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Jefferson Health Plans Silver (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Jefferson Health Plans Silver (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 Silver (HMO) in 2025, please refer to our full plan details page.
Jefferson Health Plans Silver (HMO) is a HMO plan offered by Thomas Jefferson University available for enrollment in 2025 to people living in Southern New Jersey. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Jefferson Health Plans Silver (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 Silver (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 Silver (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. Additionally, this plan comes with a Part B Premium reduction of $1.10. You must continue to pay paying your reduced 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 $6700.00 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 Silver (HMO) plan has an Enhanced Alternative drug benefit. There is no deductible for prescription drugs. In the initial coverage phase, you'll pay a copay or coinsurance depending on the drug tier and pharmacy. For example, you'll pay a $10 copay for preferred generic drugs at a standard pharmacy and 25% coinsurance for standard generic drugs. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for Part D covered drugs.
Additional Benefits
The Jefferson Health Plans Silver (HMO) plan offers a range of benefits with varying costs. For inpatient hospital stays, you'll pay a $325 copay for days 1-5, and no copay for days 6-90. Outpatient services have copays ranging from $30 to $350. Emergency services have a $100 copay, while urgently needed services have a $10 copay. This plan includes coverage for primary care with various copays, preventive services, hearing and vision services with copays, and dental services with copays. Ambulance services have a copay or coinsurance, and medical equipment and home infusion services have coinsurance. Additional benefits include acupuncture, with a $10 copay, and over-the-counter (OTC) items with a maximum benefit of $80 every three months.
Inpatient Hospital See details
Inpatient Hospital benefits are covered under the Jefferson Health Plans Silver (HMO) plan. For Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, you will pay a $325 copay for days 1-5, and no copay for days 6-90.
Outpatient Services See details
Outpatient services include coverage for all outpatient hospital services and observation services with a $350 copay, Ambulatory Surgical Center (ASC) services with a $250 copay, and outpatient substance abuse services with a $30 copay for both individual and group sessions. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered, but requires prior authorization. You will pay a $55 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Jefferson Health Plans Silver (HMO), with Medicare-covered ground ambulance services subject to a $275 copay, and air ambulance services subject to a 20% coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services are covered by the Jefferson Health Plans Silver (HMO) plan. For emergency services, there is a $100 copay, and no coinsurance. Urgently needed services have a $10 copay and no coinsurance. Worldwide Emergency Services are covered with a maximum plan benefit of $50,000. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Jefferson Health Plans Silver (HMO) plan covers primary care physician services, chiropractic services (with a $15 copay), occupational therapy services (with a $25 copay), physician specialist services (with a $30 copay), mental health specialty services (with a $30 copay for individual and group sessions), podiatry services (with a $20-$30 copay), other health care professional visits (with a $0-$30 copay), psychiatric services (with a $30 copay for individual and group sessions), physical therapy and speech-language pathology services (with a $30 copay), additional telehealth benefits (with a $0-$30 copay), and opioid treatment program services (with a $30 copay). Routine Chiropractic Care is not covered.
Preventive Services See details
The Jefferson Health Plans Silver (HMO) plan covers preventive services, including Medicare-covered preventive services with prior authorization, annual physical exams, and additional preventive services. Some additional services, such as health education, in-home safety assessments, and counseling services are not covered.
Hearing Services See details
Hearing services include routine hearing exams with a $35 copay for one visit every year, and fitting/evaluation for hearing aids and prescription hearing aids are not covered. OTC hearing aids are also not covered.
Vision Services See details
Vision services include 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
The Jefferson Health Plans Silver (HMO) plan covers dental services, including oral exams with a $45 copay, dental x-rays, other diagnostic dental services, prophylaxis (cleaning) with a $45 copay, other preventive dental services, restorative services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, and oral and maxillofacial surgery. Orthodontic services are covered up to a $1,000 annual maximum. Fluoride treatment, adjunctive general services, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Jefferson Health Plans Silver (HMO) plan, requiring prior authorization, with a $35 copay for Medicare Part B Insulin Drugs and a coinsurance between 0% and 20% depending on the drug. The plan also covers Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Jefferson Health Plans Silver (HMO) plan. You will pay 20% coinsurance for dialysis services.
Medical Equipment See details
Medical equipment coverage includes durable medical equipment, prosthetics, medical supplies, and diabetic equipment. Durable medical equipment has a 20% coinsurance, and requires prior authorization. Prosthetics and medical supplies have a 20% coinsurance, and diabetic supplies have between 0% and 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, but lab services are not covered. Diagnostic Procedures/Tests have no copay, while Diagnostic Radiological Services have a $200 copay, and Outpatient X-Ray Services have a $25 copay. Therapeutic Radiological Services have a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the Jefferson Health Plans Silver (HMO), 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 not covered by the Jefferson Health Plans Silver (HMO) plan, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Jefferson Health Plans Silver (HMO) plan, but require prior authorization. You will have no copay for days 1-20, and a $203 copay for days 21-100. 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 Silver (HMO) plan covers acupuncture with a $10 copay for up to 20 treatments per year. Over-the-counter (OTC) items are also covered, with a maximum benefit of $80 every three months. Other services such as meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and more are not covered.
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