A non-government entity
Providence Medicare Focus Medical (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Providence Medicare Focus Medical (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Providence Medicare Focus Medical (HMO) in 2025, please refer to our full plan details page.
Providence Medicare Focus Medical (HMO) is a HMO plan offered by Providence St Joseph Health available for enrollment in 2025 to people living in Portland, Willamette Valley, Central OR, Clark, WA. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Providence Medicare Focus Medical (HMO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Providence Medicare Focus Medical (HMO).
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 Providence Medicare Focus Medical (HMO), 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.
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.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3800.00 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
Prescription drugs are not covered by Providence Medicare Focus Medical (HMO).
Additional Benefits
The Providence Medicare Focus Medical (HMO) plan offers comprehensive coverage with a variety of benefits. This plan covers inpatient hospital stays with a copay, and outpatient services, including emergency and urgent care, with copays ranging from $25 to $250. Primary care, preventive, hearing, vision, and dental services are also included, often with a copay. Additional benefits include ambulance services, home health, and skilled nursing facility stays with varying copays and coinsurance. You'll also find coverage for home infusion, dialysis, medical equipment, and diagnostic services with coinsurance requirements. The plan also offers other services like acupuncture and over-the-counter items, with specific copays and benefit limits.
Inpatient Hospital See details
Inpatient Hospital services are covered. For Inpatient Hospital-Acute, you pay a $250 copay for days 1-5, and no copay for days 6-90; additional days have no copay. Inpatient Hospital Psychiatric has a $200 copay for days 1-7, and no copay for days 8-90. Non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient hospital services have a $250 copay, observation services have a $70 copay, and ambulatory surgical center services have a $200 copay. Individual and group sessions for outpatient substance abuse have a copay between $20 and $20, and outpatient blood services include a waived deductible for three pints.
Partial Hospitalization See details
Partial Hospitalization is covered by the Providence Medicare Focus Medical (HMO) plan, but requires prior authorization. There is no information provided about the cost of services, such as the copay or coinsurance.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Providence Medicare Focus Medical (HMO) plan. This plan has no coinsurance for ambulance services, but does have a copay of $50 - $275 for both ground and air ambulance services, 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 Providence Medicare Focus Medical (HMO) plan. Emergency Services have a $125 copay, and no coinsurance; Urgently Needed Services have a $25 copay, and no coinsurance; Worldwide Emergency Coverage has a $125 copay and no coinsurance; Worldwide Urgent Coverage has a $25 copay and no coinsurance; and Worldwide Emergency Transportation has a $275 copay and no coinsurance.
Primary Care See details
The Providence Medicare Focus Medical (HMO) plan covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $20 copay, physician specialist services with a $20 copay, mental health specialty services with a $20 copay for individual and group sessions, other health care professional services with a $0-$20 copay, psychiatric services with a $20 copay for individual and group sessions, physical therapy and speech-language pathology services with a $20 copay, additional telehealth benefits with a $0-$20 copay, and opioid treatment program services with a $0-$20 copay. Podiatry services are not covered.
Preventive Services See details
The Providence Medicare Focus Medical (HMO) plan covers preventive services, including annual physical exams, with no copay. Additional preventive services are covered with a copay, and some services like health education and weight management programs are not covered.
Hearing Services See details
Hearing Services are covered, including routine hearing exams with a $20 copay. Prescription hearing aids are partially covered, but inner ear, outer ear, and over the ear hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
The Providence Medicare Focus Medical (HMO) plan covers vision services including eye exams with a $20 copay, and eyewear with a combined maximum benefit of $250 every year. Contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a $20 copay, Oral Exams (2 visits per year), Dental X-Rays (up to one bitewing series and one single x-ray per year), Prophylaxis (Cleaning) (2 visits per year), and Fluoride Treatment (1 visit per year). Other services such as Other Diagnostic Dental Services, Other Preventive Dental Services, Restorative Services, Adjunctive General Services, Endodontics, Prosthodontics, removable, Prosthodontics, fixed, and Oral and Maxillofacial Surgery are offered as supplemental benefits and may require additional payment. Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. Medicare Part B Insulin Drugs have a $35 copay and a coinsurance between 0% and 20%, 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 by the Providence Medicare Focus Medical (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment, is covered. DME has a 20% coinsurance with no copay, and Prosthetic Devices and Medical Supplies have a 20% coinsurance with no copay. Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Providence Medicare Focus Medical (HMO) plan. Diagnostic Procedures/Tests have a coinsurance of at most 20%, while Lab Services are not covered. Radiological Services have a coinsurance, with a service-specific out-of-pocket maximum of $250; Diagnostic and Therapeutic Radiological Services have a coinsurance of at most 15%, while Outpatient X-Ray Services are not covered.
Home Health Services See details
Home Health Services are covered by the Providence Medicare Focus Medical (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. There is a copay for 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 require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Other Services benefit includes acupuncture with a $20 copay, and over-the-counter items with a $75 maximum benefit every three months. The meal benefit is covered for chronic illnesses. Services such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and Private Duty Nursing Services are not covered.
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