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Jefferson Health Plans Special (HMO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Jefferson Health Plans Special (HMO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Jefferson Health Plans Special (HMO D-SNP) in 2026, please refer to our full plan details page.
Jefferson Health Plans Special (HMO D-SNP) is a HMO D-SNP plan offered by Thomas Jefferson University available for enrollment in 2025 to people living in Southeastern PA, Central PA and Eastern PA. This plan received an overall rating of 3.5 out of 5 stars in 2026.
It's important to know that Jefferson Health Plans Special (HMO D-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Jefferson Health Plans Special (HMO 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 Jefferson Health Plans Special (HMO 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 Jefferson Health Plans Special (HMO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $32.70. 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 Maximum Out-Of-Pocket cost of $9250.00 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 Jefferson Health Plans Special (HMO D-SNP) features an annual prescription drug deductible of $615. Fortunately, members pay no copay for Tier 1 preferred generic drugs and Tier 6 select care drugs filled at standard pharmacies or through standard mail order. This cost-saving benefit applies to one-month, two-month, and three-month supplies of these medications. For other medication tiers, costs are based on coinsurance, including 20% for Tier 2 generic drugs and 24% for Tier 3 preferred brand drugs. Tier 4 non-preferred drugs carry a 28% coinsurance, and Tier 5 specialty drugs require a 25% coinsurance for a one-month supply. These cost-sharing percentages apply to prescriptions filled at standard pharmacies and through standard mail order.
Additional Benefits
Jefferson Health Plans Special (HMO D-SNP) offers comprehensive medical coverage, featuring no copays and a 20% coinsurance for primary and specialist care visits. Outpatient hospital services, emergency care, and ambulance rides are covered with no copays and a 30% coinsurance, while acute inpatient stays require a $1,690 copay per stay with no coinsurance. Skilled nursing facility stays also have no copay for the first 20 days, followed by a $218 daily copay for days 21 through 100. The plan also includes valuable extra benefits, such as dental care with no copays or coinsurance for most services, and up to 65 free one-way transportation trips per year to approved locations. Routine vision and hearing exams are covered with no copay and a 30% coinsurance, alongside allowances for eyewear and prescription hearing aids. Additionally, members receive home health services with no copay or coinsurance and a $250 quarterly allowance for over-the-counter items.
Inpatient Hospital See details
Inpatient hospital benefits are partially covered by Jefferson Health Plans Special (HMO D-SNP), as upgrades, additional days, and non-Medicare-covered stays are not covered. Acute inpatient stays require a $1,690 copay per stay with no coinsurance, while psychiatric inpatient stays require a $2,080 copay per stay with no coinsurance, both requiring prior authorization.
Outpatient Services See details
Jefferson Health Plans Special (HMO D-SNP) outpatient services are covered with no copays and a 30% coinsurance across outpatient hospital, ambulatory surgical center, outpatient substance abuse, and blood services. Prior authorization is required for ambulatory surgical center and outpatient hospital services.
Partial Hospitalization See details
Jefferson Health Plans Special (HMO D-SNP) covers partial hospitalization services with no copay and a 30% coinsurance. Prior authorization is required for some of these covered services.
Ambulance and Transportation Services See details
Jefferson Health Plans Special (HMO D-SNP) covers ground and air ambulance services with a 30% coinsurance and no copay, subject to prior authorization. Transportation services are partially covered, offering up to 65 one-way trips per year to plan-approved health-related locations with no copay and no coinsurance, though transportation to any health-related location is not covered.
Emergency Services See details
Jefferson Health Plans Special (HMO D-SNP) covers emergency services with a 30% coinsurance and no copay, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a 30% coinsurance and no copay. Worldwide emergency and urgent care are covered up to a $50,000 lifetime maximum with no copay and no coinsurance, though worldwide emergency transportation is not covered.
Primary Care See details
Jefferson Health Plans Special (HMO D-SNP) covers primary care, specialist, and other healthcare professional services with no copay and a 20% coinsurance. Physical, occupational, speech, mental health, psychiatric, telehealth, routine podiatry, and opioid treatment services are covered with no copay and a 30% coinsurance, while chiropractic services are not covered.
Preventive Services See details
Preventive services are partially covered by Jefferson Health Plans Special (HMO D-SNP) with no copays, featuring a 20% coinsurance for annual physicals and kidney education, and a 30% coinsurance for glaucoma, diabetes self-management, digital rectal, and EKG screenings. While memory fitness and telemonitoring are covered with no coinsurance, several services are not covered, including health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge medication reconciliation, re-admission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional/dietary benefits, palliative care, in-home support, caregiver support, smoking cessation counseling, enhanced disease management, remote access technologies, home safety modifications, and counseling.
Hearing Services See details
Hearing services are partially covered by Jefferson Health Plans Special (HMO D-SNP), including one annual routine hearing exam with no copay and a 30% coinsurance. Prescription hearing aids are covered with no coinsurance and copays ranging from $0 to $1,475, but hearing aid fittings, OTC hearing aids, and inner, outer, or over-the-ear prescription models are not covered.
Vision Services See details
Jefferson Health Plans Special (HMO D-SNP) offers partially covered vision services, including one routine eye exam per year with no copay, a 30% coinsurance, and no deductible, though other eye exam services are not covered. Eyewear is covered with no copay, no coinsurance, and no deductible, allowing for unlimited contact lenses or one annual pair of eyeglasses up to $250, while individual frames, lenses, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by Jefferson Health Plans Special (HMO D-SNP) with no copay and no coinsurance for most preventive, diagnostic, restorative, and surgical care. While the plan includes up to $5,000 annually for orthodontic services, fluoride treatment, adjunctive general services, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Jefferson Health Plans Special (HMO D-SNP) covers home infusion bundled services with no copay, though prior authorization and step therapy may be required. Associated Medicare Part B chemotherapy, radiation, and other drugs carry no coinsurance to 20% coinsurance, while Medicare Part B insulin is covered with a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under the Jefferson Health Plans Special (HMO D-SNP) with no copay and a 20% coinsurance.
Medical Equipment See details
Jefferson Health Plans Special (HMO D-SNP) covers medical equipment, including durable medical equipment, prosthetics, medical supplies, and diabetic equipment, with no copay and a 20% coinsurance. Prior authorization is required for these services, and coverage may be limited to specified manufacturers or preferred vendors.
Diagnostic and Radiological Services See details
Jefferson Health Plans Special (HMO D-SNP) covers diagnostic and radiological services with no copays, though prior authorization is required. Patients are responsible for a 30% coinsurance for diagnostic procedures, lab services, diagnostic radiological services, and outpatient X-rays, and a 20% coinsurance for therapeutic radiological services.
Home Health Services See details
Home Health Services are covered by Jefferson Health Plans Special (HMO D-SNP) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Jefferson Health Plans Special (HMO D-SNP) provides no copay and no coinsurance for cardiac rehabilitation, meaning some services are covered. However, standard Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) services are not covered and carry a 30% coinsurance.
Skilled Nursing Facility (SNF) See details
Jefferson Health Plans Special (HMO D-SNP) covers skilled nursing facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20, a $218 daily copay for days 21 through 100, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Jefferson Health Plans Special (HMO D-SNP) covers other services with no copay and no coinsurance, including acupuncture up to 20 treatments per year, homebound meal benefits, and a $250 quarterly allowance for over-the-counter items. Highly integrated dual-eligible services and Naloxone are not covered under these benefits.
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