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D-SNP (HMO)
Coverage Details
To qualify for this plan you must be eligible for both Medicare and Medicaid.
New for 2025: Eligible members can receive a Benefits Mastercard Prepaid Card* to help pay for monthly healthy food and utility expenses. Learn more about Advantage MD’s Flex Card.
| Medical | |
|---|---|
| Medical Deductible | This plan does not have any medical deductibles. |
| Primary Care Provider Visit | $0 copay |
| Specialist Visit | $0 copay |
| Referrals | Required for Specialist Visits only |
| Urgent Care | $0 copay |
| Telehealth | $0 copay |
| Ambulatory Surgical Centers Outpatient Surgery | $0 copay |
| Emergency Care | $0 copay |
| Worldwide Emergency & Urgently Needed Services | Not covered |
| Inpatient Hospital Stay | $0 copay up to 90 days |
| Routine Podiatry Services | $0 copay (up to 12 times per year) |
| Acupuncture | Medicare-covered acupuncture: |
| Routine Chiropractic Services | Medicare-covered chiropractic care: Non-Medicare covered chiropractic care (12 routine chiropractic visits per year): |
| Hearing Aid Services | Medicare-covered hearing exam to diagnose and treat hearing and Routine hearing exam: Hearing aids: |
| Flex Card | Advantage MD’s Flex Card* is a prepaid card to help eligible members pay for monthly healthy food and utility expenses. Members receive a Benefits Mastercard Prepaid Card. Advantage MD loads the card every month with $90 ($45 for groceries and $45 for utilities). |
| Silver&Fit® Program | You pay nothing at participating fitness centers. |
| Prescription | |
| Pharmacy Deductible | $0 |
| Preferred Generic (Tier 1) | $0 for a one-month supply |
| Generic (Tier 2) | $10 for a one-month supply |
| Preferred Brand (Tier 3) | 25% ($35 for Select Insulins) for a one-month supply |
| Non-Preferred Drug (Tier 4) | 25% ($35 for Select Insulins) for a one-month supply |
| Specialty Tier (Tier 5) | 25% of the total cost of a one-month supply (long-term supply is not available) |
| Mail Order | Available |
| Vision | |
| Medicare-covered exam to diagnose and treat diseases and conditions of the eye | You pay nothing |
| Yearly Glaucoma Screening | You pay nothing |
| Routine Eye Exam | (1 every year)nYou pay nothing |
| Eyeglasses or Contact Lenses after Cataract Surgery | You pay nothing |
| Routine Eyewear | Our plan pays up to $400 every year for supplemental eyewear (retail or online) from any provider. |
| Dental | |
| Medicare-covered Dental Services | You pay nothing |
| Preventive Dental Services | Preventive dental services:nCleaning (2 cleanings per year): You pay nothing |
| Fluoride Treatments | Not covered |
| Comprehensive Dental Services | (Frequency dependent on procedure.)nThe plan has a maximum coverage amount of $2,500 per year for in-network non-Medicare-covered comprehensive dental services. Members are responsible for the difference between the allowed amount and the billed amount for any out-of-network services. |
| Optional Supplemental Benefits | Not available |
| Restorative services (such as inlays, onlays, crowns, resin restoration, etc.) | You pay nothing |
| Endodontics | You pay nothing |
| Periodontics | You pay nothing |
| Extractions | You pay nothing |
| Prosthodontics/Other oral/maxillofacial surgery/Other services (such as removable complete and partial dentures, repair or replace teeth in dentures, removal of exostosis, anesthesia, etc.) | You pay nothing |
| Documents | |
*The benefits mentioned are a part of special supplemental program for the chronically ill and include the following conditions: autoimmune disorders, cardiovascular disorders, chronic heart failure, diabetes, chronic lung disorders. Other conditions apply but are not listed in this disclaimer. Not all members qualify. Coverage of the item or service depends on the chronically ill classification as defined in 42 CFR §422.102(f)(1)(i)(A) and on Johns Hopkins Advantage MD’s SSBCI coverage criteria required by 42 CFR §422.102(f)(4).
2025 Plans
Johns Hopkins Advantage MD (HMO) has an in-network out-of-pocket maximum of $7,550. Johns Hopkins Advantage MD Tribute (HMO) has an in-network out-of-pocket maximum of $6,800. Johns Hopkins Advantage MD (PPO), Johns Hopkins Advantage MD Plus (PPO), Johns Hopkins Advantage MD Primary (PPO) have an in-network out-of-pocket maximum of $7,550 and a combined in- and out-of-network maximum of $11,300. Johns Hopkins Advantage MD D-SNP (HMO) has an in-network out-of-pocket maximum of $8,850.
For out-of-network benefits, you pay a percentage for most covered services.
Limitations: 1. Members are responsible for the difference between the allowed amount and the billed amount. For more information, please review the Evidence of Coverage. 2. The comprehensive dental benefit for the Optional Supplement benefits for the Johns Hopkins Advantage MD (HMO) and Johns Hopkins Advantage MD Plus (PPO) plan has a $1,000 Annual Maximum. The comprehensive dental benefit for the Johns Hopkins Advantage MD Tribute (HMO) and Johns Hopkins Advantage MD Primary (PPO) plan has a $2,000 Annual Maximum. The comprehensive dental benefit for the Johns Hopkins Advantage MD (PPO) plan has a $1,000 Annual Maximum.The comprehensive dental benefit for the Johns Hopkins Advantage MD D-SNP (HMO) plan has a $2,500 Annual Maximum.
Prior authorizations are required for the following: endodontics, general anesthesia when medically necessary and administered in connection with oral or dental surgery, oral surgery, periodontics, bridges, crowns, inlays, onlays, and dentures (full or partial).