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Provider Partners Maryland Essential Plan (I-SNP) H8067 004 0 Plan Details

This page provides coverage and cost details for Provider Partners Health Plans’s H8067-004-0 Medicare SNP plan for 2025. Enrollment is subject to eligibility.

CMS 2025 Rating: ☆☆☆☆☆*

*This plan is new and has not yet been rated by CMS.

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system. The Provider Partners Health Plans logo is a registered trademark.[2] Its use by MedicareWire is strictly for editorial purposes. This is not a solicitation of insurance.

This private health insurance option offers all of the same basic benefits as Original Medicare, but out-of-pocket costs are different. It may include additional benefits that Medicare Part A and Part B do not cover.

Individuals must meet all Institutional SNP qualification requirements to join this I-SNP plan.

Provider Partners Maryland Essential Plan Basic Plan Details

Plan ID
H8067-004-0
Plan Type
HMO I-SNP
Plan Year
2025
Premium
$19.10/mo
Plus your Medicare Part B premium.
Health Plan Deductible
$0.00
Out-of-Pocket Maximum
9,350.00 /yr (in-network)
Part B Reduction
$0.00/mo
Drug Plan Benefit
Basic
$590.00 deductible
Supplemental Benefits
Vision, Hearing
Availability
See List
Insured By
Provider Partners Health Plans

Health Plan Out-of-Pocket Costs

The following table is a summary of the most common out-of-pocket costs you will incur if you join this Provider Partners Health Plans plan:

Doctor's Office Visits

Primary
20% Coinsurance
Specialist
20% Coinsurance
Prior Authorization Required

Emergency, Urgent, and Inpatient Hospital Coverage

Emergency room care
20% Coinsurance
Urgent care
20% Coinsurance
Ground ambulance
20% Coinsurance
Inpatient hospital care
Skilled Nursing Facility

Foot Care

Foot Exams and Treatments (Medicare-covered)
20% Coinsurance
Routine Foot Care
Not Covered

Chiropractic Care

Medicare-covered chiropractic
20% Coinsurance
Routine chiropractic
Not Covered

Mental Health Services

Outpatient individual therapy
20% Coinsurance
Outpatient group therapy
20% Coinsurance
Inpatient psychiatric hospital care

Rehabilitation Services

Physical therapy and speech and language therapy
20% Coinsurance
Prior Authorization Required
Occupational therapy
20% Coinsurance
Prior Authorization Required

Medical Equipment and Supplies

Diabetes supplies
20% Coinsurance
Durable medical equipment
20% Coinsurance
Prior Authorization Required
Prosthetics
20% Coinsurance

Diagnostics, Lab Services, and Imaging

Diagnostic radiology services
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

Chemotherapy
20% Coinsurance
Other Part B drugs (Medicare-covered)
20% Coinsurance

Dental Services

Medicare Covered Preventive Dental
20% Coinsurance
Oral exam
$0
Dental x-rays
$0
Cleaning
$0
Periodontics
Not Covered
Endodontics
Not Covered
Restorative Services
Not Covered
Maximum dental benefit
$3,000.00 (Every year)

Hearing Aids and Services

Fitting/evaluation
Covered
Limits may apply
Hearing aids
Not Covered
Hearing exam
Covered
Limits may apply

Vision Services

Medicare-covered eye exam
20% Coinsurance
Routine eye exam
Covered
Limits may apply
Eyewear benefits
None

Prescription Drug Costs & Benefits

Provider Partners Maryland Essential Plan includes an basic benefit Medicare Part D plan (PDP). This simply means that the plan covers the minimum amount required by the Centers for Medicare & Medicaid Services, whereas enhanced benefit plans cover more.

Prescription Drug Premium with Extra Help

Extra Help is a Social Security program that helps people with limited income and resources lower or cut Part D costs. The following table outlines premium assistance details with Extra Help.

Low Income Premium Subsidy: ${part_d_lips_amount}
Low Income Premium Subsidy CMS Pays: $19.10
Low Income Subsidy Premium: $0.00

If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.

Prescription Drug Deductible

The Medicare Part D annual deductible with this plan is $590.00. You must pay this amount at the pharmacy before Provider Partners Health Plans begins paying its share.

Prescription Drug Out-of-Pocket Costs

In addition to the plan's monthly premium and deductible, Provider Partners Maryland Essential Plan has out-of-pocket costs you must pay when you pick up your prescriptions.

Drug Tier Retail Mail Order
Cost data not available.
*The Part D deductible does not apply.

How to Qualify to Enroll in
Provider Partners Maryland Essential Plan

To be eligible to enroll in Provider Partners Maryland Essential Plan, you must meet three requirements:

  1. You are eligible for Medicare;
  2. You live in Allegany County (the plan’s service area); and
  3. You require the level of care provided in an institutionalized setting, such as a long-term care nursing facility, for 90 days or more.

If you live at home and require an equivalent level of skilled care, you may be eligible for an Institutional Equivalent Special Needs Plan (IE-SNP).

Before joining Provider Partners Maryland Essential Plan, consider these questions:

  • Does the plan's provider network include my nursing home or home care provider?
  • What costs should I expect with my coverage (premiums, deductibles, copayments)?
  • Is there an annual limit on my out-of-pocket costs?
  • Will I be able to use my doctors? Are they in the plan's network?
  • Are the plan's in-network providers and facilities in convenient locations?
  • Does the plan provide coverage for services I receive from out-of-network providers?
  • Do I need a referral to see a specialist?
  • Are my medications on the Part D plan's formulary?
  • What special accommodations does the plan make for persons with disabilities?
  • What special language and cultural accommodations does the plan make?