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EmblemHealth Medicare Advantage HMO Plan

With the EmblemHealth Medicare Advantage HMO plan, you get comprehensive coverage, just like with the HIP Prime® HMO plan — but with an additional enhanced pharmacy benefit. And, you save with lower copays while your premium contribution stays the same.

You get coverage for your medical, preventive care, outpatient, and hospital services. Your doctor visits and hospital services are covered with $0 copays. You also have four-tier pharmacy coverage with $0 copays for generic and brand-name formulary drugs, while non-formulary drugs are covered with a $40 copay. Select Care drugs are covered with $0 copay. 

These benefits are neither offered nor guaranteed under contract with the FEHB Program, but are made available to all enrollees and family members who become members of the EmblemHealth Medicare Advantage HMO plan.

Quick Links

To Enroll: See www.opm.gov/healthcare-insurance, or contact your employing or retirement office.

Customer Service: 877-842-3625 (TTY: 711) from 8 a.m. to 6 p.m., seven days a week (excluding major holidays).

 

Eligibility

You can enroll in the EmblemHealth Medicare Advantage HMO plan if you:

  • Are enrolled in the HIP Prime HMO High Option plan (enrollment codes 511, 513, 512).
  • Live in the plan’s Medicare-approved service area, which includes New York City (the Bronx, Brooklyn, Manhattan, Queens, and Staten Island), Nassau, Suffolk, and Westchester counties.
  • Are enrolled in Medicare Part A.
  • Are enrolled in Medicare Part B.

 

Enrollment codes and rates 2024

Below are the biweekly and monthly premium contributions, which are the same as with the HIP Prime HMO active plan.

 

Type of Enrollment Enrollment Code Premium Rate
Biweekly Monthly
Gov't Share Your Share
 Gov't Share Your Share

Greater New York

High Option Self Only 511

 $271.43 $264.43 $588.10 $572.93
High Option Self Plus One 513

 $586.50 $392.00 $1270.75 $849.33
High Option Self and Family 512

 $646.18 $911.59  $1400.06 $1975.11

More Plan Details

What the Plan Costs and Covers

Benefits at a Glance: EmblemHealth Medicare Advantage HMO

This is just a summary. It does not contain the full details of your EmblemHealth Medicare Advantage HMO plan.

High Option — In-Network

Medical Care

PCP office visit: $0 copay

Specialist office visit: $0 copay

Preventive Care

Routine physical exam: $0 copay

Women’s wellness services: $0 copay

Other Services

Outpatient mental health: $0 copay

Urgent care: $0 copay

Ambulatory surgery: $0 copay

Ambulance: $0 copay

Prescription drugs: $0 generic/$0 brand-name/$40 non-formulary copay/$0 Select Care Drugs

Hospital Services

Inpatient care: $0 copay

Anesthesia: $0 copay

Emergency room: $0 copay

For complete details about the benefits available through these plans, please read Federal RI 73-001.

The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formularies, pharmacy networks, provider networks, premiums and/or copayments/coinsurance may change on Jan. 1 of each year.

Provider Network

As always, with your HIP FEHB High Option plan (HIP Prime HMO), you have access to network doctors and hospitals throughout all five boroughs of New York City, Long Island, Westchester, Rockland, and Orange counties.

And your network has grown! Through our expanded network, you now also have access to 25,000 more medical professionals and 37 more hospitals and facilities throughout these additional counties: Albany, Broome, Columbia, Delaware, Dutchess, Fulton, Greene, Montgomery, Otsego, Putnam, Rensselaer, Saratoga, Schenectady, Schoharie, Sullivan, Ulster, Warren, and Washington.

And, rest assured, you will continue to have access to the area’s top hospitals, like:

  • The Hospital for Special Surgery
  • Northwell Health
  • Memorial Sloan-Kettering Cancer Center
  • NYU Hospital Center
  • Montefiore Medical Center
  • And many more    

Need to see a doctor?

Enrollment Information and Resources

In your secure member portal, myEmblemHealth, you have convenient access to your personal information, including benefits and valuable health management tools.

Once you're registered, you can check:

  • The status of a claim, approval, or the amount you have paid toward your deductible, if any. (A deductible is the amount you pay before your plan starts to pay.)
  • Descriptions of your health benefits.
  • Messages — You can communicate securely with us through the Message Center.
  • A list of your covered drugs.
  • You can also order member ID cards, download forms, and update your email address.

Assess and track your health

myEmblemHealth has lots of tools to help you take care of your health and meet your personal wellness goals.

  • Health Assessment: Gives you an overall picture of your health and shows you steps you can take to make healthy lifestyle changes. Both you and your covered dependents can fill out your own individual Health Assessment.
  • Health Action Plans: These personalized programs help you make healthy choices and manage your health conditions. Each Action Plan is based on your personal choices to help you change things like sleep and nutrition habits, or improve your blood pressure and cholesterol. They can last anywhere from a few days to a few weeks, depending on your unique needs.

Get your documents online

When you register for myEmblemHealth, you can go paperless by signing up to get your documents online. They will be neatly stored in your secure Message Center on myEmblemHealth.

You can choose to get the following:

  • Explanations of Benefits (EOBs).
  • Alerts about when your claims are processed.
  • Personalized information about your health.
  • Your plan newsletter.
  • Updated information about your coverage and benefits.

Enrollment and Customer Service

If you are a prospective member and have questions about enrollment, call 866-640-3856, from 8 a.m. to 8 p.m., seven days a week (excluding major holidays). Use the interactive voice response (IVR) system after business hours. If you have a hearing or speech impairment and use a TYY, call 711.

If you are a current plan member, call the number on your member ID card, from
8 a.m. to 8 p.m., seven days a week (excluding major holidays).

Choosing EmblemHealth Medicare Advantage HMO

By calling the number above, you can speak with an EmblemHealth Medicare expert or schedule a one-on-one consultation. We will provide you with a Medicare Advantage enrollment form. There are no enrollment codes to enter when completing the form. You can mail back the completed form or leave it with an EmblemHealth Medicare expert during your consultation. For premium rates, visit the Enrollment Rates section.

Health Management and Support Services

Your plan provides more than just coverage. You can take advantage of the many free programs and support services we offer to help you live a healthy lifestyle and manage your condition if you get sick or injured.

Health and wellness programs

We know good health is worth holding on to. That’s why we want to make staying healthy as easy as possible for you, with programs, tools, and more to help you stay fit and enhance your quality of life.

In addition to your doctor’s care, you may have access to the following services when you enroll in this plan to help you and your enrolled family members stay healthy.

To see the full list, visit emblemhealth.com/live-well.

  • Honor Yoga – Honor yoga Now’s Video on Demand service puts a library of more than 300 classes (and growing) right at your fingertips.
  • Forte – Stream live and on-demand boutique fitness classes from top studios worldwide directly to you.
  • CoPilot – CoPilot provides a 1-on-1 remote personal trainer to build you a personalized fitness plan and help you stick to it.
  • Fit4Mom – FIT4MOM On Demand provides at-home workouts for moms at all stages of motherhood, including cardio, barre, HIIT, strength training, prenatal, yoga and mama and mini classes you can do anytime, anywhere.
  • MOSSA ON DEMAND – MOSSA Workouts – cardio, strength, cycle, dance, mind-body, HIIT, kickboxing, and more- and feel the power of together, in group workouts made for every mover, from newcomers to athletes.
  • Stronger Thru Cancer – Stronger Thru Cancer is a nationally accessible exercise and wellness program for people with cancer created by cancer survivor, Priscilla Fitzpatrick.
  • Healthy body, Healthy Baby – Healthy body, Healthy Baby is a virtual health coaching program that helps individuals create a healthy lifestyle, physically and emotionally, from pre-conception through the first twelve weeks of parenthood.
  • Best Whole Self – With six different health coaching programs available, there is something for everyone.
  • Diet-To-Go – For less than the cost of eating out you can have healthy and portion-controlled meal plans that are fully prepared and restaurant-quality.
  • Gym Membership – Receive a discount of the standard retail rate within the program network.

For more about these services, call the number on your member ID card or visit  emblemhealth.com/goodhealth.

* Please note: Services included in the Healthy Discounts programs are available only through participating vendors. These discount programs are not health care benefits and we do not insure them.

 

2024 Plan Documents

 

2023 Plan Documents

Provider Coverage

With our robust network of quality doctors, you can get care from many of the region’s leading doctors, clinicians and facilities, including hospitals and urgent care centers.

A partner in wellness

The Right Care, Right in Your Neighborhood

AdvantageCare Physicians are the newest addition to the EmblemHealth family and are now one of the largest primary and specialty care practices in New York City. With 37 locations throughout New York City and Long Island, you can find a convenient location near home or work.

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© 2020 EmblemHealth. All Rights Reserved.

Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office.

Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.