| Dual Plus (HMO D-SNP) | Medicaid OHP | |
|---|---|---|
| Inpatient Hospital Coverage1 | $0 copay | $0 copay for Medicaid-covered services |
| Outpatient Hospital Coverage1 | $0 copay | $0 copay for Medicaid-covered services |
| Ambulatory Surgery Center1 | $0 copay | $0 copay for Medicaid-covered services |
| Primary Care Provider visit | $0 copay | $0 copay for Medicaid-covered services |
| Specialist visit | $0 copay | $0 copay for Medicaid-covered services |
| Preventive Care | $0 copay | $0 copay for Medicaid-covered services |
| Emergency Care | $0 copay | $0 copay for Medicaid-covered services |
| Urgently Needed Services | $0 copay | $0 copay for Medicaid-covered services |
Plan Details
Providence Medicare Dual Plus (HMO D-SNP)
Overview
|
Monthly Premium |
$0 |
|
Annual Deductible |
$0 per year |
|
Maximum Out-of-Pocket |
$0 In-network |
Additional Benefits
$450/every 6 months for dental services
$40 quarterly for OTC items
$200 quarterly for food & produce if you qualify*
$0 eye exam and $150 for glasses
24 one-way rides for non-medical transportation if you qualify*
$0 gym membership
These amounts depend on your level of Medicaid eligibility. Providence Medicare Dual Plus (HMO D-SNP) is available to you if you have Medicare Part A and B, you have full Oregon Health Plan (OHP) Medicaid benefits, and you live in Clackamas, Multnomah, or Washington County. You must continue to pay your Medicare Part B premium. The Part B premium is covered for full dual enrollees who are eligible for Providence Medicare Dual Plus (HMO D-SNP). Premiums, co-pays, co-insurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.
*This benefit is part of a special supplemental program for the chronically ill. Members with diabetes mellitus, chronic and disabling mental health conditions, cardiovascular disorders, chronic lung disorders, neurologic disorders, and other eligible conditions not listed may qualify to receive this benefit. Eligibility for this benefit cannot be guaranteed based solely on your condition. All applicable eligibility requirements must be met before the benefit is provided. For more details, please contact us at 1-833-949-0263 (TTY: 711), 8 a.m. to 5 p.m. (Pacific Time) Monday - Friday.
Maximum Out-of-Pocket: You are not responsible for paying any out-of-pocket costs toward the maximum out-of-pocket amount for covered Part A and Part B services. Your yearly limit(s) in this plan in-network: $9,250. Additionally, maximum Out-of-pocket (does not include Rx drugs).
Important information about this plan
This plan is available in Clackamas, Multnomah, and Washington Counties in Oregon.
Does not include any Part B premium you may have to pay. You must continue to pay your Medicare Part B premium.
- Find out if you qualify for Extra Help with your premiums
- Medical appeals, determination, and grievance processes
For more information about Providence Medicare Advantage Plans, please contact the sales team.
This information is available in a different format, including audio CDs. If you need plan information in another format, please call Customer Service at 503-574-8000 or 1-800-603-2340 (TTY: 711). Service is available between 8 a.m. to 8 p.m. (Pacific Time) 7 days a week from October 1st through March 31st and Monday - Friday, from April 1st through September 30th.
Important note about these benefits
Providence Medicare Dual Plus (HMO D-SNP) is available to you if you have Medicare Part A and B, you have full Oregon Health Plan (OHP) Medicaid benefits, and you live in Clackamas, Multnomah, or Washington County. You must continue to pay your Medicare Part B premium. The Part B premium is covered for full dual enrollees who are eligible for Providence Medicare Dual Plus (HMO D-SNP). Please contact the plan for further details.
Benefit Summary
-
Benefits
-
Diagnostic Services + Labs & Imaging1
Dual Plus (HMO D-SNP) Medicaid OHP Diagnostic radiology services (e.g. MRI, ultrasounds, CT Scans) $0 copay $0 copay for Medicaid-covered services Therapeutic radiology services $0 copay $0 copay for Medicaid-covered services Outpatient x-rays $0 copay $0 copay for Medicaid-covered services Diagnostic test and procedures $0 copay $0 copay for Medicaid-covered services Lab services $0 copay $0 copay for Medicaid-covered services -
Hearing Services
Dual Plus (HMO D-SNP) Medicaid OHP Medicare-covered $0 copay $0 copay for Medicaid-covered services -
Dental Services
Dual Plus (HMO D-SNP) Medicaid OHP Medicare-covered 20% of the total cost $0 copay for Medicaid-covered services Flex Dental Card $450 every 6 months to spend on dental services $0 copay for Medicaid-covered services -
Vision Services
Dual Plus (HMO D-SNP) Medicaid OHP Medicare-covered $0 copay $0 copayment for Medicaid-covered services; Medical eye exam once every 24 months for adults age 21 or older Routine exam There is no coinsurance or copayment for one routine vision exam (including refraction) per calendar year $0 copayment for Medicaid-covered services; once every 24 months for adults age 21 or older Medicare-Covered Eyewear $0 copay for one pair of Medicare-covered eyeglasses or contact lenses after each cataract surgery. $0 copayment for Medicaid-covered services; only for specific medical conditions Routine eyeglasses or contact lenses Allowance of up to $150 per calendar year for any combination of routine prescription eyewear $0 copayment for Medicaid-covered services; only for specific medical conditions -
Mental Health Services1
Dual Plus (HMO D-SNP) Medicaid OHP Inpatient visit $0 copay for each benefit period
$0 copay for days 1-60
$0 copay each day for days 61-90
$0 copay per each "lifetime reserve day" for days 91-190
You pay for all costs beyond lifetime reserve days$0 copay for Medicaid-covered services Outpatient individual and group therapy visit $0 copay $0 copay for Medicaid-covered services -
Skilled Nursing Facility1
Dual Plus (HMO D-SNP) Medicaid OHP Skilled Nursing Facility $0 copay $0 copay for Medicaid-covered services. Medicaid covers up to 20 days in a SNF. -
Physical Therapy1
Dual Plus (HMO D-SNP) Medicaid OHP Physical Therapy $0 copay $0 copay for Medicaid-covered services -
Ambulance1
Dual Plus (HMO D-SNP) Medicaid OHP Ambulance $0 copay $0 copay for Medicaid-covered services -
Transportation
Dual Plus (HMO D-SNP) Medicaid OHP Transportation: (This plan includes non-medical transportation) $0 copay for 24 one-way trips (max of 25 miles each way) if you qualify*
*This benefit is part of a special supplemental program for the chronically ill. Members with diabetes mellitus, chronic and disabling mental health conditions, cardiovascular disorders, chronic lung disorders, neurologic disorders, and other eligible conditions not listed may qualify to receive this benefit. Eligibility for this benefit cannot be guaranteed based solely on your condition. All applicable eligibility requirements must be met before the benefit is provided. For more details, please contact us at 1-833-949-0263 (TTY: 711), 8 a.m. to 5 p.m. (Pacific Time) Monday - Friday.$0 copay for Medicaid-covered services; non-emergency medical transportation to covered appointments -
Medicare Part B Drugs1
Dual Plus (HMO D-SNP) Medicaid OHP Medicare Part B Drugs $0 copay $0 copay for Medicaid-covered services -
Meal Delivery Program
Dual Plus (HMO D-SNP) Medicaid OHP Meal Delivery Program
(post-discharge only)$0 copay for 2 meals per day for 28 days, following a qualifying inpatient hospitalization Not covered -
Flex Card
Dual Plus (HMO D-SNP) Medicaid OHP Over-the-Counter Items $40 quarterly for OTC.
Use your card to by eligible over-the-counter items. (Retail card, catalog, online ordering and telephonic ordering.)
Unspent dollars will rollover from quarter to quarter then expire on December 31, 2026 at 11:59 p.m.Not covered Food and Produce $200 quarterly for groceries if you qualify*
Use your card to buy eligible health food items (retail only).
Unspent dollars will rollover from quarter to quarter then expire on December 31, 2026 at 11:59 p.m.
*This benefit is part of a special supplemental program for the chronically ill. Members with diabetes mellitus, chronic and disabling mental health conditions, cardiovascular disorders, chronic lung disorders, neurologic disorders, and other eligible conditions not listed may qualify to receive this benefit. Eligibility for this benefit cannot be guaranteed based solely on your condition. All applicable eligibility requirements must be met before the benefit is provided. For more details, please contact us at 1-833-949-0263 (TTY: 711), 8 a.m. to 5 p.m. (Pacific Time) Monday - Friday.Not covered -
Personal Emergency Response System
Dual Plus (HMO D-SNP) Medicaid OHP Personal Emergency Response System (PERS) $0 copay Not covered -
Fitness Program
Dual Plus (HMO D-SNP) Medicaid OHP Fitness Program $0 copay for monthly gym memberships with participating fitness clubs Not covered
1Services may require prior authorization.
Prescription Drugs
-
Prescription Drug Deductible
Yearly Deductible
Because there is no deductible for the plan, this payment stage does not apply to you.
-
For Generic Drugs
You Pay:
(including brand drugs treated as generic)$0, $1.60, or $5.10 copay -
For All Other Drugs
You Pay:
(You may get your drugs at network retail pharmacies and mail order pharmacies)$0, $4.90, or $12.65 copay If you reside in a long-term care facility, you pay the same as at a standard retail pharmacy. You may get drugs from an out-of-network pharmacy, but may pay more than you pay at an in-network pharmacy.
You may get drugs from a standard in-network pharmacy, but may pay more than you pay at a preferred in-network pharmacy. -
Participating Pharmacies
With thousands of pharmacies nationwide, we've got a pharmacy that's close to your home.
Explore our provider and pharmacy directory to search for a participating in-network pharmacy near you. To learn more about our formularies or more about our prescription drug coverage click here.
The Formulary and/or pharmacy network may change at any time. You will receive notice when necessary.
Important Message About What You Pay for Vaccines - Our plan covers most Part D vaccines at no cost to you. Call Customer Service for more information.
Important Message About What You Pay for Insulin - You won’t pay more than $35 for a one-month supply of each insulin product covered by our plan, no matter what cost-sharing tier it’s on.
Page current as of: 10/1/2025