. This coverage excludes acute upgrades, additional psychiatric or acute hospital days, and non-Medicare-covered stays.
Outpatient Services See details
Outpatient services are covered by the Provider Partners North Carolina Essential Plan (HMO I-SNP) with no copays and a 20% coinsurance for outpatient hospital care, ambulatory surgical center services, outpatient substance abuse sessions, and blood services. Prior authorization is required for most of these outpatient services, though the deductible is waived for the first three pints of blood.
Partial Hospitalization See details
Partial hospitalization services are covered by the Provider Partners North Carolina Essential Plan (HMO I-SNP) with no copay and a 20% coinsurance, subject to prior authorization.
Ambulance and Transportation Services See details
Provider Partners North Carolina Essential Plan (HMO I-SNP) covers ground and air ambulance services with a 20% coinsurance and no copay. Transportation services are partially covered with no copay and no coinsurance for up to 48 one-way trips per year to any health-related location, though transportation to plan-approved health-related locations is not covered.
Emergency Services See details
Provider Partners North Carolina Essential Plan (HMO I-SNP) covers emergency services with a 20% coinsurance and no copay (up to $100 per visit) and urgently needed services with a 20% coinsurance and no copay (up to $40 per visit). Some worldwide emergency services are covered, but worldwide emergency coverage, worldwide urgent coverage, and worldwide emergency transportation are not covered.
Primary Care See details
Provider Partners North Carolina Essential Plan (HMO I-SNP) covers primary care, specialist visits, mental health, telehealth, and therapy services with no copay and a 20% coinsurance. Chiropractic services are not covered, while routine podiatry is limited to six visits per year with no copay and a 20% coinsurance.
Preventive Services See details
Provider Partners North Carolina Essential Plan (HMO I-SNP) covers Medicare-covered zero-dollar preventive services with no copay and no coinsurance. Annual physical exams, kidney disease education, and select screenings (such as glaucoma and diabetes self-management training) are covered with no copay and a 20% coinsurance, whereas additional preventive services are not covered.
Hearing Services See details
Provider Partners North Carolina Essential Plan (HMO I-SNP) offers partially covered hearing services with no copays for exams or prescription hearing aids, though routine exams require a 20% coinsurance. This plan covers one routine exam annually, four fitting evaluations every two years, and up to $2,000 every two years for prescription hearing aids with no coinsurance, while over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
Vision services are partially covered by the Provider Partners North Carolina Essential Plan (HMO I-SNP), featuring no deductibles, no copays, and a 20% coinsurance for routine eye exams and contact lenses. Covered eyewear has a combined annual limit of $300, but other eye exam services, upgrades, and eyeglasses (lenses and frames) are not covered.
Dental Services See details
Dental Services are partially covered by the Provider Partners North Carolina Essential Plan (HMO I-SNP), offering Medicare-covered dental care with no copay and a 20% coinsurance, and other preventive and comprehensive dental benefits with no copay or coinsurance up to a $3,000 annual limit. Most diagnostic, restorative, and orthodontic treatments are covered, though adjunctive general services are not covered under this plan.
Home Infusion bundled Services See details
Home infusion bundled services are covered by the Provider Partners North Carolina Essential Plan (HMO I-SNP) with no copay and no coinsurance, though prior authorization is required. Covered Medicare Part B chemotherapy and other drugs have no copay and a coinsurance ranging from no coinsurance to 20%, while Part B insulin drugs require a $35 copay and a coinsurance ranging from no coinsurance to 20%.
Dialysis Services See details
Provider Partners North Carolina Essential Plan (HMO I-SNP) covers Dialysis Services with no copay and a 20% coinsurance.
Medical Equipment See details
Provider Partners North Carolina Essential Plan (HMO I-SNP) covers medical equipment, including durable medical equipment, prosthetics, and diabetic supplies, with no copay and a 20% coinsurance. Prior authorization is required for durable medical equipment and prosthetics.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered under the Provider Partners North Carolina Essential Plan (HMO I-SNP) with no copays, but a 20% coinsurance applies to all Medicare-covered diagnostic procedures, lab services, radiological services, and outpatient X-rays. Prior authorization is required for diagnostic services.
Home Health Services See details
Home Health Services are covered by the Provider Partners North Carolina Essential Plan (HMO I-SNP) with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Provider Partners North Carolina Essential Plan (HMO I-SNP). This includes standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) rehabilitation services, meaning there are no copay or coinsurance benefits available for these treatments.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) care is covered by the Provider Partners North Carolina Essential Plan (HMO I-SNP) with no coinsurance, though prior authorization is required and Medicare-defined copays apply. Covered services do not require a prior three-day inpatient hospital stay, but additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Provider Partners North Carolina Essential Plan (HMO I-SNP) partially covers Other Services, offering over-the-counter (OTC) items with no copay and no coinsurance up to a maximum benefit of $180 every three months. Other sub-services under this benefit, such as acupuncture and meal benefits, are not covered.
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