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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 2026, 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 2026.
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 $29.00. 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 $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 combined Maximum Out-Of-Pocket cost of $13900.00 (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 $13900.00 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) prescription drug plan has an annual drug deductible of $615. You must pay this deductible amount out-of-pocket for your covered medications before the plan begins to pay its share of your drug costs. Detailed information regarding drug tiers, copays, and coinsurance is currently unavailable for this plan. To determine your specific medication costs and coverage details, you should consult the plan's comprehensive drug formulary.
Additional Benefits
The Medica Advantage Dual (PPO D-SNP) plan offers comprehensive medical coverage with no copays for most services, though many outpatient benefits require a twenty percent coinsurance. Major services like inpatient hospital stays, skilled nursing facility care, and home health services are fully covered with no copay and no coinsurance. For outpatient care, primary care visits, diagnostics, and emergency services, you will pay no copay alongside a twenty percent coinsurance. While the plan provides no-copay preventive care and covers Medicare-approved dental, vision, and hearing exams, it does not cover routine dental, routine vision, or hearing aids. Additionally, members can access over-the-counter items with no copay and no coinsurance through a reimbursement program. Prior authorization is required for several key services, including inpatient stays, medical equipment, and select outpatient procedures.
Inpatient Hospital See details
Inpatient hospital services are partially covered by Medica Advantage Dual (PPO D-SNP) with no copays and no coinsurance, though prior authorization is required for acute stays. Under this plan, additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Medica Advantage Dual (PPO D-SNP) covers outpatient services, including outpatient hospital, ambulatory surgical center, substance abuse, and blood services, with no copay and a 20% coinsurance. Prior authorization is required for ambulatory surgical center and outpatient hospital services.
Partial Hospitalization See details
Partial hospitalization services are covered by Medica Advantage Dual (PPO D-SNP) with no copay and a 20% coinsurance.
Ambulance and Transportation Services See details
Ambulance and transportation services under the Medica Advantage Dual (PPO D-SNP) plan cover ground and air ambulance services with a 20% coinsurance and no copay, though prior authorization is required. Transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Emergency services are covered by Medica Advantage Dual (PPO D-SNP) with a 20% coinsurance and no copay (up to $115 per visit), while urgently needed services require a 20% coinsurance and no copay (up to $40 per visit). Worldwide emergency, urgent, and transportation services are not covered under this plan.
Primary Care See details
Medica Advantage Dual (PPO D-SNP) offers coverage for primary care, specialists, mental health, and therapy services with no copay and 20% coinsurance. Chiropractic services are partially covered, excluding routine care, while podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered by Medica Advantage Dual (PPO D-SNP) with no copay and no coinsurance for covered benefits like kidney disease education, fitness benefits, and remote access technologies. Several sub-services are not covered under this plan, including annual physical exams, health education, in-home safety assessments, personal emergency response systems, and medical nutrition therapy.
Hearing Services See details
Hearing services under Medica Advantage Dual (PPO D-SNP) include coverage for hearing exams with no copay, no coinsurance, and no deductible. However, routine hearing exams, fitting and evaluation services, prescription hearing aids, and OTC hearing aids are not covered.
Vision Services See details
Vision services are covered by Medica Advantage Dual (PPO D-SNP) with no copay, no deductible, and a 20% coinsurance, though only some services are covered. Routine eye exams, other eye exam services, contact lenses, eyeglasses, and upgrades are not covered under this plan.
Dental Services See details
Dental Services are partially covered by Medica Advantage Dual (PPO D-SNP), which offers Medicare-covered dental services with no copay and a 20% coinsurance. However, non-Medicare dental services—including oral exams, cleanings, x-rays, fluoride, restorative services, endodontics, periodontics, prosthodontics, implants, and orthodontics—are not covered.
Home Infusion bundled Services See details
Medica Advantage Dual (PPO D-SNP) covers Home Infusion bundled Services with no copay, though prior authorization is required. Under this benefit, Medicare Part B insulin is covered with a $35 copay and no coinsurance, while chemotherapy and other Part B drugs have no copay and a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis services are covered under the Medica Advantage Dual (PPO D-SNP) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medica Advantage Dual (PPO D-SNP) covers 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 Medica Advantage Dual (PPO D-SNP) with no copay and a 20% coinsurance, subject to prior authorization. This includes outpatient diagnostic procedures, lab services, X-rays, and therapeutic radiological services.
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.
Cardiac Rehabilitation Services See details
Medica Advantage Dual (PPO D-SNP) offers coverage for Cardiac Rehabilitation Services with no copay and a 20% coinsurance. While some services are covered, specific options such as cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) are not covered.
Skilled Nursing Facility (SNF) See details
Medica Advantage Dual (PPO D-SNP) partially covers Skilled Nursing Facility (SNF) services with no copay and no coinsurance, although prior authorization is required. A three-day prior hospital stay is not required for admission, but additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Medica Advantage Dual (PPO D-SNP) partially covers other services, offering over-the-counter (OTC) items with no copay and no coinsurance through reimbursement. Acupuncture, meal benefits, nicotine replacement therapy, and naloxone are not covered under this benefit.
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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.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
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