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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 2025, 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 2025.
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 $51.20. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $1.20. 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:
Sign up for Provider Partners North Carolina Essential Plan (HMO I-SNP)
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Drug Coverage
The Provider Partners North Carolina Essential Plan (HMO I-SNP) has a $590.00 deductible for prescription drugs. After you meet your deductible, you will pay the costs for your drugs based on the tier and pharmacy you use, until your total drug costs reach $2000.00. Once you reach this amount, you enter the next coverage phase. If you qualify for the low-income subsidy (LIS), your monthly Part D premium will be $51.20. In the catastrophic coverage phase, after your yearly out-of-pocket drug costs reach $2000.00, you pay nothing for Medicare Part D covered drugs.
Additional Benefits
The Provider Partners North Carolina Essential Plan (HMO I-SNP) offers a range of benefits, including coverage for inpatient and outpatient services, with coinsurance requirements for many services. Emergency and ambulance services have no copay, but coinsurance applies. This plan also includes coverage for a variety of services, such as primary care, preventive services, hearing, vision, and dental, as well as home health and medical equipment with coinsurance. Additional benefits include coverage for home infusion, dialysis, and diagnostic services. The plan offers a quarterly allowance for over-the-counter items. However, it's important to note that some services, like cardiac rehabilitation, certain home health care, and additional days for inpatient stays, are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Acute and Psychiatric, are covered, but the specific cost-sharing details for copays are not provided. Additional Days for Inpatient Hospital-Acute, Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including Outpatient Hospital Services and Observation Services, are covered with a 20% coinsurance. Ambulatory Surgical Center (ASC) Services and Outpatient Substance Abuse Services are covered with a minimum of 20% coinsurance, and a maximum of 20% coinsurance. Outpatient Blood Services are covered with a 20% coinsurance, and the plan waives the three (3) pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered under the Provider Partners North Carolina Essential Plan (HMO I-SNP) with prior authorization required. You will pay 20% coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with no copay for any ambulance service. Ground and air ambulance services have a 20% coinsurance. Transportation Services - Any Health-related Location is covered for up to 30 one-way trips per year. Transportation Services - Plan Approved Health-related Location is not covered.
Emergency Services See details
Emergency Services and Urgently Needed Services are covered with a 20% coinsurance, while Worldwide Emergency Services are not covered. There is no copay for these services.
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 under the Provider Partners North Carolina Essential Plan (HMO I-SNP). Primary Care Physician Services, Chiropractic Services, Physician Specialist Services, Physical Therapy and Speech-Language Pathology Services, and Additional Telehealth Benefits have a 20% coinsurance. Individual and Group Sessions for Mental Health and Psychiatric Services have a 20% coinsurance. Podiatry, Other Health Care Professional, and Opioid Treatment Program Services also have a 20% coinsurance. Routine Chiropractic Care is not covered.
Preventive Services See details
Preventive services include Medicare-covered services with no copay, and additional services such as an annual physical exam with 20% coinsurance. Other preventive services like glaucoma screenings, barium enemas, digital rectal exams, and EKG following Welcome Visit are covered with a coinsurance between 20% and 20%.
Hearing Services See details
Hearing services include coverage for hearing exams with a coinsurance of at most 20%, routine hearing exams once per year, and fitting/evaluation for hearing aids up to four times every two years. Prescription Hearing Aids are partially covered, with coverage for inner ear, outer ear, and over the ear hearing aids, and a maximum benefit of $2000 every two years. OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams have a 20% coinsurance, and routine eye exams are limited to one per year. Eyewear, including contact lenses, eyeglass lenses, and eyeglass frames, also has a 20% coinsurance and a combined maximum of $300 per year, but eyeglass frames are not covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with 20% coinsurance, and other dental services with a $3,000 annual maximum. Oral exams, dental X-rays, other diagnostic dental services, prophylaxis (cleaning), and fluoride treatments are covered once per year. Restorative services, endodontics, periodontics, prosthodontics (removable, fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics are covered. Adjunctive general services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Provider Partners North Carolina Essential Plan (HMO I-SNP), including Medicare Part B Insulin Drugs with a $35 copay and between 0% and 20% coinsurance, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with between 0% and 20% coinsurance. Prior authorization is required for this benefit.
Dialysis Services See details
Dialysis Services are covered by the Provider Partners North Carolina 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), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, while Prosthetic Devices, Medical Supplies, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts also have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with no copay. Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services have a coinsurance of at most 20%.
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, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Provider Partners North Carolina Essential Plan (HMO I-SNP). Prior authorization is required for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered, but require prior authorization. The plan does not cover additional days beyond Medicare-covered SNF stays or non-Medicare-covered SNF stays.
Other Services See details
Other Services includes coverage for Over-the-Counter (OTC) items, with a maximum benefit of $80 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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