2016 Healthfirst Life Improvement Plan (HMO SNP) - H3359-021-0 ...

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2016 Medicare Advantage Plan Details
Medicare Plan Name:Healthfirst Life Improvement Plan (HMO SNP)
Location:Westchester, New York Click to see other locations
Plan ID:H3359 - 021 - 0 Click to see other plans
Member Services:1-888-260-1010 TTY users 1-888-542-3821
— This plan information is for research purposes only. — Click here to see plans for the current plan year
Medicare Contact Information:Please visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) for information on all of your options. TTY users 1-877-486-2048or contact your local SHIP for assistance
Email a copy of the Healthfirst Life Improvement Plan (HMO SNP) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 for people who qualify for both Medicare and Medicaid. (see Plan Premium Details below)
Annual Rx Deductible:$0 for people who qualify for both Medicare and Medicaid.
Annual Rx Initial Coverage Limit (ICL):$3,310
Health Plan Type:Local HMO
Special Needs Plan (SNP)Eligibility Requirement:Dual-Eligible.
Drug Benefit Type ❔Defined Standard (DS)
Additional Rx Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:3,171 drugsBrowse the Healthfirst Life Improvement Plan (HMO SNP) Formulary
This plan has drug tiers. See cost-sharing for all pharmacies and tiers.
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy Cost-Sharing during initial coverage phase:cost-sharing data not available.
• Number of Drugs per Tier:
Plan's Pharmacy Search:http://www.healthfirst.org/medicare
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in Westchester, New York:956 members
Number of Members enrolled in this plan in (H3359 - 021):69,976 members
Plan’s Summary Star Rating: 4 out of 5 Stars.
• Customer Service Rating: 4 out of 5 Stars.
• Member Experience Rating: 3 out of 5 Stars.
• Drug Cost Accuracy Rating: 4 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows: ❔TotalPremiumPart CPremiumPart D BasicPremiumPart D SupplementalPremium
$39.00$0.00$39.00$0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%Subsidy75%Subsidy50%Subsidy25%Subsidy
Monthly Part D Premium with LIS:$0.00$9.70$19.50$29.20
Total Monthly Premium with LIS (Parts C & D): $0.00$9.70$19.50$29.20
— Plan Health Benefits —
** Cost **
Monthly premium, deductible, and limits on how much you pay for covered services
$39 per month. In addition you must keep paying your Medicare Part B premium.
$0 to $74 per year for Part D prescription drugs.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
In this plan you may pay nothing for Medicare-covered services depending on your level of [insert State Medicaid plan name] eligibility.
Your yearly limit(s) in this plan:
  • $3 400 for services you receive from in-network providers.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Refer to the "Medicare & You" handbook for Medicare-covered services. For [insert State Medicaid plan name]-covered services refer to the Medicaid Coverage section in this document. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.
** Doctor and Hospital Choice **
Acupuncture
For up to 15 visit(s) every year: You pay nothing
** Extra Benefits **
Inpatient mental health care
For inpatient mental health care see the "Mental Health Care" section.
Outpatient prescription drugs
For Part B drugs such as chemotherapy drugs1: You pay nothing
Other Part B drugs1: You pay nothing
Depending on your income and institutional status you pay the following: For generic drugs (including brand drugs treated as generic) either:
  • $0 copay; or
  • $1.20 copay; or
  • $2.95 copay
    • For all other drugs either:
  • $0 copay; or
  • $3.60 copay; or
  • $7.40 copay.
    • You may get your drugs at network retail pharmacies and mail order pharmacies.
    If you reside in a long-term care facility you pay the same as at a retail pharmacy.
    You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.
    After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay nothing for all drugs.
    ** Important Information **
    Monthly premium, deductible, and limits on how much you pay for covered services
    $39 per month. In addition you must keep paying your Medicare Part B premium.
    $0 to $74 per year for Part D prescription drugs.
    Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
    In this plan you may pay nothing for Medicare-covered services depending on your level of [insert State Medicaid plan name] eligibility.
    Your yearly limit(s) in this plan:
    • $3 400 for services you receive from in-network providers.
    If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year. Refer to the "Medicare & You" handbook for Medicare-covered services. For [insert State Medicaid plan name]-covered services refer to the Medicaid Coverage section in this document. Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
    Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.
    ** Outpatient Care and Services **
    Acupuncture
    For up to 15 visit(s) every year: You pay nothing
    Ambulance
    0% or 20% of the cost
    Chiropractic care
    Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): You pay nothing
    Dental services
    Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): You pay nothing
    Preventive dental services:
  • Cleaning (for up to 1 every six months): You pay nothing
  • Dental x-ray(s) (for up to 1 every six months): You pay nothing
  • Oral exam (for up to 1 every six months): You pay nothing
    • Diabetes supplies and services
    Diabetes monitoring supplies: You pay nothing
    Diabetes self-management training: You pay nothing
    Therapeutic shoes or inserts: You pay nothing
    Diagnostic tests, lab and radiology services, and x-rays (Costs for these services may be different if received in an outpatient surgery setting)
    Diagnostic radiology services (such as MRIs CT scans): 0% or 20% of the cost
    Diagnostic tests and procedures: 0-20% of the cost depending on the service
    Lab services: You pay nothing
    Outpatient x-rays: 0% or 20% of the cost
    Therapeutic radiology services (such as radiation treatment for cancer): 0% or 20% of the cost
    Doctor's office visits
    Primary care physician visit: You pay nothing
    Specialist visit: You pay nothing
    Durable medical equipment (wheelchairs, oxygen, etc.)
    0% or 20% of the cost
    If you go to a preferred vendor your cost may be less. Contact us for a list of preferred vendors.
    Emergency care
    $0 or $75 copay
    If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section for other costs.
    Foot care (podiatry services)
    Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing
    Hearing services
    Exam to diagnose and treat hearing and balance issues: You pay nothing
    Routine hearing exam (for up to 1 every year): You pay nothing
    Hearing aid fitting/evaluation (for up to 1 every year): You pay nothing
    Hearing aid: You pay nothing
    Our plan pays up to $1 000 every three years for hearing aids.
    Home health care
    You pay nothing
    Mental health care
    Inpatient visit:
    Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.
    Our plan covers 90 days for an inpatient hospital stay.
    Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days.
    • $0 or $325 copay per day for days 1 through 6
    • You pay nothing per day for days 7 through 90
      • Outpatient group therapy visit: 0% or 20% of the cost
      Outpatient individual therapy visit: 0% or 20% of the cost
      Outpatient rehabilitation
      Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): 0-20% of the cost depending on the service
      Occupational therapy visit: You pay nothing
      Physical therapy and speech and language therapy visit: You pay nothing
      Outpatient substance abuse
      Group therapy visit: 0% or 20% of the cost
      Individual therapy visit: 0% or 20% of the cost
      Outpatient surgery
      Ambulatory surgical center: 0% or 20% of the cost
      Outpatient hospital: 0% or 20% of the cost
      Over-the-counter items
      Please visit our website to see our list of covered over-the-counter items.
      Prosthetic devices (braces, artificial limbs, etc.)
      Prosthetic devices: 0% or 20% of the cost
      Related medical supplies: 0% or 20% of the cost
      Renal dialysis
      0% or 20% of the cost
      Transportation
      You pay nothing
      Urgently needed services
      $0 or $35 copay
      Vision services
      Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing
      Routine eye exam (for up to 1 every year): You pay nothing
      Contact lenses (for up to 1 every year): You pay nothing
      Eyeglasses (frames and lenses) (for up to 1 every year): You pay nothing
      Eyeglasses or contact lenses after cataract surgery: You pay nothing
      ** Hospice **
      Hospice
      You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.
      ** Preventive Care **
      Preventive care
      You pay nothing
      Our plan covers many preventive services including:
      • Abdominal aortic aneurysm screening
      • Alcohol misuse counseling
      • Bone mass measurement
      • Breast cancer screening (mammogram)
      • Cardiovascular disease (behavioral therapy)
      • Cardiovascular screenings
      • Cervical and vaginal cancer screening
      • Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
      • Depression screening
      • Diabetes screenings
      • HIV screening
      • Medical nutrition therapy services
      • Obesity screening and counseling
      • Prostate cancer screenings (PSA)
      • Sexually transmitted infections screening and counseling
      • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
      • Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
      • "Welcome to Medicare" preventive visit (one-time)
      • Yearly "Wellness" visit
      Any additional preventive services approved by Medicare during the contract year will be covered.
      Annual physical exam: You pay nothing
      ** Inpatient Care **
      Inpatient hospital care
      Our plan covers an unlimited number of days for an inpatient hospital stay.
      • $0 or $360 copay per day for days 1 through 6
      • You pay nothing per day for days 7 through 90
      • You pay nothing per day for days 91 and beyond
        • Inpatient mental health care
        For inpatient mental health care see the "Mental Health Care" section.
        Skilled Nursing Facility (SNF)
        Our plan covers up to 100 days in a SNF.
        • $0 or $25 copay per day for days 1 through 20
        • $0 or $160 copay per day for days 21 through 100
          • Outpatient prescription drugs
          For Part B drugs such as chemotherapy drugs1: You pay nothing
          Other Part B drugs1: You pay nothing
          Depending on your income and institutional status you pay the following: For generic drugs (including brand drugs treated as generic) either:
        • $0 copay; or
        • $1.20 copay; or
        • $2.95 copay
          • For all other drugs either:
        • $0 copay; or
        • $3.60 copay; or
        • $7.40 copay.
          • You may get your drugs at network retail pharmacies and mail order pharmacies.
          If you reside in a long-term care facility you pay the same as at a retail pharmacy.
          You may get drugs from an out-of-network pharmacy at the same cost as an in-network pharmacy.
          After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay nothing for all drugs.
          ** Outpatient Care **
          Diabetes supplies and services
          Diabetes monitoring supplies: You pay nothing
          Diabetes self-management training: You pay nothing
          Therapeutic shoes or inserts: You pay nothing
          Foot care (podiatry services)
          Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing
          Hearing services
          Exam to diagnose and treat hearing and balance issues: You pay nothing
          Routine hearing exam (for up to 1 every year): You pay nothing
          Hearing aid fitting/evaluation (for up to 1 every year): You pay nothing
          Hearing aid: You pay nothing
          Our plan pays up to $1 000 every three years for hearing aids.
          ** Outpatient Medical Services and Supplies **
          Outpatient substance abuse
          Group therapy visit: 0% or 20% of the cost
          Individual therapy visit: 0% or 20% of the cost
          Prosthetic devices (braces, artificial limbs, etc.)
          Prosthetic devices: 0% or 20% of the cost
          Related medical supplies: 0% or 20% of the cost
          ** Additional Benefits **
          Inpatient mental health care
          For inpatient mental health care see the "Mental Health Care" section.

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