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Dean Advantage Essential (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Dean Advantage Essential (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Dean Advantage Essential (HMO) in 2025, please refer to our full plan details page.
Dean Advantage Essential (HMO) is a HMO plan offered by Medica Holding Company available for enrollment in 2025 to people living in South Central Wisconsin. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Dean Advantage Essential (HMO) 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 Dean Advantage Essential (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 Dean Advantage Essential (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.
This plan has a $420.00 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 $5500.00 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 Dean Advantage Essential (HMO) plan has a $420 deductible for prescription drugs. After meeting the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy. For example, preferred generic drugs have an $8 copay at preferred pharmacies, while standard generic drugs have 20% coinsurance at preferred pharmacies. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered Part D drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Those who qualify for the low-income subsidy will have no copay for Part D drugs.
Additional Benefits
The Dean Advantage Essential (HMO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay, while outpatient services have copays depending on the service. Emergency services have a $125 copay, and ambulance services have copays or coinsurance depending on the type of transport. This plan covers primary care, specialist visits, and various therapies with copays. Preventive services are covered, as well as hearing, vision, and dental services, each with different copays or coinsurance. The plan also provides coverage for home health, medical equipment, and diagnostic services.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric services, are covered by the Dean Advantage Essential (HMO) plan. For inpatient hospital acute and psychiatric services, there is a $350 copay for days 1-6, and no copay for days 7-90.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay between $0 and $450, and observation services with a $450 copay. Ambulatory Surgical Center (ASC) Services are covered with no copay, and outpatient substance abuse services are covered with a $30 copay for individual sessions and a $20 copay for group sessions. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Dean Advantage Essential (HMO) plan, but requires prior authorization. The copay for this benefit is $105.
Ambulance and Transportation Services See details
Ambulance and Transportation Services includes coverage for ground and air ambulance services, as well as transportation services to any health-related location. Ground ambulance services have a $300 copay, while air ambulance services have a 20% coinsurance. Transportation services to a plan-approved health-related location are not covered, but transportation services to any health-related location are covered for up to 24 one-way trips per year via bus/subway.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage have a copay of $125, no coinsurance, and Worldwide Urgent Coverage has a copay of $125 and no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
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 are covered. Chiropractic Services and Routine Chiropractic Care have a $20 copay, while Occupational Therapy Services, Podiatry Services, Other Health Care Professional, and Psychiatric Services have a $30-$40 copay depending on the service. Physical Therapy and Speech-Language Pathology Services have a $40 copay, and Additional Telehealth Benefits have a $0-$30 copay.
Preventive Services See details
Preventive services are covered, including annual physical exams and additional services like In-Home Support Services, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, Remote Access Technologies, Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. However, Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), 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, Support for Caregivers of Enrollees, Enhanced Disease Management, Telemonitoring Services, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing Services include coverage for hearing exams with a $30 copay, and Routine Hearing Exams and Fitting/Evaluation for Hearing Aids, each covered once per year. Prescription Hearing Aids (all types) are covered up to $750 per year, but Prescription Hearing Aids - Inner Ear, Outer Ear, and Over the Ear are not covered, and OTC Hearing Aids are not covered.
Vision Services See details
Vision services include coverage for routine eye exams, with one visit every year, and eyewear, including contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames. Eyewear has a combined maximum benefit of $250 every two years.
Dental Services See details
Dental Services are covered, including Medicare Dental Services with a $55 copay, and other dental services with a $500 annual maximum benefit. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), and fluoride treatments are covered, with limitations on the number of visits. Restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), implant services, and oral and maxillofacial surgery are covered with a 50% coinsurance, while maxillofacial prosthetics and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered with prior authorization required. Medicare Part B Insulin Drugs have a copay of $30-$35, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0-20%.
Dialysis Services See details
Dialysis Services are covered under the Dean Advantage Essential (HMO) plan. You will pay a 20% coinsurance for these services.
Medical Equipment See details
Medical equipment is covered under the Dean Advantage Essential (HMO) plan. Durable Medical Equipment (DME) has a coinsurance between 0% and 20%, and Prosthetic Devices and Medical Supplies have a 20% coinsurance, while Diabetic Therapeutic Shoes/Inserts have a coinsurance between 20% and 20%.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Procedures/Tests with a $25 copay, Lab Services with no copay, Diagnostic Radiological Services with a copay of up to $250, Therapeutic Radiological Services with a 20% coinsurance, and Outpatient X-Ray Services with a $30 copay. All Radiological Services require prior authorization.
Home Health Services See details
Home Health Services are covered by the Dean Advantage Essential (HMO) 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, but the plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services. There is a copay for these services, but the exact amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by the Dean Advantage Essential (HMO) plan, but require prior authorization. For days 1-20, the copay is $10 per day, and for days 21-100, the copay is $214 per day, with no coinsurance. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Under the Dean Advantage Essential (HMO) plan, acupuncture has a $45 copay for up to 12 treatments per year, and other services include a $300 copay for non-transport ambulance services and $25 every three months for over-the-counter items. The plan also covers a meal benefit for a chronic illness and additional home infusion services, but does not cover Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management, and other services.
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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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