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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 2025, 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 2025.
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 $48.40. 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 Maximum Out-Of-Pocket cost of $8850.00 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) plan has a $590 deductible for prescription drugs. After the deductible is met, you pay the costs for drugs in each tier until your total drug costs reach $2,000. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you will pay nothing for Medicare Part D covered drugs. The plan's premium may be reduced if you qualify for the low-income subsidy, with the Part D premium costing $48.40.
Additional Benefits
The Jefferson Health Plans Special (HMO D-SNP) plan offers a range of benefits with varying cost-sharing. Many services, including primary care, outpatient services, and preventive services, have a 20% coinsurance. Some services, like home health and ambulance services, have no copay. The plan also covers specific services like hearing, vision, and dental, often with coinsurance requirements. It includes coverage for medical equipment, diagnostic services, and other services like acupuncture and over-the-counter items.
Inpatient Hospital See details
Inpatient Hospital benefits for Jefferson Health Plans Special (HMO D-SNP) include Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with cost sharing based on Medicare guidelines and no cost sharing on the day of discharge. Additional days, non-Medicare stays, and upgrades for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include outpatient hospital services and observation services, each with a 20% coinsurance, and outpatient substance abuse services including individual and group sessions with a 20% coinsurance. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Jefferson Health Plans Special (HMO 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 include coverage for all ambulance services and transportation services to plan-approved health-related locations. 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, Urgently Needed Services, and Worldwide Emergency Services are covered under the Jefferson Health Plans Special (HMO D-SNP) plan. Emergency Services and Urgently Needed Services have a 20% coinsurance, while Worldwide Emergency Services has a maximum plan benefit coverage of $50,000. Worldwide Emergency Transportation is not covered.
Primary Care See details
Primary Care Physician Services, Physician Specialist Services, Physical Therapy and Speech-Language Pathology Services, and Additional Telehealth benefits are covered with a 20% coinsurance. Chiropractic Services, Occupational Therapy Services, Mental Health Specialty Services, Podiatry Services, Other Health Care Professional, Psychiatric Services, and Opioid Treatment Program Services are covered with a 20% coinsurance. Routine Chiropractic Care is not covered.
Preventive Services See details
The Jefferson Health Plans Special (HMO D-SNP) plan covers preventive services, including annual physical exams with 20% coinsurance. Medicare-covered zero-dollar preventive services are covered, and other preventive services are covered with a 20% coinsurance for services like glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a Welcome Visit. However, health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, and several other services are not covered.
Hearing Services See details
Hearing Services are covered, including routine hearing exams with a coinsurance of at most 20% and a limit of one exam per year. Prescription hearing aids are covered up to a maximum of $1500 per year, but fitting/evaluation for hearing aids, prescription hearing aids for the inner ear, prescription hearing aids for the outer ear, prescription hearing aids over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with 20% coinsurance, and coverage for contact lenses and eyeglasses (lenses and frames). Eyeglass lenses, eyeglass frames and upgrades are not covered.
Dental Services See details
The Jefferson Health Plans Special (HMO D-SNP) plan covers a variety of dental services, including oral exams (3 visits per year), dental x-rays (1 per year), other diagnostic dental services, prophylaxis (cleaning) (3 visits per year), other preventive dental services, restorative services, endodontics, periodontics, prosthodontics (removable), maxillofacial prosthetics, implant services, prosthodontics (fixed), and oral and maxillofacial surgery. Fluoride treatment and orthodontics are not covered, and the plan has a maximum benefit of $5,000 per year for orthodontic services.
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. For Medicare Part B Insulin Drugs, there is a $35 copay and a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Jefferson Health Plans Special (HMO D-SNP) 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 by the Jefferson Health Plans Special (HMO D-SNP) plan. DME and Diabetic Supplies have a 20% coinsurance, while Prosthetic Devices, Medicare-covered Prosthetic Devices, and Medicare-covered Medical Supplies also have a 20% coinsurance; there is no copay for any of these services. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the Jefferson Health Plans Special (HMO D-SNP), with no copay for all services. Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services have a coinsurance of at most 20%.
Home Health Services See details
Home Health Services are covered by Jefferson Health Plans Special (HMO D-SNP) with no copay and no coinsurance, but authorization is required. 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 coinsurance for these services, but the specific amount is not provided.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but prior authorization is required. The plan does not provide Skilled Nursing Facility Services as a supplemental benefit under Part C, and additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The Jefferson Health Plans Special (HMO D-SNP) plan covers acupuncture with a limit of 20 treatments per year. Over-the-counter items are covered up to $300 every three months, including nicotine replacement therapy. The plan also offers a meal benefit for medical conditions that require the enrollee to remain at home for a period of time.
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1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
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