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Medica Advantage Dual (PPO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Medica Advantage Dual (PPO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Medica Advantage Dual (PPO D-SNP) in 2025, please refer to our full plan details page.
Medica Advantage Dual (PPO D-SNP) is a PPO D-SNP plan offered by Medica Holding Company available for enrollment in 2025 to people living in Select ND counties. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Medica Advantage Dual (PPO D-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Medica Advantage Dual (PPO 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 Medica Advantage Dual (PPO 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 Medica Advantage Dual (PPO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $50.60. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your 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 combined Maximum Out-Of-Pocket cost of $14000.00 (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 $14000.00 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 Medica Advantage Dual (PPO D-SNP) plan has a $590 deductible for prescription drugs. Once the deductible is met, you will pay the costs for drugs in each tier until your total drug costs reach $2,000, at which point you enter the next coverage phase. If you qualify for the low-income subsidy (LIS), your monthly Part D premium is $50.60. After your yearly out-of-pocket drug costs reach $2,000, you pay nothing for Medicare Part D covered drugs. This plan's formulary should be checked for specific drugs covered.
Additional Benefits
The Medica Advantage Dual (PPO D-SNP) plan offers a wide range of covered services. Many services have a 20% coinsurance, including outpatient services, emergency services, primary care, hearing exams, vision services, dental services, and ambulance services. The plan also includes benefits with no copay, such as diagnostic and radiological services, home health services, and medical equipment. Additional benefits include coverage for home infusion, cardiac rehabilitation, and skilled nursing facilities.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, but the specific cost-sharing details are not provided. Additional days for Inpatient Hospital-Acute and Psychiatric, non-Medicare-covered stays, and upgrades are not covered.
Outpatient Services See details
Outpatient Services, including Outpatient Hospital Services, Observation Services, Ambulatory Surgical Center (ASC) Services, and Outpatient Substance Abuse Services are covered. Outpatient Hospital Services and Observation Services have a 20% coinsurance, while Ambulatory Surgical Center (ASC) Services and Outpatient Substance Abuse Services have a coinsurance of at least 20%. Outpatient Blood Services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Medica Advantage Dual (PPO 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 by the Medica Advantage Dual (PPO D-SNP) plan. Ground and Air Ambulance Services have a 20% coinsurance, and there is no copay. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered, with a 20% coinsurance. Urgently Needed Services are covered, also with a 20% coinsurance. Worldwide Emergency Services, including Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation, are not covered.
Primary Care See details
The Medica Advantage Dual (PPO D-SNP) plan covers primary care physician services, chiropractic services, occupational therapy services, physician specialist services, mental health specialty services, other health care professional services, psychiatric services, physical therapy and speech-language pathology services, additional telehealth benefits, and opioid treatment program services. Most services require a 20% coinsurance, with routine chiropractic care and podiatry services not covered.
Preventive Services See details
Preventive Services are covered, including Medicare-covered zero dollar services, fitness benefits, and remote access technologies, but annual physical exams, health education, and several other services are not covered. Glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit are also covered.
Hearing Services See details
Hearing Services are partially covered under the Medica Advantage Dual (PPO D-SNP) plan. Hearing exams have a coinsurance of at most 20%, while routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids are not covered.
Vision Services See details
Vision Services are partially covered under the Medica Advantage Dual (PPO D-SNP) plan. Eye Exams are covered with a 20% coinsurance, while Eyewear is covered with a 20% coinsurance.
Dental Services See details
Dental Services are covered, with a 20% coinsurance for Medicare Dental Services. Orthodontic Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Medica Advantage Dual (PPO D-SNP) plan, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay, while other services have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Medica Advantage Dual (PPO D-SNP) plan. You will pay 20% coinsurance for dialysis services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, but no copay, while Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies and Diabetic Equipment have a 20% coinsurance, but no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Medica Advantage Dual (PPO D-SNP) plan. Diagnostic procedures, tests, and lab services have no copay and a coinsurance of at most 20%, while diagnostic radiological services, therapeutic radiological services, and outpatient X-ray services also have no copay and a coinsurance of at most 20%.
Home Health Services See details
Home Health Services are covered by the Medica Advantage Dual (PPO 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 covered under the Medica Advantage Dual (PPO D-SNP) plan, but Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. There is a coinsurance for some Cardiac and Pulmonary Rehabilitation Services, but no other cost-sharing information is available.
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 for SNF, and does not cover non-Medicare-covered stays for SNF.
Other Services See details
Other Services include Over-the-Counter (OTC) Items, but 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. There is no copay or coinsurance for OTC items.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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