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Highmark Health Options Duals (HMO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Highmark Health Options Duals (HMO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Highmark Health Options Duals (HMO D-SNP) in 2025, please refer to our full plan details page.
Highmark Health Options Duals (HMO D-SNP) is a HMO D-SNP plan offered by Highmark Health available for enrollment in 2025 to people living in Kent, New Castle, Sussex. The overall rating for this plan is not yet available for 2025.
It's important to know that Highmark Health Options Duals (HMO D-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Highmark Health Options Duals (HMO D-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 Highmark Health Options Duals (HMO D-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 Highmark Health Options Duals (HMO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $46.30. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $4.00. 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 Highmark Health Options Duals (HMO D-SNP) plan has a $590 deductible for prescription drugs. After you meet your deductible, you will pay the costs for drugs in each tier 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 will pay $46.30 for Part D. After your yearly out-of-pocket drug costs reach $2000, you pay nothing for Medicare Part D covered drugs.
Additional Benefits
The Highmark Health Options Duals (HMO D-SNP) plan offers a range of benefits with varying cost-sharing. Many services, like emergency care, home health, and diagnostic services, have no copay, while others, such as outpatient services, primary care, and hearing/vision services, have a coinsurance of 20%. This plan also includes additional benefits like dental services, home infusion, and transportation services. However, certain services like cardiac rehabilitation, acupuncture, and private duty nursing are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric services, are covered under the Highmark Health Options Duals (HMO D-SNP) plan, but additional days, non-Medicare covered stays, and upgrades for acute and psychiatric services are not covered. Copays apply for covered services, as defined by Original Medicare.
Outpatient Services See details
Outpatient services include outpatient hospital services and observation services, each with a 20% coinsurance, as well as ambulatory surgical center services and outpatient substance abuse services, both with a 20% coinsurance. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Highmark Health Options Duals (HMO D-SNP) plan, but requires prior authorization. You will pay 20% coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including both ground and air ambulance services, each with a 20% coinsurance. Transportation Services to a plan-approved health-related location are covered for 36 one-way trips per year, with various modes of transportation available, while transportation to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Highmark Health Options Duals (HMO D-SNP) plan. Emergency Services have a $110 copay with no coinsurance, and Urgently Needed Services have a $45 copay with no coinsurance. Worldwide Emergency Services are not covered.
Primary Care See details
Primary care services include coverage for 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. Primary Care Physician Services, Chiropractic Services, Physician Specialist Services, Physical Therapy and Speech-Language Pathology Services, and Additional Telehealth Benefits have a 20% coinsurance, while Mental Health Specialty Services, Podiatry Services, Other Health Care Professional, Psychiatric Services, and Opioid Treatment Program Services have a minimum coinsurance of 20% and a maximum coinsurance of 20%.
Preventive Services See details
Preventive Services are covered, but annual physical exams, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, 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, and telemonitoring services are not covered. Other preventive services, including glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit, have a 20% coinsurance.
Hearing Services See details
Hearing Services include hearing exams with a coinsurance of at most 20%, and prescription hearing aids (all types) with a limit of 2 every three years, and fitting/evaluation for hearing aids. OTC hearing aids, and prescription hearing aids - inner ear, outer ear, and over the ear 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 also has a 20% coinsurance, with coverage for contact lenses, eyeglass lenses, and eyeglass frames, but eyeglass frames are limited to one per year with a maximum benefit of $400. Eyeglasses (lenses and frames) are not covered.
Dental Services See details
Highmark Health Options Duals (HMO D-SNP) covers Medicare Dental Services with 20% coinsurance and requires prior authorization, while other dental services have a $3,000 annual maximum. Oral exams are limited to one every six months, dental x-rays are limited to one set of panoramic and full mouth x-rays every 5 years, and bitewing, periapical, and occlusal x-rays every six months, and prophylaxis (cleaning) is limited to four per year. Fluoride treatments, maxillofacial prosthetics, implant services, prosthodontics, fixed, and orthodontics are not covered, while oral and maxillofacial surgery is covered with no coinsurance.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Highmark Health Options Duals (HMO D-SNP) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment, Prosthetics/Medical Supplies, and Diabetic Equipment. For Durable Medical Equipment, there is a 20% coinsurance and authorization is required, but there is no copay. Prosthetic Devices and Medical Supplies have a 20% coinsurance, and there is no copay. Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Highmark Health Options Duals (HMO D-SNP) plan. All diagnostic services have no copay, with coinsurance for diagnostic procedures/tests and lab services at a maximum of 20%. Radiological services have no copay, with coinsurance for diagnostic and therapeutic radiological services, and outpatient X-ray services at a maximum of 20%.
Home Health Services See details
Home Health Services are covered by the Highmark Health Options Duals (HMO D-SNP) plan with no copay and no coinsurance. Additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Highmark Health Options Duals (HMO D-SNP) 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, but additional days beyond Medicare-covered SNF and non-Medicare-covered SNF stays are not covered. You will pay the Medicare-defined cost share for tier 1, and a prior authorization is required.
Other Services See details
The Highmark Health Options Duals (HMO D-SNP) plan does not cover acupuncture, 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, Self-Directed Personal Assistance Services, or Dual Eligible SNPs with Highly Integrated Services. The plan does cover over-the-counter (OTC) items, with a maximum benefit of $208 per month, and a meal benefit for chronic illnesses.
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