2027 Medicare Advantage plan

Provider Partners Indiana Advantage Plan (HMO I-SNP): 2027 benefits and costs

Provider Partners Health Plans HMO I-SNP Special Needs Plan

CMS plan ID: H4444-001-0 · Plan year: 2027

Provider Partners Indiana Advantage Plan (HMO I-SNP) is a 2027 Medicare Advantage plan offered by Provider Partners Health Plans. It is listed in Indiana.

2027 plan costs at a glance

Monthly plan premium$17.00

Drug deductible$700.00

In-network medical out-of-pocket maximum$9,850.00

Organization: Provider Partners Health Plans
Plan organization: PROVIDER PARTNERS HEALTH PLAN OF INDIANA
Parent company: Rifkin Managed Care Holding, LLC
Plan type: HMO I-SNP
Part C premium: $0.00
Part D premium: $17.00
Prescription drug coverage: Yes
Special Needs Plan type: Institutional
2027 CMS Star Rating

Standard monthly Medicare Part B premium: $209.50 (estimated)

You must continue to pay your Medicare Part B premium.

In-network medical deductible: Same as Medicare's Part B deductible
Applies to in-network Medicare-covered services.
In-network medical maximum: $9,850.00

Who can join this Special Needs Plan?

This plan has institutional care eligibility requirements. The plan must confirm your qualifying care needs or living situation before you enroll.

Plan eligibility type: Institutional
Institutional plan type: Facility-based Institutional special needs plan (FI-SNP)

2027 benefit summary

Doctor visits and medical care

Plan-level deductibles may still apply when a service-specific deductible is listed as No.

Common medical services and member costs
Service	In-network	What to know
Primary care doctor	20% coinsurance Service-specific deductible No
Specialist visit	20% coinsurance Service-specific deductible No	Approval required No Referral required No
Telehealth	20% coinsurance Service-specific deductible No	Approval required No Referral required No
Emergency care	20% coinsurance
Urgent care	20% coinsurance
Home health	$0 Service-specific deductible No	Approval required Yes Referral required No
Dialysis	20% coinsurance Service-specific deductible No	Approval required No Referral required No
Part B chemotherapy and radiation drugs	0% to 20% coinsurance Deductible applies No	Approval required Yes
Other Part B drugs	0% to 20% coinsurance Deductible applies No	Approval required Yes
Kidney disease education services	20% coinsurance Service-specific deductible No	Approval required No Referral required No
Medicare-covered chiropractic	20% coinsurance Service-specific deductible No	Approval required No Referral required No
Medicare-covered foot care	20% coinsurance Service-specific deductible No	Approval required No Referral required No
Other health professionals	0% to 20% coinsurance Service-specific deductible No	Approval required No Referral required No

Hospital, outpatient surgery and observation care

Inpatient stays and skilled nursing care

In-network stays. Charges can depend on the number of days and the benefit period.
Care	Your share of the cost	What to know
Inpatient hospital stay	Original Medicare cost-sharing rules apply.	Approval required Yes Referral required No Benefit period Original Medicare
Inpatient mental health care	Original Medicare cost-sharing rules apply.	Approval required Yes Referral required No Benefit period Original Medicare

See plan documents for out-of-network hospital and skilled nursing costs.

Hospital, outpatient surgery and observation care and member costs
Service	In-network	What to know
Outpatient hospital care	20% coinsurance Service-specific deductible No
Hospital observation services	20% coinsurance Service-specific deductible No
Ambulatory surgical center	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Outpatient blood	20% coinsurance Service-specific deductible No	Approval required No Referral required No

Tests, imaging and laboratory services

Tests, imaging and laboratory services and member costs
Service	In-network	What to know
Diagnostic procedures and tests	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Laboratory services	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Diagnostic radiology (CT, MRI)	20% coinsurance Service-specific deductible No	Approval required No Referral required No
Therapeutic radiology	20% coinsurance Service-specific deductible No	Approval required No Referral required No
X-rays	20% coinsurance Service-specific deductible No	Approval required No Referral required No

Mental health and substance use treatment

Mental health and substance use treatment and member costs
Service	In-network	What to know
Partial hospitalization	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Intensive outpatient program	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Substance use treatment, individual sessions	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Substance use treatment, group sessions	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Opioid treatment program	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Mental health, individual sessions	20% coinsurance Service-specific deductible No	Approval required No Referral required No
Mental health, group sessions	20% coinsurance Service-specific deductible No	Approval required No Referral required No
Psychiatry, individual sessions	20% coinsurance Service-specific deductible No	Approval required No Referral required No
Psychiatry, group sessions	20% coinsurance Service-specific deductible No	Approval required No Referral required No

Therapy and rehabilitation

Therapy and rehabilitation and member costs
Service	In-network	What to know
Occupational therapy	$0 Service-specific deductible No	Approval required Yes Referral required No
Physical and speech therapy	$0 Service-specific deductible No	Approval required Yes Referral required No
Cardiac rehabilitation	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Intensive cardiac rehabilitation	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Pulmonary rehabilitation	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Supervised exercise for peripheral artery disease	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No

Ambulance, medical equipment and supplies

Ambulance, medical equipment and supplies and member costs
Service	In-network	What to know
Ground ambulance	20% coinsurance Service-specific deductible No	Approval required No
Air ambulance	20% coinsurance Service-specific deductible No	Approval required No
Durable medical equipment	20% coinsurance Service-specific deductible No	Approval required Yes
Prosthetic devices	20% coinsurance Service-specific deductible No	Approval required Yes
Medical supplies	20% coinsurance Service-specific deductible No	Approval required Yes
Diabetic supplies	20% coinsurance Service-specific deductible No	Approval required No
Diabetic shoes and inserts	20% coinsurance Service-specific deductible No	Approval required No
Diabetic monitors	20% coinsurance Service-specific deductible No	Approval required No

Dental benefits

Dental benefits and member costs
Service	In-network	What to know
Medicare-covered dental	20% coinsurance
Oral examsAdditional plan benefit	$0
Dental X-raysAdditional plan benefit	$0
Other diagnostic dentalAdditional plan benefit	$0
Dental cleaningAdditional plan benefit	$0
FluorideAdditional plan benefit	$0
Other preventive dentalAdditional plan benefit	$0
Restorative dental careAdditional plan benefit	$0
Root canal treatment (endodontics)Additional plan benefit	$0
Gum treatment (periodontics)Additional plan benefit	$0
Removable dentures (prosthodontics)Additional plan benefit	$0
Maxillofacial prostheticsAdditional plan benefit	$0
Dental implantsAdditional plan benefit	$0
Fixed dental restorations (prosthodontics)Additional plan benefit	$0
Oral surgeryAdditional plan benefit	$0
OrthodonticsAdditional plan benefit	$0
Other dental servicesAdditional plan benefit	$0

Vision benefits

Vision benefits and member costs
Service	In-network	What to know
Medicare-covered eye exams	20% coinsurance Service-specific deductible No	Approval required No Referral required No
Routine eye examsAdditional plan benefit	$0	Approval required No Referral required No
Medicare-covered eyewear	20% coinsurance Service-specific deductible No	Approval required No Referral required No
Contact lensesAdditional plan benefit	$0	Approval required No Referral required No
Eyeglasses, lenses and framesAdditional plan benefit	$0	Approval required No Referral required No
Eyeglass lensesAdditional plan benefit	$0	Approval required No Referral required No
Eyeglass framesAdditional plan benefit	$0	Approval required No Referral required No

Hearing benefits

Hearing benefits and member costs
Service	In-network	What to know
Medicare-covered hearing exams	20% coinsurance Service-specific deductible No	Approval required No Referral required No
Routine hearing examsAdditional plan benefit	$0	Approval required No Referral required No
Hearing aid fitting and evaluationAdditional plan benefit	$0	Approval required No Referral required No
Prescription hearing aids (all types)Additional plan benefit	$0 Service-specific deductible No	Approval required No Referral required No

Extra benefits

Extra benefits and member costs
Service	In-network	What to know
Over-the-counter health itemsAdditional plan benefit	$0 Service-specific deductible No
Annual physical examAdditional plan benefit	20% coinsurance Service-specific deductible No	Approval required No Referral required No

Allowances and optional benefits

Benefits for qualifying members

Food and Produce and Essential Clothing

The plan must confirm eligibility, including any qualifying condition.

Qualifying conditions: Chronic alcohol use disorder and other substance use disorders (SUDs); Autoimmune disorders; Cancer; Cardiovascular disorders; Chronic heart failure; Dementia; Diabetes mellitus; Overweight, obesity, and metabolic syndrome; Chronic gastrointestinal disease; Chronic kidney disease (CKD); Severe hematologic disorders; HIV/AIDS; Chronic lung disorders; Chronic and disabling mental health conditions; Neurologic disorders; Stroke; Post-organ transplantation; Immunodeficiency and Immunosuppressive disorders; Conditions associated with cognitive impairment; Conditions with functional challenges; Chronic conditions that impair vision, hearing (deafness), taste, touch, and smell; Conditions that require continued therapy services in order for individuals to maintain or retain functioning
Included services: Food and produce; Support for daily living
Some package benefits are exempt from the deductible: No

Prescription drug coverage

Costs shown are for initial coverage.

This plan uses a non-tiered standard drug benefit; individual drug prices are not listed here.

Available prescription supply lengths, not price quotes
Pharmacy	Supply
Standard retail	30 days
Standard retail	60 days
Standard retail	90 days
Standard mail order	30 days
Standard mail order	60 days
Standard mail order	90 days
Out-of-network pharmacy	30 days
Long-term care pharmacy	31 days

Where this plan is offered

CMS lists this plan in 1 state or territory. Availability can vary by county and ZIP code.

View all locations 69 county listings across 1 state or territory