2020 Healthfirst 65 Plus Plan (HMO) - H3359-001-0 In NY Plan ...

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2020 Medicare Advantage Plan Benefit Details for the Healthfirst 65 Plus Plan (HMO) - H3359-001-0 This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.
2020 Medicare Advantage Plan Details
Medicare Plan Name:Healthfirst 65 Plus Plan (HMO)
Location:Queens, New York Click to see other locations
Plan ID:H3359 - 001 - 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 65 Plus Plan (HMO) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 (see Plan Premium Details below)
Annual Rx Deductible:$350 (Tier 1 excluded from the Deductible.)
Annual Rx Initial Coverage Limit (ICL):$3,750
Health Plan Type:Local HMO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$6,700
Drug Benefit Type ❔Enhanced Alternative (EA)
Additional Rx Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:3,173 drugsBrowse the Healthfirst 65 Plus Plan (HMO) Formulary
This plan has 5 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:$0.00$10.00$47.00$100.0026%
• Number of Drugs per Tier:323523931777619
Plan's Pharmacy Search:http://www.healthfirst.org/medicare
Plan Offers Mail Order?Yes
Medicare Plan Pharmacy Numbers: BIN: 004336 PCN: MEDDADV See BIN/PCNs for all plans
Number of Members enrolled in this plan in Queens, New York:11,112 members
Number of Members enrolled in this plan in (H3359 - 001):44,222 members
Plan’s Summary Star Rating: 4 out of 5 Stars.
• Customer Service Rating: 5 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
$0.00$0.00$0.00$0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%Subsidy75%Subsidy50%Subsidy25%Subsidy
Monthly Part D Premium with LIS:$0.00$0.00$0.00$0.00
Total Monthly Premium with LIS (Parts C & D): $0.00$0.00$0.00$0.00
— Plan Health Benefits —
** Base Plan **
Premium
• Health plan premium: $0
• Drug plan premium: $0
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: $0
• Other health plan deductibles: In-network: Yes
• Drug plan deductible: $350.00 annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $6,700 In-network
Optional supplemental benefits
• No
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: No
Doctor visits
• Primary: $10 copay per visit
• Specialist: $45 copay per visit (authorization required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: $50 copay (authorization required)
• Lab services: $0 copay (authorization required)
• Diagnostic radiology services (e.g., MRI): $100 copay (authorization required)
• Outpatient x-rays: $15 copay (authorization required)
Emergency care/Urgent care
• Emergency: $90 copay per visit (always covered)
• Urgent care: $45 copay per visit (always covered)
Inpatient hospital coverage
• $393 per day for days 1 through 5$0 per day for days 6 through 90 (authorization required)
Outpatient hospital coverage
• 20% coinsurance per visit (authorization required)
Skilled Nursing Facility
• $0 per day for days 1 through 20$178 per day for days 21 through 100 (authorization required)
Preventive care
• $0 copay
Ground ambulance
• $225 copay
Rehabilitation services
• Occupational therapy visit: $40 copay (authorization required)
• Physical therapy and speech and language therapy visit: $40 copay (authorization required)
Mental health services
• Inpatient hospital - psychiatric: $293 per day for days 1 through 6$0 per day for days 7 through 90 (authorization required)
• Outpatient group therapy visit with a psychiatrist: $40 copay (authorization required)
• Outpatient individual therapy visit with a psychiatrist: $40 copay (authorization required)
• Outpatient group therapy visit: $40 copay (authorization required)
• Outpatient individual therapy visit: $40 copay (authorization required)
Opioid treatment program services
• In-network: $40.00 copay (authorization required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs): 20% coinsurance per item (authorization required)
• Diabetes supplies: $0 copay (authorization required)
Dialysis
• 20% coinsurance (authorization required)
Hearing
• Hearing exam: $45 copay
• Fitting/evaluation: $0 copay (limits apply)
• Hearing aids: $0 copay (limits apply, authorization required)
Preventive dental
• Oral exam: $0 copay (limits apply)
• Cleaning: $0 copay (limits apply)
• Fluoride treatment: Not covered
• Dental x-ray(s): $0 copay (limits apply)
Comprehensive dental
• Non-routine services: $0 copay (limits apply, authorization required)
• Diagnostic services: $0 copay (limits apply, authorization required)
• Restorative services: $0 copay (limits apply, authorization required)
• Endodontics: $0 copay (limits apply, authorization required)
• Periodontics: $0 copay (limits apply, authorization required)
• Extractions: $0 copay (limits apply, authorization required)
• Prosthodontics, other oral/maxillofacial surgery, other services: $0 copay (limits apply, authorization required)
Vision
• Routine eye exam: $0 copay (limits apply)
• Other: Not covered
• Contact lenses: $0 copay (limits apply, authorization required)
• Eyeglasses (frames and lenses): $0 copay (limits apply, authorization required)
• Eyeglass frames: Not covered
• Eyeglass lenses: Not covered
• Upgrades: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• Not covered
Foot care (podiatry services)
• Foot exams and treatment: $25 copay (authorization required)
• Routine foot care: $25 copay (limits apply, authorization required)
Medicare Part B drugs
• Chemotherapy: 20% coinsurance (authorization required)
• Other Part B drugs: 20% coinsurance (authorization required)
Medically-approved non-opioid pain management services
• Chiropractic services: Not covered
• Acupuncture: Some coverage
• Therapeutic Massage: Not covered
• Alternative Therapies: Not covered
More benefits
• Over-the-counter drug benefits: Not covered
• Meals for short duration: Some coverage
• Annual physical exams: Some coverage
• Telehealth: Some coverage
• WorldWide emergency transportation: Some coverage
• WorldWide emergency coverage: Some coverage
• WorldWide emergency urgent care: Some coverage
• Fitness Benefit: Some coverage
• In-Home Support Services: Not covered
• Bathroom Safety Devices: Not covered
• Health Education: Some coverage
• In-Home Safety Assessment: Not covered
• Personal Emergency Response System (PERS): Not covered
• Medical Nutrition Therapy (MNT): Not covered
• Post discharge In-Home Medication Reconciliation: Not covered
• Re-admission Prevention: Not covered
• Wigs for Hair Loss Related to Chemotherapy: Not covered
• Weight Management Programs: Not covered
• Adult Day Health Services: Not covered
• Nutritional/Dietary Benefit: Some coverage
• Home-Based Palliative Care: Not covered
• Support for Caregivers of Enrollees: Not covered
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Not covered
• Enhanced Disease Management: Not covered
• Telemonitoring Services: Not covered
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage
• Counseling Services: Not covered

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