2020 Healthfirst Life Improvement Plan (HMO D-SNP) - H3359-021 ...

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2020 Medicare Advantage Plan Benefit Details for the Healthfirst Life Improvement Plan (HMO D-SNP) - H3359-021-0 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 Life Improvement Plan (HMO D-SNP)
Location:Bronx, 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 D-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):$4,020
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:3,246 drugsBrowse the Healthfirst Life Improvement Plan (HMO D-SNP) Formulary
This plan has 1 drug tier. 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
• Number of Drugs per Tier:3246
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 Bronx, New York:30,465 members
Number of Members enrolled in this plan in (H3359 - 021):108,461 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
$36.60$0.00$36.60$0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%Subsidy75%Subsidy50%Subsidy25%Subsidy
Monthly Part D Premium with LIS:$0.00$9.20$18.30$27.50
Total Monthly Premium with LIS (Parts C & D): $0.00$9.20$18.30$27.50
— 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: No
• Drug plan deductible: $435.00 annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $3,400 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: $0 copay
• Specialist: $0 copay (authorization required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: $0 copay (authorization required)
• Lab services: $0 copay (authorization required)
• Diagnostic radiology services (e.g., MRI): $0 copay (authorization required)
• Outpatient x-rays: $0 copay (authorization required)
Emergency care/Urgent care
• Emergency: $0 copay
• Urgent care: $0 copay
Inpatient hospital coverage
• $0 copay (authorization required)
Outpatient hospital coverage
• $0 copay (authorization required)
Skilled Nursing Facility
• $0 copay (authorization required)
Preventive care
• $0 copay
Ground ambulance
• $0 copay
Rehabilitation services
• Occupational therapy visit: $0 copay (authorization required)
• Physical therapy and speech and language therapy visit: $0 copay (authorization required)
Mental health services
• Inpatient hospital - psychiatric: $0 copay (authorization required)
• Outpatient group therapy visit with a psychiatrist: $0 copay (authorization required)
• Outpatient individual therapy visit with a psychiatrist: $0 copay (authorization required)
• Outpatient group therapy visit: $0 copay (authorization required)
• Outpatient individual therapy visit: $0 copay (authorization required)
Opioid treatment program services
• In-network: 20% coinsurance (authorization required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): $0 copay (authorization required)
• Prosthetics (e.g., braces, artificial limbs): $0 copay (authorization required)
• Diabetes supplies: $0 copay (authorization required)
Dialysis
• 20% coinsurance (authorization required)
Hearing
• Hearing exam: $0 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 (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
• $0 copay (limits apply, authorization required)
Foot care (podiatry services)
• Foot exams and treatment: $0 copay (authorization required)
• Routine foot care: $0 copay (limits apply, authorization required)
Medicare Part B drugs
• Chemotherapy: $0 copay (authorization required)
• Other Part B drugs: $0 copay (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
• Transportation services: Some coverage
• Transportation services for non-emergency care: Plan-approved locations: Not covered
• Over-the-counter drug benefits: Some coverage
• 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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