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EssentiaCare Access (PPO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for EssentiaCare Access (PPO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on EssentiaCare Access (PPO) in 2025, please refer to our full plan details page.
EssentiaCare Access (PPO) is a PPO plan offered by UCare Minnesota available for enrollment in 2025 to people living in St. Louis County, MN and 3 County WI. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that EssentiaCare Access (PPO) 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 EssentiaCare Access (PPO).
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 EssentiaCare Access (PPO), 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. Additionally, this plan comes with a Part B Premium reduction of $11.00. 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 $125.00 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 combined Maximum Out-Of-Pocket cost of $6500.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $6500.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
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 EssentiaCare Access (PPO) plan has a $125 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and the pharmacy you use. For generic drugs at a standard pharmacy, you will pay a $10 copay for preferred generics and a $47 copay for standard generics. Brand name drugs at a standard pharmacy have a $100 copay, while non-preferred drugs have a 28% coinsurance. After your total yearly drug costs reach $2000, you will pay nothing for your Part D covered drugs.
Additional Benefits
The EssentiaCare Access (PPO) plan offers a wide range of benefits, including inpatient hospital stays with a copay, outpatient services, and various therapies. It also covers emergency services, primary care visits, and preventive services, often with a copay. Additional benefits include coverage for hearing, vision, and dental services, with specific copays and maximum annual benefits. The plan also provides coverage for home infusion, dialysis, medical equipment, and diagnostic services, some with coinsurance. Home health services are covered with no copay, and skilled nursing facility stays have a copay after the first 20 days. Other notable benefits include OTC items and cardiac rehabilitation services.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For days 1-5, there is a $300 copay, and for days 6-90, there is no copay. Additional Days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute are not covered, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including Outpatient Hospital Services, Observation Services, Ambulatory Surgical Center (ASC) Services, and Outpatient Blood Services, are covered. Outpatient Hospital Services, Observation Services, and Ambulatory Surgical Center (ASC) Services have a $395 copay, while Outpatient Substance Abuse Services (Individual and Group Sessions) are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the EssentiaCare Access (PPO) plan.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by EssentiaCare Access (PPO). Ground and Air Ambulance Services have a $350 copay, with no coinsurance, while Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the EssentiaCare Access (PPO) plan. Emergency Services and Worldwide Emergency Coverage have a $100 copay, Urgently Needed Services has a $45 copay, and Worldwide Emergency Transportation has a $350 copay; all have no coinsurance.
Primary Care See details
The EssentiaCare Access (PPO) plan covers primary care physician services with a $10 copay, chiropractic services with a $20 copay, occupational therapy services with a $40 copay, physician specialist services with a $50 copay, other health care professional services with a copay between $10 and $50, physical therapy and speech-language pathology services with a $40 copay, and telehealth services with a copay between $0 and $50. Routine chiropractic care, individual and group sessions for mental health and psychiatric services, and podiatry services are not covered.
Preventive Services See details
The EssentiaCare Access (PPO) plan covers preventive services, including Medicare-covered services with no copay. Additional services like smoking cessation counseling (6 visits) and a fitness benefit (Memory Fitness) are covered, with a maximum plan benefit coverage amount of $30.00 per month. However, services such as health education, in-home safety assessments, and counseling services are not covered.
Hearing Services See details
Hearing services include hearing exams with a $50 copay and up to $600 per year for both in and out-of-network services. Fitting/Evaluation for Hearing Aid services are covered, and Prescription Hearing Aids (all types) are covered, but Prescription Hearing Aids - Inner Ear, Prescription Hearing Aids - Outer Ear, and Prescription Hearing Aids - Over the Ear are not covered. OTC Hearing Aids are not covered.
Vision Services See details
Vision Services include coverage for eye exams with a copay of $0-$50, and a routine eye exam once per year. Eyewear is covered with 20% coinsurance, with a combined maximum of $600 per year for contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades.
Dental Services See details
The EssentiaCare Access (PPO) plan covers a variety of dental services, including oral exams, dental x-rays, and other diagnostic services, with a maximum benefit of $600 per year, applicable to both in-network and out-of-network services. Additional covered services include cleanings, fluoride treatments, other preventive services, restorative services, and more.
Home Infusion bundled Services See details
Home Infusion bundled Services includes coverage for Medicare Part B Insulin Drugs with a $35 copay. Also covered are Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, both with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the EssentiaCare Access (PPO) plan. The coinsurance for dialysis services is 20%.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, is covered. DME has a 20% coinsurance, Prosthetics and Medical Supplies have a 20% coinsurance, and Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts each have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the EssentiaCare Access (PPO) plan, including diagnostic procedures and tests, diagnostic radiological services, therapeutic radiological services, and outpatient X-ray services. There is no copay for these services, but you may have to pay coinsurance of up to 20% for diagnostic procedures/tests, diagnostic radiological services, therapeutic radiological services, and outpatient X-ray services. Lab services are not covered.
Home Health Services See details
Home Health Services are covered by the EssentiaCare Access (PPO) plan, with no copay or coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
EssentiaCare Access (PPO) covers Cardiac Rehabilitation Services, but does not cover the sub-services of Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. There is a copay for some services, but the specific amount is not listed.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the EssentiaCare Access (PPO) plan. You will have no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered SNF stays are not covered.
Other Services See details
Under the EssentiaCare Access (PPO) plan, "Other Services" includes coverage for Over-the-Counter (OTC) items with a maximum benefit of $50.00 per month, including Nicotine Replacement Therapy (NRT) and Naloxone. 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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