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Call for a quote, to enroll, or for more info: 866-282-8814, TTY 711

2022 PacificSource Dual Care (HMO D-SNP) Plan


This plan has special enrollment requirements. To be eligible, you must qualify for full Medicaid benefits and Medicare.

This plan's premium is $0

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.

Am I eligible to enroll?

PacificSource Dual Care (HMO D-SNP) is available to you, if:
  • You qualify for Medicare Parts A and B
  • You're eligible or enrolled in full Medicaid benefits (The Oregon Health Plan)
  • You live in our service area: Clackamas, Crook, Deschutes, Hood River, Jefferson, Lane, Multnomah, Wasco, or Washington Counties, or northern Klamath zip codes 97731, 97733, 97737, and 97739

  • View Summary of Benefits

    The Summary of Benefits provides you with a summary of covered benefits. For each benefit, you can see what this plan covers and what Original Medicare covers. This plan offers all the benefits that Original Medicare offers, plus more.

  • Multi-language Interpreter Services

    We have free language interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 888-863-3637. This is a free service.



2022 PacificSource Dual Care** (HMO D-SNP)
$0 per month
Benefit Highlights In-Network
Annual Medical Deductible $0
Referrals No Referrals Required
Annual Out-of-Pocket Maximum
(Medical)
$6,700
Primary Care Provider $0 copay
Specialist $0 copay
Laboratory $0 copay
X-ray $0 copay
Advanced Diagnostics $0 copay
Hospitalization $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
Emergency Room
Urgent Care
$0 copay
Part B Drugs
(e.g., chemotherapy)
$0 copay
Preventive Care In-Network
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)
$0 copay
Pap and Pelvic Exams $0 copay
Annual Wellness Visit $0 copay
Diabetes Screening $0 copay
Extra Benefits In-Network
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
$0 copay
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
Urgent Care N/A
Emergency Room N/A
Ambulance (Ground and Air) N/A
Part D Prescription Drug Benefits Standard Retail & Mail Pharmacies
STAGE ONE
Deductible

$0

STAGE TWO
Tier 1
Preferred Generic

$0 copay

Tier 2
Generic

$0, $1.35 or $3.95 copay

Tier 3
Preferred Brand

$0, $4.00 or $9.85 copay

Tier 4
Non-Preferred Drug

Generic: $0, $1.35 or $3.95 copay
Brand: $0, $4.00 or $9.85 copay

Tier 5
Specialty

Generic: $0, $1.35 or $3.95 copay
Brand: $0, $4.00 or $9.85 copay

Tier 6
Select Care Drugs

$0 copay

STAGE THREE What you pay after total drug costs4 reach $4,430
Most Generic

$0, $1.35 or $3.95 copay

Most Brand

$0, $4.00 or $9.85 copay

Additional Gap Coverage
Selected Medications

$0 copay

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

$0 copay


**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.

Out-of-Pocket Costs: Everything you, and others on your behalf, have paid during Stage Two and Stage Three.


$0 Fitness Benefit


Silver and Fit logo 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:

  • A no-cost fitness center/YMCA membership at a participating location
  • One Home Fitness Kit per benefit year with wearable fitness tracker option
  • Digital workout videos on the Silver&Fit website or mobile app
  • Healthy Aging Coaching
  • And other member resources

Learn more at SilverandFit.com

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.

Hearing Benefits


The Dual Care plan includes several benefits for your hearing health. You are eligible for:

  • $0 Hearing exams. Some limitations apply.
  • $0 Hearing aids: One hearing aid for each ear every 5 years.
  • 60 hearing aid batteries per year.

Prior authorization required for hearing aids and batteries.

Vision Benefits


Our PacificSource Dual Care plan covers routine vision exams once per calendar year and routine prescription eyeglasses or contact lenses up to $250 benefit limit per year, with the freedom to choose the style you like best.

Telehealth Benefits


Video- and phone-based care with in-network providers, including primary care, specialists, and mental health, are covered for the same cost as an in-person visit. Subject to provider availability and limitations.

Rewards for Healthy Actions


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
Mammogram $25
Diabetic A1c (blood glucose test) $15 - First test
$25 - Second test
Diabetic eye exam $25
Flu shot $10
Dexa Scan $20
Colonoscopy or Fit Kit $20
Health Risk Assessment $15

A few key details

  • There are no copays for these services (no cost to you).
  • No registration is needed.
  • There are no fees associated with gift card activation. Gift cards are valid for 18 months after date of issue.

For a full list of participating retailers, click here. To redeem your certificate, visit Engage.IncommIncentives.com/PacificSource.

Meals as Medicine


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.

  • Two meals per day for 14 days
  • Condition-specific menus, such as heart-healthy, diabetic friendly, and low-sodium
  • Vegetarian and kosher options
  • No extra cost to you, and no limit per calendar year

24-Hour NurseLine


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.

Over-the-Counter Benefits


$400 for hundreds of over-the-counter items ($100 per quarter) provided through Nations OTC. Contact Customer Service for more information.

Groceries for Eligible Members


$200 in groceries available to those with certain chronic conditions ($50 per quarter). This benefit is available to members with Congestive Heart Failure, Diabetes, and Chronic Lung disorders. Services provided through Nations OTC Food and Produce.

Additional Benefits and Plan Features


The following benefits and services are available to PacificSource Medicare members at no additional cost:

Plan Availability


The 2022 PacificSource Dual Care (HMO D-SNP) Plan service area includes the following counties in Oregon:

  • Clackamas
  • Crook
  • Deschutes
  • Hood River
  • Jefferson
  • Klamath: 97731, 97733, 97737, 97739
  • Lane
  • Multnomah
  • Wasco
  • Washington

Services Not Covered or Limited


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.

  • Care received in any non-Medicare approved hospital or skilled nursing facility
  • Cosmetic surgery or procedures
  • Custodial care
  • EBT (Electron-Beam Tomography) Scans
  • Elective or voluntary enhancement procedures, services, supplies, and medications
  • Experimental or investigational medical and surgical procedures, equipment, and medications
  • Immunizations for the sole purpose of travel
  • Incontinence supplies
  • Long-term services
  • Orthognathic Surgery for TMJ
  • Orthopedic shoes (some exceptions apply)
  • Private room in a hospital, unless medically necessary
  • Radial keratotomy, LASIK surgery, vision therapy, and other low vision aids and services
  • Routine dental care such as cleanings (unless your plan includes dental or you have purchased optional dental coverage), fillings, or dentures
  • Routine lab work, X-rays, or EKG’s done without medical indication except as outlined in the Preventive Services section of the Summary of Benefits
  • Items and services that are specifically excluded by Medicare, with exception of services listed in the benefit chart. To find out more, go to www.Medicare.gov/coverage .

Enrollment Resources


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.

  • View Summary of Benefits

    The Summary of Benefits provides you with a summary of covered benefits. For each benefit, you can see what this plan covers and what Original Medicare covers. This plan offers all the benefits that Original Medicare offers, plus more.

  • Attend a Seminar or Educational Class

    Attend one of our seminars about the plans we offer. Have questions about Medicare? Attend an educational class that is free to the public about Medicare (plan-specific information will not be shared).

  • Multi-Language Interpreter Services

    We have free language interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 888-863-3637. This is a free service.

  • Enrollment Form

    Use this form to enroll today or to change your plan.

Am I eligible to enroll in PacificSource Medicare?


PacificSource Dual Care (HMO D-SNP) is available to you, if:

  1. You qualify for Medicare Parts A and B
  2. You''re eligible or enrolled in full Medicaid benefits (The Oregon Health Plan)
  3. You live in one of these areas of Oregon: Clackamas, Crook, Deschutes, Hood River, Jefferson, Lane, Multnomah, Wasco, or Washington Counties, or northern Klamath County (zip codes 97731, 97733, 97737, or 97739)

When can I enroll?


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:

  • You can enroll in a D-SNP at any time, year-round

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:

  • Once per special enrollment period (SEP):
    • January 1 – March 31
    • April 1 – June 30
    • July 1 – September 30
  • Or any time during the Annual Enrollment Period (AEP):
    • October 15 – December 7


When will my coverage begin?


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.


How do I enroll?


We offer a variety of ways to enroll:

Enroll online

Use our online enrollment center.

By phone

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.


What happens after I enroll?


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.

What Is Medicare?


Medicare is a health insurance program for:
  • People age 65 or older
  • People under age 65 with certain disabilities
  • People of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)

Different Parts of Medicare


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:

  • 1-800-MEDICARE (1-800-633-4227). TTY users should call 877-486-2048, 24 hours a day/7 days a week;
  • The Social Security Office at 800-772-1213 between 7:00 a.m. and 7:00 p.m., Monday through Friday. TTY users should call 800-325-0778; or
  • Your State Medicaid Office.

What You Pay


Below are some of the costs you will pay if you only had original Medicare‡:

Part B (Medical)

  • $148.50 monthly premium*
  • $203 yearly Part B deductible (you must first pay this amount for covered services before Medicare begins paying for your coverage)
  • 20% of the costs for most services including doctor office visits, outpatient surgery, emergency and urgent care

Part A (Hospital)

  • $1,484 deductible per benefit period
  • $0 per day (days 1-60)
  • $371 per day (days 61-90)
  • $742 per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime)
  • You pay all costs beyond lifetime reserve days

Part D (Prescription)

  • Monthly premium: varies by plan and income

‡ 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.


What Medicare Doesn't Cover


There are some limitations to Original Medicare. In most cases, the following are not covered:

  • You are not covered outside the United States
  • Outpatient prescription drug coverage
  • No annual limit to your total out-of-pocket expenses (example: you will continue paying 20% for most services all year)
  • Not all doctors accept Original Medicare


Medicare Advantage and Medicare Supplement


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.


How Can I Get More Information About Medicare?


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.