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Jefferson Health Plans Dual Pearl (HMO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Jefferson Health Plans Dual Pearl (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 Dual Pearl (HMO D-SNP) in 2025, please refer to our full plan details page.
Jefferson Health Plans Dual Pearl (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. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Jefferson Health Plans Dual Pearl (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 Dual Pearl (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 Dual Pearl (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 Dual Pearl (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 Dual Pearl (HMO D-SNP) has a $590 deductible for prescription drugs. If you qualify for the low-income subsidy, your monthly Part D premium will be $48.40. During the initial coverage phase, after you meet your deductible, you will pay the costs for drugs in each tier until your total drug costs reach $2000. After your yearly out-of-pocket drug costs reach $2000, you pay nothing for Medicare Part D covered drugs.
Additional Benefits
The Jefferson Health Plans Dual Pearl (HMO D-SNP) plan offers a variety of health benefits. Many services, such as ambulance, transportation, home health, and diagnostic services, have no copay. Other services, like outpatient, primary care, and vision, have a 20% coinsurance. The plan also includes additional benefits such as hearing, dental, and home infusion services with varying cost-sharing. It also covers acupuncture and over-the-counter items. However, some services like cardiac rehabilitation are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered and require prior authorization. The plan's coinsurance details are available elsewhere. Additional days, non-Medicare-covered stays, and upgrades for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services, observation services, ambulatory surgical center (ASC) services, and outpatient substance abuse services. Outpatient hospital and observation services have a 20% coinsurance, while the plan has a minimum and maximum 20% coinsurance for Ambulatory Surgical Center (ASC) Services and Outpatient Substance Abuse Services. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Jefferson Health Plans Dual Pearl (HMO D-SNP) plan and requires prior authorization. You will pay a 20% coinsurance for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required for all ambulance services. Ground and air ambulance services have a 20% coinsurance, and there is no copay. Transportation Services to a plan-approved health-related location are covered, with no copay or coinsurance, and the plan covers one-way rideshare services, bus/subway, medical transport, and other transportation. Transportation Services to any other health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by the Jefferson Health Plans Dual Pearl (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, while Occupational Therapy Services, Mental Health Specialty Services, Psychiatric Services, and Opioid Treatment Program Services have a 20% coinsurance. Chiropractic Services are covered with a 20% coinsurance, but Routine Chiropractic Care is not covered. Podiatry Services are covered with a 20% coinsurance for Routine Foot Care.
Preventive Services See details
Preventive services include coverage for Medicare-covered zero dollar preventive services with prior authorization, Annual Physical Exams with 20% coinsurance, and additional preventive services. Other services such as Health Education, In-Home Safety Assessment, and Personal Emergency Response System (PERS) are not covered.
Hearing Services See details
Hearing Services include hearing exams with a coinsurance of at most 20% and an annual allowance of $1,500 for prescription hearing aids, while fitting/evaluation for hearing aids, prescription hearing aids - inner ear, prescription hearing aids - outer ear, prescription hearing aids - over the ear, and OTC hearing aids are not covered. Routine hearing exams are covered once per year.
Vision Services See details
Vision services include coverage for eye exams with a 20% coinsurance. Eyewear benefits include coverage for contact lenses, and eyeglasses (lenses and frames), while eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services are covered, including oral exams (3 visits per year), dental x-rays (1 per year), other diagnostic dental services, prophylaxis (cleaning), restorative services, endodontics, periodontics, prosthodontics (removable), maxillofacial prosthetics, implant services, and prosthodontics (fixed), with some services requiring prior authorization. Fluoride treatment, adjunctive general services, oral and maxillofacial surgery, and orthodontics are not covered. Orthodontic Services has a maximum plan benefit of $10,000 per year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs. 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, coinsurance is between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Jefferson Health Plans Dual Pearl (HMO D-SNP) plan with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment with 20% coinsurance for covered supplies, though Durable Medical Equipment for use outside the home is not covered. There is no copay for any of these services.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including all diagnostic services, diagnostic procedures/tests, and lab services, with no copay and a coinsurance of at most 20%. Additionally, all radiological services, diagnostic radiological services, therapeutic radiological services, and outpatient X-ray services are covered, with no copay and a coinsurance of at most 20%.
Home Health Services See details
Home Health Services are covered by the Jefferson Health Plans Dual Pearl (HMO D-SNP) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires authorization.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Jefferson Health Plans Dual Pearl (HMO D-SNP) plan. This includes 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 Dual Pearl (HMO D-SNP), but additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered. Prior authorization is required, and coinsurance applies.
Other Services See details
The Jefferson Health Plans Dual Pearl (HMO D-SNP) plan covers acupuncture with a limit of 20 treatments per year, and also covers over-the-counter items with a maximum benefit coverage amount of $245 every three months. The plan also provides a meal benefit for medical conditions that require the enrollee to stay home. However, 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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