This is a special kind of Medicare Advantage HMO plan called a Dual Eligible Special Needs plan (or HMO D-SNP). It provides extra benefits for no additional cost to people who qualify for both Medicare and Medicaid. It combines your Original Medicare benefits, your Part D prescription drug coverage, and your Medicaid benefits.
HMO stands for Health Maintenance Organization. As a member of this plan, you must use in-network providers to get your medical care and services. Nearly every doctor in the region is accepted so finding a doctor is easy. To find a provider near you, click on Find a Doctor.
|2022 PacificSource Dual Care** (HMO D-SNP)
$0 per month
|Annual Medical Deductible||$0|
|Referrals||No Referrals Required|
|Annual Out-of-Pocket Maximum
|Primary Care Provider||$0 copay|
|Advanced Diagnostics||$0 copay|
|Outpatient Surgery||$0 copay|
|Physical Therapy||$0 copay|
|Skilled Nursing Facility||$0 copay|
|Durable Medical Equipment||$0 copay|
|Ambulance (Ground and Air)||$0 copay|
|Part B Drugs
|Bone Mass Measurement (Diagnostic and Screening)||$0 copay|
|Mammograms (Preventive and first Diagnostic exam per calendar year)||$0 copay|
|Prostate Cancer Screenings||$0 copay|
|Cardiovascular Disease Testing||$0 copay|
|Flu and Pneumonia shots||$0 copay|
|Colorectal Cancer Screenings
(Preventive and Diagnostic)
|Pap and Pelvic Exams||$0 copay|
|Annual Wellness Visit||$0 copay|
|Diabetes Screening||$0 copay|
|Preventive Dental||Covered with limitations|
|Comprehensive Dental||Covered with limitations|
|Annual Physical Exams||$0 copay|
|Routine Vision Exams||$0 copay|
|Routine Hearing Exams||Covered with limitations|
|Eyeglasses and Contacts||$250 allowance per calendar year|
|24-Hour NurseLine||$0 copay|
|Silver&Fit© Fitness Program||$0 copay|
|Alternative Care||$0 copay
12 combined visits total
Additional visits for acupuncture, chiropractic care, massage, and yoga are covered for treatment of a covered illness or injury through your Medicaid coverage. Prior authorization is required.
|Chronic Care Management
Transitional Care Management
|Over-the-Counter (OTC)||$100 allowance per quarter|
|Telehealth Services||$0 copay|
|Assist America® Travel Benefits||Not Covered|
|Meal Delivery Following Hospital or Nursing Facility Stay||$0 copay
28 meals for 14 days
|Rewards & Incentives: earn gift cards for completing preventive care activities||Included
Up to $205 in rewards, see Evidence of Coverage for details
|Worldwide Coverage for Travelers||In-Network|
|Ambulance (Ground and Air)||N/A|
|Part D Prescription Drug Benefits||Standard Retail & Mail Pharmacies|
$0, $1.35 or $3.95 copay
$0, $4.00 or $9.85 copay
Generic: $0, $1.35 or $3.95 copay
Generic: $0, $1.35 or $3.95 copay
Select Care Drugs
|STAGE THREE||What you pay after total drug costs4 reach $4,430|
$0, $1.35 or $3.95 copay
$0, $4.00 or $9.85 copay
|Additional Gap Coverage
|STAGE FOUR||After your out-of-pocket costs5 reach $7,050, the maximum you pay until the end of the calendar year|
|All Covered Drugs||
**This plan has special enrollment requirements. To be eligible, you must qualify for full Medicaid benefits and Medicare. Cost shares, benefits, premiums, and deductibles listed reflect Medicare and Medicaid coverage. Your costs may vary if your Medicaid eligibility category and/or the level of Extra Help you receive changes.
4 Total Drug Costs: Both what you, and others on your behalf pay, and what PacificSource Medicare pays for your prescriptions.
5 Out-of-Pocket Costs: Everything you, and others on your behalf, have paid during Stage Two and Stage Three.
As a member, you can enjoy the Silver&Fit® Healthy Aging and Fitness program at no additional cost beyond your monthly premium. Or for an additional buy-up price, you can join a Premium location.
The Silver&Fit program gives you the digital tools and personalized support you need to enjoy a better life balance. This benefit includes:
Silver&Fit is provided by American Specialty Health Fitness, Inc. a subsidiary of American Specialty Health Incorporated (ASH). Silver&Fit is a federally registered trademark of ASH.
The Dual Care plan includes several benefits for your hearing health. You are eligible for:
Prior authorization required for hearing aids and batteries.
You can earn valuable gift cards — just for completing preventive care services!
We think healthy behaviors should be rewarded. So we're pleased to give you a gift card to your choice of popular retail stores when you complete the preventive screenings shown below.
How it works: Just complete one or more of the $0 copay services below. Once your claim has been processed, you’ll receive a reward certificate in the mail. The certificate allows you to choose a gift card from hundreds of popular retail stores.
Rewards may be earned once per calendar year, except for colonoscopy, which is eligible for a reward once every 10 years.
|Routine physical or annual wellness visit||$50|
|Diabetic A1c (blood glucose test)||$15 - First test
$25 - Second test
|Diabetic eye exam||$25|
|Colonoscopy or Fit Kit||$20|
|Health Risk Assessment||$15|
A few key details
When you’re recovering from a hospital stay, the last thing you need to worry about is cooking. Our plans include 28 home-delivered meals after a recent hospital or nursing facility stay.
Toll-free: 855-834-6150, TTY 711
Have a health-related question? Our 24-Hour NurseLine is staffed around the clock, 7 days a week, and there’s no cost to you. When you have a concern that is not life threatening, you can receive trusted health information and advice from the comfort of your home.
$400 for hundreds of over-the-counter items ($100 per quarter) provided through Nations OTC. Contact Customer Service for more information.
The following benefits and services are available to PacificSource Medicare members at no additional cost:
The following are some of the items and services that aren’t covered under Original Medicare or by our plans. This is a partial list and does not include all limitations and exclusions. For a detailed list, please see your Evidence of Coverage.
We understand the importance of choosing a plan that best fits your needs. Start by comparing benefits, copays, coinsurance, monthly premiums, and prescription drug coverage. The links and documents below will help you decide on a plan.
Below you'll also find the D-SNP eligibility requirements, enrollment dates, and ways to enroll.
PacificSource Dual Care (HMO D-SNP) is available to you, if:
When you can enroll in PacificSource Dual Care (HMO D-SNP) depends on your current situation.
If you have just become eligible for Medicare and full Medicaid benefits:
If you already have both Medicare and Medicaid, or are already enrolled in a D-SNP, you can enroll in or switch D-SNP plans:
When your coverage begins depends on your situation and when you submit your application. If you’re already on Medicare, it could be as soon as the first day of the month after we receive your application.
Please contact us for details.
888-992-9215, TTY 711
October 1 – March 31: 7 days a week, 8 a.m. – 8 p.m.
April 1 – September 30: Monday – Friday, 8 a.m. – 8 p.m.
We offer a variety of ways to enroll:
Use our online enrollment center.
We’re here to help. Simply contact us.
Contact a broker
PacificSource Medicare partners with select local insurance producers (brokers) who can help. Or call us for assistance.
Contact a community partner
Trained community partners across the state can help you fill out an application. It's free.
Visit OregonHealthCare.gov to find community partners in your area.
After you enroll in a PacificSource Medicare plan we will send your completed enrollment form to the Centers for Medicare & Medicaid Services (CMS) for approval. Once we receive confirmation from CMS, we will send you a confirmation letter.
You will also receive your new member packet and ID card within 10 business days after we receive confirmation from CMS. Your coverage will begin on your effective date. If you have any questions, please call or email us.
Members may enroll in the plan only during specific times of the year. You must have Part A and Part B to enroll in the plan. Contact us for more information.
Original Medicare Includes Part A and Part B:
Part A - Hospital Insurance:
Part A helps cover inpatient care in hospitals, skilled nursing facilities (not custodial or long-term care), hospice and some home health care. Many people automatically get Part A after you get disability benefits from Social Security. Most people don't pay a premium for Part A because they or a spouse already paid for it through their payroll taxes while working.
Part B - Medical Insurance:
Part B helps cover doctors' services, outpatient hospital care, preventive care, physical and occupational therapists, and some home health care. Most people pay a monthly premium for Part B. You will need to sign up for Part B during your initial enrollment period (the 7-month period that begins 3 months before the month you turn age 65, includes the month you turn age 65, and ends 3 months after the month you turn age 65). If you don’t sign up for Part B when you are first eligible, you may have to pay a late enrollment penalty.
Part C – Medicare Advantage Plans:
Part C is Medicare Advantage plans (like HMO and PPO plans). PacificSource offers Medicare Advantage Plans. Part C is health coverage run by private companies like PacificSource under contract with Medicare. These plans include both Medicare Part A and Part B in the convenience of one plan and fill in some of the gaps in Medicare coverage. Some plans also include Part D Prescription drug coverage and preventive dental in the convenience of one plan. Most people will pay a monthly premium for this coverage. You must continue to pay your Part B premium and must have both Part A and Part B to enroll.
Part D - Prescription Drug Coverage:
Part D is prescription drug coverage run by private companies approved and under contract with Medicare. These plans help lower prescription drug costs and help protect against higher costs in the future. Like other insurance, if a beneficiary decides not to enroll in a drug plan when they are first eligible, they may pay a penalty if they choose to join later. Most people will pay a monthly premium for this coverage.
You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:
Below are some of the costs you will pay if you only had original Medicare‡:
Part B (Medical)
Part A (Hospital)
Part D (Prescription)
‡ The costs above are for 2022, and may change for 2023.
* Most people will pay the standard monthly Part B premium. However, some people will pay a higher premium because of their yearly income (over $85,000 for singles, $170,000 for married couples). For more information about Part B premiums based on income, call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users should call 877-486-2048. You may also call Social Security at 800-772-1213. TTY users should call 800-325-0778.
There are some limitations to Original Medicare. In most cases, the following are not covered:
If you decide you need extra coverage in additional to Original Medicare, you have two options for purchasing additional coverage through Medicare Advantage and Medicare Supplement plans. On both plans, you are still on Medicare. Here are the main differences between these plans:
Medicare Advantage Plan (like PacificSource Medicare plans)
These plans (PacificSource Medicare HMO and PPO plans) fill in the gaps by covering some of the costs Medicare does not cover. We provide more benefits than Medicare alone and Medigap plans. And we provide personal service to make it easy.
We offer a variety of plans to meet your needs, including low-priced plans to help save you money. You will also get the convenience of plans that include medical (Part A and Part B) and prescription drug coverage (Part D) all in one plan. Most of our Medicare Advantage plans include dental benefits. We also have the option to add preventive or comprehensive dental coverage for an additional monthly premium. For those who qualify for both Medicare and Medicaid, we also offer a dual special needs plan.
Finding a doctor is easier because nearly every doctor in the region is accepted by PacificSource. And, with all our Explorer plans, you have the freedom to see any doctor you want that accepts Medicare wherever you are in the United States. Rest assured you are covered when you travel with worldwide urgent and emergency care.
When you go to the doctor you will need only one ID card: your PacificSource Medicare ID card. The front of the card will show whether you have medical, prescription drug, and/or preventive dental coverage. The doctor will need to send the bill to only one company, your Medicare Advantage plan like PacificSource Medicare. We will pay the bills on behalf of Medicare. Medicare reimburses us for their portion of the costs. Since we deal directly with Medicare, you and your doctor will have less paperwork.
Monthly premiums are the same for all ages. Everyone on one plan will pay the same premium for that year.
For more information on Medicare Advantage plans, or to enroll, please call: 866-282-8814, TTY 711
Medicare Supplement Plan (Medigap)
These plans also fill in the gaps in Medicare coverage. Original Medicare will cover the services under Part A and Part B. The Medigap plan will then cover some of the additional costs Medicare did not cover. If you also wanted Part D coverage, you would need to purchase a Part D prescription drug plan in addition to your Medigap plan.
Not all doctors accept Original Medicare. If your doctor does not accept Original Medicare, then you will either need to find another doctor, pay for the services yourself, or enroll in a plan that has a contract with your doctor. Generally, services outside the United States are not covered.
When you go to the doctor you will need two ID cards: your red, white, and blue Medicare card and your Medigap card. The doctor will need to send the bill to two places: first to Medicare to pay their portion and then to your Medigap plan to pay the plan's portion.
Monthly premiums are based on your age.
Call 1-800-MEDICARE (1-800-633-4227) or visit www.medicare.gov for more information about Medicare benefits and services including general information regarding medical or Part D benefits. TTY users should call 877-486-2048, 24 hours a day/7 days a week.