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Jefferson Health Plans Giveback (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Jefferson Health Plans Giveback (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 Giveback (HMO) in 2025, please refer to our full plan details page.
Jefferson Health Plans Giveback (HMO) is a HMO plan offered by Thomas Jefferson University available for enrollment in 2025 to people living in Southeastern 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 Giveback (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 Giveback (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 Giveback (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 $125.00. 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 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 $8300.00 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 Giveback (HMO) plan has a $590 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy type. For preferred generic drugs at a standard pharmacy or through mail order, you'll pay a $10 copay. Standard generic drugs have a 20% coinsurance, while preferred brand drugs have a 35% coinsurance. 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 Giveback (HMO) plan offers a wide range of benefits with varying costs. This plan covers inpatient hospital stays with a $310 copay for the first 5 days, outpatient services with copays ranging from $40 to $350, and emergency services with a $100 copay. Primary care visits and many specialist services have copays between $15 and $40, and preventive services are generally covered with no copay. The plan also includes coverage for hearing and vision services, with copays for routine exams, and dental services with a $40 copay for Medicare dental services. Home health services have no copay, while durable medical equipment and some other services have a 20% coinsurance. Additional benefits include acupuncture with a $10 copay, and over-the-counter items with a maximum benefit.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered under this plan. For Inpatient Hospital-Acute, you will pay a $310 copay for days 1-5 and no copay for days 6-90; and for Inpatient Hospital Psychiatric, you will pay a $310 copay for days 1-5 and no copay for days 6-90. Additional days for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, as well as Non-Medicare-covered stays and upgrades are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, and ambulatory surgical center services, with copays of $350, $350, and $300 respectively. Outpatient substance abuse services are covered with a copay of $40 for both individual and group sessions, but outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Jefferson Health Plans Giveback (HMO) plan. This benefit has a $55 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Jefferson Health Plans Giveback (HMO) plan. Ground ambulance services have a $275 copay, while air ambulance services have a 20% coinsurance. Transportation services to plan-approved or any health-related locations are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Jefferson Health Plans Giveback (HMO) plan. Emergency Services have a $100 copay, and Urgently Needed Services have a $15 copay, and there is no coinsurance for either. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Jefferson Health Plans Giveback (HMO) plan covers primary care physician services, chiropractic services with a $15 copay, occupational therapy services with a $35 copay, physician specialist services with a $40 copay, and mental health specialty services with a $40 copay. The plan also covers podiatry services with a $40 copay, other health care professional services with a copay between $0 and $40, psychiatric services with a $40 copay, physical therapy and speech-language pathology services with a $40 copay, additional telehealth benefits with a copay between $0 and $40, and opioid treatment program services with a $40 copay. Routine chiropractic care is not covered.
Preventive Services See details
The Jefferson Health Plans Giveback (HMO) plan covers preventive services including Medicare-covered preventive services, annual physical exams, and additional preventive services, with some services like health education and in-home safety assessments not covered. The plan also covers kidney disease education services, glaucoma screening, diabetes self-management training, and other preventive services with no copay or coinsurance.
Hearing Services See details
Hearing services include routine hearing exams with a $40 copay, covered once per year, while fitting/evaluation for hearing aids, prescription hearing aids, and OTC hearing aids are not covered.
Vision Services See details
Vision services are covered, including routine eye exams with a $40 copay, contact lenses with no copay, and eyeglasses (lenses and frames). Eyeglasses (lenses and frames) are limited to one pair per year, with a maximum plan benefit coverage amount of $200. 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, along with oral exams and dental X-rays, both of which require prior authorization. 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 are also covered. Fluoride treatments, adjunctive general services, implant 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 Giveback (HMO) plan. Medicare Part B Insulin Drugs have a $35 copay and a coinsurance between 0% and 20%. Other Medicare Part B drugs, as well as Medicare Part B Chemotherapy/Radiation Drugs, have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Jefferson Health Plans Giveback (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits are covered by the Jefferson Health Plans Giveback (HMO) plan, including Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment. Diabetic Supplies have a coinsurance between 0% and 20%, 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 by the Jefferson Health Plans Giveback (HMO) plan. Diagnostic Procedures/Tests have a $20 copay, while Lab Services are not covered. Diagnostic Radiological Services have a $250 copay, Therapeutic Radiological Services have 20% coinsurance, and Outpatient X-Ray Services have a $30 copay.
Home Health Services See details
Home Health Services are covered by the Jefferson Health Plans Giveback (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 in practice, 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 Giveback (HMO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $203. Additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
The Jefferson Health Plans Giveback (HMO) plan covers acupuncture with a $10 copay and over-the-counter items, with a maximum benefit coverage amount of $30 every three months. Meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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