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Jefferson Health Plans Platinum (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Jefferson Health Plans Platinum (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 Platinum (HMO) in 2025, please refer to our full plan details page.
Jefferson Health Plans Platinum (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 Platinum (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 Platinum (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 Platinum (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $30.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $0.50. 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 $6500.00 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 Platinum (HMO) plan has an enhanced alternative drug benefit. There is no deductible for prescription drugs. During the initial coverage phase, you will pay either a copay or coinsurance depending on the drug tier and pharmacy. For example, you may pay a $10 copay for preferred generic drugs at a standard pharmacy. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Jefferson Health Plans Platinum (HMO) plan offers a range of benefits with varying cost-sharing. Inpatient hospital stays have a copay, while outpatient services and some diagnostic services have copays, with some coinsurance for ambulance, air ambulance, and some medical equipment. Preventive services, primary care, vision, dental, and hearing exams are covered with copays, and home health services have no copay.
Inpatient Hospital See details
The Jefferson Health Plans Platinum (HMO) plan covers inpatient hospital stays, with a copay of $250 for days 1-5 and no copay for days 6-90 for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. Additional days, non-Medicare-covered stays, and upgrades for these benefits are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services and Observation Services, each with a $300 copay, and Ambulatory Surgical Center (ASC) Services with a $200 copay. Outpatient Substance Abuse Services are partially covered, with Individual and Group Sessions for Outpatient Substance Abuse not covered, and Outpatient Blood Services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the Jefferson Health Plans Platinum (HMO) plan, with a $55 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Jefferson Health Plans Platinum (HMO) plan. Ground Ambulance Services have a $210 copay, while Air Ambulance Services have a 20% coinsurance, and Transportation Services are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered. Emergency Services has a $100 copay, Urgently Needed Services has a $10 copay, and Worldwide Emergency Services has a maximum plan benefit coverage of $50,000. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Jefferson Health Plans Platinum (HMO) plan covers primary care physician services, occupational therapy services, physician specialist services, podiatry services, other health care professional services, physical therapy and speech-language pathology services, and opioid treatment program services. Chiropractic Services and Mental Health Specialty Services require prior authorization, and Routine Chiropractic Care, Individual Sessions for Mental Health Specialty Services, and Group Sessions for Mental Health Specialty Services, Individual Sessions for Psychiatric Services, and Group Sessions for Psychiatric Services are not covered. Physical Therapy and Speech-Language Pathology Services have a $25 copay, and no coinsurance.
Preventive Services See details
Preventive services are covered by the Jefferson Health Plans Platinum (HMO) plan, including Medicare-covered services with prior authorization, an annual physical exam, and other preventive services like Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit. The plan does not cover 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, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), Home and Bathroom Safety Devices and Modifications, or Counseling Services.
Hearing Services See details
Hearing services include routine hearing exams with a $35 copay for one visit every year, but fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids are not covered.
Vision Services See details
Vision services include routine eye exams, with a $40 copay. Eyeglasses (lenses and frames) are covered, with one pair per year and a maximum plan benefit coverage amount of $200. Contact lenses are covered, and eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services include coverage for Medicare dental services with a $40 copay, oral exams with a copay of $40 for up to 3 visits per year, dental x-rays, other diagnostic dental services, prophylaxis (cleaning) with a copay of $40 for up to 3 visits per year, other preventative dental services, restorative services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, and oral and maxillofacial surgery. Fluoride treatment, adjunctive general services, implant services, and orthodontics are not covered. Orthodontic services have a maximum plan benefit coverage of $2,000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. For Medicare Part B Insulin Drugs, there is a $35 copay, with coinsurance between 0% and 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, there is coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Jefferson Health Plans Platinum (HMO) plan. The plan has a coinsurance between 20% and 20% for these services.
Medical Equipment See details
The Jefferson Health Plans Platinum (HMO) plan covers medical equipment, including Durable Medical Equipment (DME) with 20% coinsurance and Prosthetics/Medical Supplies with 20% coinsurance. Diabetic Equipment, including Diabetic Supplies with 0-20% coinsurance and Diabetic Therapeutic Shoes/Inserts with 20% coinsurance, are also covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Procedures/Tests with no copay, while Lab Services are not covered. Diagnostic Radiological Services have a copay of $200.00, and Therapeutic Radiological Services have 20% coinsurance. Outpatient X-Ray Services have a $25 copay.
Home Health Services See details
Home Health Services are covered by the Jefferson Health Plans Platinum (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but none of the sub-services are covered. The plan does not cover Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Jefferson Health Plans Platinum (HMO) plan, but require prior authorization. There is no copay for days 1-20, and a $203 copay for days 21-100.
Other Services See details
The Jefferson Health Plans Platinum (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 $125 every three months, including nicotine replacement therapy. Other services such as meal benefits, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and others are not covered.
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