Provider Partners Indiana Essential Plan (I-SNP) H4444 003 0 Plan Details
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*This plan is new and has not yet been rated by CMS.
Provider Partners Indiana Essential Plan (I-SNP) is a Institutional Medicare Special Needs Plan. The 2025 Annual Enrollment period starts October 15. Plan benefits begin January 1.
The delivery of healthcare services and costs by Provider Partners Health Plan of Indiana is different than Original Medicare. This private health insurance option may include additional benefits that are not provided by Medicare Part A and Part B.
Only individuals who meet all Institutional SNP qualification requirements are eligible to join this I-SNP plan.
Plan Basics | |
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Plan ID: | H4444-003-0 |
Plan Type: | HMO I-SNP |
Plan Year: | 2025 |
Premium: | $49.60/mo Plus your Part B premium. |
Health Plan Deductible: | $0.00 |
Out-of-Pocket Maximum: | 9,350.00 /yr |
Part B Reduction: | $0.00/mo |
Drug Plan Benefit: | $590.00 deductible |
Supplemental Benefits: | Vision, Hearing |
Availability: | See List |
Insured By: | Provider Partners Health Plan of Indiana |
Summary of Benefits |
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Health Plan Cost Sharing & Benefits
The following table is a summary of the most common out-of-pocket costs you will incur if you join this Provider Partners Health Plan of Indiana plan:
Healthcare Service | Member Cost |
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Doctor Visits (In-Network) | |
Primary: | 20% Coinsurance |
Specialist: | 20% Coinsurance Prior Authorization Required |
Preventive care: | 20% Coinsurance |
Foot Care (In-Network) | |
Foot exams and treatment (Medicare-covered): | 20% Coinsurance |
Routine foot care: | $0 |
Chiropractic Care (In-Network) | |
Medicare-covered chiropractic care: | 20% Coinsurance |
Routine chiropractic care: | $0 |
Emergency Care / Urgent Care | |
Emergency room care: | 20% Coinsurance |
Urgent care: | 20% Coinsurance |
Ground ambulance: | 20% Coinsurance |
Inpatient hospital coverage: | |
Outpatient hospital coverage: | 20% Coinsurance Prior Authorization Required |
Skilled Nursing Facility: | Unknown |
Optional supplemental benefits: | Not Covered |
Mental Health Services (In-Network) | |
Outpatient individual therapy visit with a psychiatrist: | 20% Coinsurance |
Outpatient group therapy visit with a psychiatrist: | 20% Coinsurance |
Inpatient hospital - psychiatric: | |
Outpatient group therapy visit: | 20% Coinsurance |
Outpatient individual therapy visit: | 20% Coinsurance Prior Authorization Required |
Rehabilitation Services (In-Network) | |
Physical therapy and speech and language therapy visit: | 20% Coinsurance Prior Authorization Required |
Occupational therapy visit: | 20% Coinsurance Prior Authorization Required |
Medical Equipment / Supplies (In-Network) | |
Diabetes supplies: | 20% Coinsurance |
Durable medical equipment (e.g., wheelchairs, oxygen): | 20% Coinsurance Prior Authorization Required |
Prosthetics (e.g., braces, artificial limbs): | 20% Coinsurance |
Diagnostic Procedures / Lab Services / Imaging (In-Network) | |
Diagnostic radiology services (e.g., MRI): | 20% Coinsurance Prior Authorization Required |
Lab services: | 20% Coinsurance Prior Authorization Required |
Outpatient x-rays: | 20% Coinsurance Prior Authorization Required |
Diagnostic tests and procedures: | 20% Coinsurance Prior Authorization Required |
Medicare Part B Drugs (In-Network) | |
Chemotherapy: | 20% Coinsurance |
Other Part B drugs (Medicare-covered) | 20% Coinsurance |
Feel free to download our Provider Partners Indiana Essential Plan Summary of Benefits information.
Supplemental Health Plan Benefits (H4444-003-0)
The following is a summary of the supplemental benefits Provider Partners Health Plan of Indiana includes with this plan:
Supplemental Healthcare Service | Member Cost |
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Preventive Dental | |
Oral exam (In-Network) | Not Covered |
Fluoride treatment (In-Network) | Not Covered |
Dental x-ray(s) (In-Network) | Not Covered |
Cleaning (In-Network) | Not Covered |
Comprehensive Dental | |
Periodontics (In-Network) | Not Covered |
Non-routine services (In-Network) | Not Covered |
Diagnostic services (In-Network) | Not Covered |
Extractions (In-Network) | Not Covered |
Endodontics (In-Network) | Not Covered |
Restorative services (In-Network) | Not Covered |
Prosthodontics, other oral/maxillofacial surgery, other services (In-Network) | Not Covered |
Hearing | |
Fitting/evaluation (In-Network) | Covered Limits may apply |
Hearing aids (In-Network) | Not Covered |
Hearing exam (In-Network) | Covered Limits may apply |
Vision | Maximum vision benefit: | $2.00 Every three years |
Eyeglasses (frames and lenses) (In-Network) | Not Covered |
Routine eye exam (In-Network) | Covered Limits may apply |
Contact lenses (In-Network) | Not Covered |
Prescription Drug Plan Costs & Benefits
Prescription Drug Plan Premium
Although the prescription drug plan (Part D) premium is bundled with the total plan cost, some plans have supplemental costs and/or offer low-income subsidy (LIS) assistance. The following table outlines the details of this plan's prescription drug plan premium.
Basic Part D Premium: | |
Supplemental Part D Premium: | |
Total Part D Premium: | |
Part D Premium with Full LIS Assistance: |
The Social Security Extra Help page has more information about the low-income subsidy (LIS) and how to enroll in the program.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $590.00. This is the amount you must pay at the pharmacy before Provider Partners Health Plan of Indiana begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, Provider Partners Indiana Essential Plan has out-of-pocket costs that you must pay when you pick up your prescriptions. The following table shows you those costs.
Drug Tier | Preferred | Standard |
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$0 copay on all covered generic and brand-name prescriptions. |
CMS 5-Star Rating Marks
Each year CMS rates Medicare Special Needs Plans in nine broad categories based on a 5-star system. The table below shows the quality ratings for this Provider Partners Health Plan of Indiana plan.
CMS Measure | Star Rating |
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2025 Overall Rating | |
Staying Healthy: Screenings, Tests, Vaccines | Plan too new to be measured |
Managing Chronic (Long Term) Conditions | Plan too new to be measured |
Member Experience with Health Plan | Plan too new to be measured |
Complaints and Changes in Plans Performance | Plan too new to be measured |
Health Plan Customer Service | Plan too new to be measured |
Drug Plan Customer Service | Plan too new to be measured |
Complaints and Changes in the Drug Plan | Plan too new to be measured |
Member Experience with the Drug Plan | Plan too new to be measured |
Drug Safety and Accuracy of Drug Pricing | Plan too new to be measured |
Plan Availability
Provider Partners Indiana Essential Plan (H4444-003-0) is available in the following locations (click to open):
Additional I-SNP Plan Options
Here are some additional Medicare SNP plans that might be worth reviewing:
- H4444-001-0: Provider Partners Indiana Advantage Plan ()
- H4444-002-0: Provider Partners Indiana Community Plan ()
- H4444-003-0: Provider Partners Indiana Essential Plan ()
Contact Provider Partners Health Plan of Indiana
Website: | Provider Partners Health Plan of Indiana Plan Page |
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Providers: | Provider Partners Health Plan of Indiana Providers Page |
Formulary: | Provider Partners Health Plan of Indiana Formulary Page |
Pharmacy: | Provider Partners Health Plan of Indiana Pharmacy Page |
New Member Health Plan Help: | (800)405-9681 |
New Member Health Plan TTY: | 711 |
New Member Part D Help: | (800)405-9681 |
New Member Part D TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Advantage program on www.medicare.gov.
Health Plan Compatibility
Medicare Advantage Special Need Plans are not compatible with most other forms of health insurance. If you have Medicare Part A and/or Medicare Part B and join a SNP plan, you will be disenrolled from Original Medicare. You cannot simultaneously enroll in an SNP plan and Medicare Supplement Insurance.
With a D-SNP, members retain their existing Medicaid plan and benefits. Veterans who have VA Health Benefits may also be able to receive care at their local VA hospital.
Citations & References
- Provider Partners Health Plan of Indiana, http://www.pphealthplan.com, Last Accessed October 13, 2024
- Medicaid.gov, "Medicaid & CHIP in Indiana", Last Accessed October 1, 2024
- CMS.gov, Landscape Source Files, Last Accessed October 2, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed October 2, 2024
- CMS.gov, Plan Benefits Package, Last Accessed October 5, 2024
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.