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Jefferson Health Plans Complete (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Jefferson Health Plans Complete (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Jefferson Health Plans Complete (HMO) in 2025, please refer to our full plan details page.
Jefferson Health Plans Complete (HMO) is a HMO 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 Complete (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 Jefferson Health Plans Complete (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 Jefferson Health Plans Complete (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 no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $5700.00 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:
Sign up for Jefferson Health Plans Complete (HMO)
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Drug Coverage
The Jefferson Health Plans Complete (HMO) plan has a $0 deductible for prescription drugs. During the initial coverage phase, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, you will pay a $10 copay at standard and mail order pharmacies. Standard generic drugs have a 25% coinsurance, and preferred brand drugs have a 35% coinsurance at standard and mail order pharmacies. Non-preferred drugs have a 33% coinsurance at standard and mail order pharmacies.
Additional Benefits
The Jefferson Health Plans Complete (HMO) plan offers a range of benefits, including inpatient hospital stays with a copay, and outpatient services with copays varying by service type. You'll find coverage for ambulance and transportation services, emergency services, and primary care with no copay for primary care physician services. This plan also covers preventive, vision, and dental services with copays, as well as hearing exams. Additionally, it includes services like home health, dialysis, and medical equipment with coinsurance or copays. However, certain services such as cardiac rehabilitation, and additional home health and personal care services are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered by Jefferson Health Plans Complete (HMO). For Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, you will pay a $250 copay for days 1-6, and no copay for days 7-90.
Outpatient Services See details
Outpatient Services, including outpatient hospital services and observation services, have a $300 copay, while Ambulatory Surgical Center (ASC) Services have a $200 copay. Individual and Group Sessions for Outpatient Substance Abuse have a copay between $25 and $25. Outpatient Blood Services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Jefferson Health Plans Complete (HMO) plan, but requires prior authorization. You will have a $55 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Jefferson Health Plans Complete (HMO) plan. Ground ambulance services have a $250 copay, while air ambulance services have 20% coinsurance. Transportation services to plan-approved health-related locations are covered for up to 22 one-way trips per year. 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 Complete (HMO) plan. Emergency Services have a $100 copay, and Urgently Needed Services have a $10 copay, while Worldwide Emergency Services have a maximum plan benefit coverage of $50,000.
Primary Care See details
The Jefferson Health Plans Complete (HMO) plan covers primary care physician services with no copay, chiropractic services with a $15 copay, occupational therapy services with a $25 copay, and physician specialist services with a $25 copay. Mental health specialty services, psychiatric services, and podiatry services each have a $25 copay, and physical therapy and speech-language pathology services have a $25 copay. Additional telehealth benefits have a copay between $0 and $25, and opioid treatment program services have a $25 copay.
Preventive Services See details
The Jefferson Health Plans Complete (HMO) plan covers preventive services, including annual physical exams, with no copay. Some additional preventive services like Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), Medical Nutrition Therapy (MNT), and more are not covered.
Hearing Services See details
Hearing Services include hearing exams with a $35 copay, with routine hearing exams covered once per year. Fitting/Evaluation for Hearing Aids, Prescription Hearing Aids, and OTC Hearing Aids are not covered.
Vision Services See details
Vision services are covered, including eye exams with a $45 copay, contact lenses, and eyeglasses (lenses and frames). Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services include coverage for Medicare dental services with a $45 copay. Other covered dental services include oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), other preventive dental services, restorative services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, and oral and maxillofacial surgery. Fluoride treatment, implant services, adjunctive general services, and orthodontics are not covered. Orthodontic services have a maximum benefit of $2,000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Jefferson Health Plans Complete (HMO) plan, with prior authorization required. Insulin has 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 under the Jefferson Health Plans Complete (HMO) plan. You will pay 20% coinsurance for this service.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a 20% coinsurance and Prosthetics/Medical Supplies with a 20% coinsurance. Diabetic Supplies have a 0-20% coinsurance, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, but Lab Services are not covered. Diagnostic Procedures/Tests have a $5 copay, Diagnostic Radiological Services have a $250 copay, Therapeutic Radiological Services have 20% coinsurance, and Outpatient X-Ray Services have a $25 copay.
Home Health Services See details
Home Health Services are covered by Jefferson Health Plans Complete (HMO), with no copay or coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Jefferson Health Plans Complete (HMO) plan. Specifically, Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Jefferson Health Plans Complete (HMO) plan, but require prior authorization. There is no copay for days 1-20, but there is a $203 copay for days 21-100; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services includes acupuncture, which has a $10 copay per visit, and Over-the-Counter (OTC) items, which are covered with a maximum benefit of $150 every three months. Other services such as meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and many others are not covered.
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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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