Questions about getting a COVID-19 vaccine? See the latest on our blog
Call for a quote, to enroll, or for more info: 866-282-8814, TTY: 711. We accept all relay calls.

2023 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.

PacificSource Dual Care is an HMO plan, which means you're covered at any of more than 30,000+ providers in our network. You're also covered for urgent and emergency care worldwide, regardless of provider, at the in-network level. The plan doesn't include coverage for providers outside the network, except in an emergency.

You can find in-network doctors and facilities in our Provider Directory, including many of the best-known names in the region.

This plan also includes prescription drug coverage (Medicare Part D). You can learn about costs for covered medications with our Drug Search tool, and find nearby pharmacies with our Pharmacy Search.

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 (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

    This Medicare Advantage plan includes all the benefits of Original Medicare, plus many more. The Summary of Benefits details what's covered by each plan.

  • Multi-language Interpreter Services

    You can get an interpreter to answer any questions about our health or drug plans. To get an interpreter, call us at 888-863-3637. This is a free service.

2023 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
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
24 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) $200 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 Summary of Benefits 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


Tier 1
Preferred Generic

$0 copay

Tier 2

$0, $1.45 or $4.15 copay

Tier 3
Preferred Brand

$0, $4.30 or $10.35 copay

Tier 4
Non-Preferred Drug

Generic: $0, $1.45 or $4.15 copay
Brand: $0, $4.30 or $10.35 copay

Tier 5

Generic: $0, $1.45 or $4.15 copay
Brand: $0, $4.30 or $10.35 copay

Tier 6
Select Care Drugs

$0 copay

STAGE THREE What you pay after total drug costs4 reach $4,660
Most Generic

$0, $1.45 or $4.15 copay

Most Brand

$0, $4.30 or $10.35 copay

Additional Gap Coverage
Selected Medications

$0 copay

STAGE FOUR After your out-of-pocket costs5 reach $7,400, 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.

Included Dental Benefits

This plan includes dental services, such as checkups, cleanings and x-rays, all with zero copay. To learn what’s covered, see the Summary of Benefits at the top of the page.

Over-the-Counter Spending Allowance

Here's savings and convenience in one: This plan includes a quarterly credit good for popular health and wellness items from NationsOTC. Their catalog includes vitamins, supplements, and hundreds of popular products—all with free 2-day shipping.

The amount you can spend each quarter is $200.

$0 Fitness Benefit

Silver and Fit logo The Silver&Fit® Healthy Aging and Exercise Program includes:

  • Thousands of on-demand workout videos
  • Home Fitness Kits, including a fitness tracker option at no cost
  • Customized workout plans and one-on-one coaching by phone
  • Fitness center membership (premium clubs available at extra cost)

Learn more at

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.

Eyeglass and 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 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

Just complete one or more of the activities below and you can select a gift card from one of more than 100 popular stores and restaurants. For a full list of participating retailers, click here. There's no need to register; award certificates will come in the mail once your claims are processed.

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
Bone density scan $20
At-home colon cancer test or colonoscopy $20
Health risk questionnaire $15

Post-Hospital Meal Delivery

Your plan includes 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

Rides to Health Visits

We help members get rides to covered healthcare services. This benefit is called Non-Emergent Medical Transportation (or NEMT). The NEMT provider will work with you to get you the best ride type for your needs. There is no cost to you for this service.

24-Hour NurseLine

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.

Groceries for Eligible Members

A yearly credit of $240 in groceries ($60 per quarter) is available to those with certain chronic conditions. This benefit is available for 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 2023 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 .

Enrollment Resources

To find a plan that's right for you, we recommend you look at two or more plans, comparing their 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

    This Medicare Advantage plan includes all the benefits of Original Medicare, plus many more. The Summary of Benefits details what's covered by each plan.

  • Attend a Free Seminar

    Have questions about Medicare? Join us at one of our free eduational events.

  • Multi-Language Interpreter Services, updated 10/4/2023

    You can get an interpreter to answer any questions about our health or drug plans. To get an interpreter, 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 for PacificSource Dual Care?

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 (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 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. Contact us with questions.

Ready to enroll?

We offer a variety of ways to enroll:


Use our online enrollment center.

By phone

Call us at 866-282-8814. Our knowledgeable, local staff will guide you through the process.

With a broker

PacificSource Medicare partners with select local insurance producers (brokers) who can help. Contact us for help finding a broker.

Contact a community partner

Trained community partners across the state can help you fill out an application. It's free.
Visit 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 65 or older
  • People under 65 with certain disabilities
  • People of all ages with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a kidney transplant)

The Parts of Medicare: A, B, C & D

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 once they start receiving 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 65; includes the month you turn 65; and ends 3 months after the month you turn 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 such as HMOs and PPOs. PacificSource offers Medicare Advantage Plans. Part C is administered by insurers such as PacificSource under contract with Medicare. These plans include both Medicare Part A and Part B in one convenient plan, and fill in some of the gaps in Medicare coverage. Some plans also include Part D Prescription drug coverage and preventive dental in a single plan. Most people will pay a monthly premium for Part C 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 by 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, call:

  • 800-MEDICARE (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 have only original Medicare:

Part B (Medical)

  • $164.90 monthly premium*
  • $226 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)

  • $1,600 deductible per benefit period
  • $0 per day (days 1-60)
  • $400 per day (days 61-90)
  • $800 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

*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 800-MEDICARE (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:

  • Care received outside the United States
  • Outpatient prescription drugs

Also, note that not all doctors accept Original Medicare, and there is no annual limit on your total out-of-pocket expenses.

Medicare Advantage and Medicare Supplement

If you want extra coverage in additional to Original Medicare, you can purchase it either through a Medicare Advantage plan or with a Medicare Supplement plan. With both plans, you are still on Medicare. Here are the main differences:

Medicare Advantage Plan (such as PacificSource Medicare plans)
These plans fill in the gaps by covering some of the costs Medicare does not cover. We provide more benefits than Medicare alone, or Medigap plans. And we provide personal service to make it easy.

We offer a variety of plans, including low-priced plans to help save you money. You can 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. You also have the option to add supplemental dental coverage for an additional monthly premium. For those who qualify for both Medicare and Medicaid, we also offer a PacificSource Dual Care, an HMO D-SNP plan.

Finding a doctor is easy, because nearly every doctor in the region accepts PacificSource. And, with all our PPO and HMO-POS plans, you have the freedom to see any doctor who accepts Medicare in the United States. You're also 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 dental coverage. The doctor's office will bill us. 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 have less paperwork.

Monthly premiums are the same for all ages. Everyone on a particular 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 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 want prescription coverage, you would need to purchase a Part D plan in addition to your Medigap plan.

Not all doctors accept Original Medicare. If your doctor does not accept Original Medicare, 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 see a doctor, you must bring two ID cards: your red, white, and blue Medicare card and your Medigap card. The doctor will send bills to two places: first to Medicare to pay their portion, then to your Medigap plan to pay the plan's portion.

With Medigap, monthly premiums are based on your age.

Want to Learn More About Medicare?

Call 800-MEDICARE (800-633-4227) or visit 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.