2018 EmblemHealth VIP Dual (HMO SNP)

  • EmblemHealth VIP Dual (HMO SNP) is a special needs plan for people enrolled in both Medicare and New York State Medicaid. It provides coverage through our extensive VIP Prime Network. You may pay as little as $0 each month for this plan based on your Low Income Subsidy (LIS) level. You pay $0 for covered services in this plan. You will also get benefits Medicare does not cover. Like comprehensive dental, hearing aids, vision, 48 acupuncture visits, 24 one-way transportation visits to approved health care locations, a SilverSneakers® membership and a $1,200 over-the-counter items debit card. You will also get prescription drugs.

    MONTHLY PLAN PREMIUM
    (Amount you pay for your insurance every month)
    All Counties

    Your level of Extra Help Premium
    0% (Full Premium) $39.00
    25% $29.30
    50% $19.50
    75% $9.80
    100% $0.00


    Plan Highlights

    Benefits

    What you pay

    Primary Care Doctor Visit $0
    Specialist Doctor Visit $0
    Preventive Care
    (Services that keep you healthy)
    $0
    Urgently Needed Services $0
    Emergency Room $0
    Inpatient Hospital Coverage $0
    Diagnostic Services/Labs/Imaging $0
    Foot Care $0
    Dental Services
    (No annual dollar limit)
    Comprehensive and Preventive
    Hearing Aid $1,500 every 3 years
    Routine Eyewear $0 per year
    ($200 plan limit every two years)
    24-Hour Nurse Hotline Yes
    SilverSneakers Yes
    Prescription Drug Yes

    Disclaimer

    HIP Health Plan of New York (HIP) is an HMO plan with a Medicare contract. Enrollment in HIP depends on contract renewal. HIP is an EmblemHealth company. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.

    Our Medicare Special Needs Plan is for people with both Medicare and Medicaid. Your eligibility to enroll in this plan may depend on your Medicaid status. Premium, copays, coinsurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

    The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary.

    The SilverSneakers® fitness program is provided by Tivity Health, Inc., an independent company. © 2018. All rights reserved.


    To view the Portable Document Format (PDF) files, you need Adobe Acrobat Reader . If you do not already have this software, you can download a free copy from Adobe®. Download the Adobe Reader® now . Follow Adobe's instructions for download and installation.

  • Find a Doctor

    Search the VIP Prime Network

    Note: To find a dentist, please use the dental provider link below.

    Dental Provider Search

    Search for a Dentist

    Download Directories -


    Monthly Provider Directory Updates

    This document includes recent additions, deletions and changes to the provider network. A group of health care professionals or facilities, such as hospitals, that contract with EmblemHealth for all the counties.


    Disclaimer

    HIP Health Plan of New York (HIP) is an HMO plan with a Medicare contract. Enrollment in HIP depends on contract renewal. HIP is an EmblemHealth company. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.

    Our Medicare Special Needs Plan is for people with both Medicare and Medicaid. Your eligibility to enroll in this plan may depend on your Medicaid status. Premium, copays, coinsurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

    The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary.

    The SilverSneakers® fitness program is provided by Tivity Health, Inc., an independent company. © 2018. All rights reserved.


    To view the Portable Document Format (PDF) files, you need Adobe Acrobat Reader . If you do not already have this software, you can download a free copy from Adobe®. Download the Adobe Reader® now . Follow Adobe's instructions for download and installation.

  • Prescription Drug Benefits — Coverage When You Need It

    As a member of this plan, you are automatically enrolled in Medicare Part D. Because of your eligibility for Medicaid and Medicare, you should receive Extra Help in paying for your prescription drug coverage.

    This means that you will receive help in paying for your monthly Medicare Part D premium (The amount you pay for your insurance every month), yearly deductible (amount you pay before your plan starts to pay) and prescription drug copays (the amount you pay for drugs).

    Our plan groups each drug into one of five “tiers (levels).” You will need to use the formulary (list of covered drugs) to find what tier a drug is on.

    Below are the five drug tiers:

    Tier 1 Preferred Generic

    Tier 2 Generic

    Tier 3 Preferred Brand

    Tier 4 Non-Preferred Drug

    Tier 5 Specialty Tier

    Low Income Subsidy

    Based on a determination by the Social Security Administration (SSA), you may be eligible for additional Part D savings through the Low Income Subsidy (LIS). In this plan, depending on your eligibility level for Extra Help, you may pay up to an $83 yearly deductible and some small copays (the amount you pay for drugs) or coinsurances (the percentage you pay for drugs) when you fill your prescriptions at pharmacies that contract with EmblemHealth.

    After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through home delivery pharmacy) reach $5,000, you pay the greater of: 5% of the cost or you pay $3.35 for generic drugs (including brand drugs treated as generic). You pay $8.35 for all other drugs.

    For more information and an application for Low Income Subsidy (LIS), please call Social Security at 1-800-772-1213 (TTY: 1-800-325-0778), Monday through Friday, 7 am to 7 pm. Or visit ssa.gov.

    Your LIS category will entitle you to one of the following:

    LIS Category (Subsidy Level) Out-of-pocket costs through the coverage gap Generic/Brand Catastrophic Level Drug Copay Over $5,000 Generic/Brand Premium (the amount you pay for your insurance every month)
    Category 0 Not eligible for low income subsidy; amounts listed in benefit summary The greater of $3.35/$8.35 or 5% of the cost $39
    Category 1 (100%) $3.35 / $8.35 $0 $0
    Category 2 (100%) $1.25 / $3.70 $0 $0
    Category 3 (100%) $0 (institutional) $0 $0
    Category 4 (100%) $83 deductible/15% of the cost $3.35 / $8.35 $0
    Category 4 (75%) $83 deductible/15% of the cost $3.35 / $8.35 $9.80
    Category 4 (50%) $83 deductible/15% of the cost $3.35 / $8.35 $19.50
    Category 4 (25%) $83 deductible/15% of the cost $3.35 / $8.35 $29.30

    See Covered Drugs
    Find the prescription drugs you take in EmblemHealth’s list of covered drugs called a formulary.

    Find a Pharmacy
    There’s an EmblemHealth network pharmacy near you. Here’s how to find one.

    Set up Home Delivery and Refills for Prescription Drugs
    Have your prescriptions and refills delivered directly to your home through Express Scripts, Inc. (ESI), our home-delivery pharmacy.

    Rx Cost Calculator
    Look up the costs of each prescription drugs you take.

    Additional Pharmacy Information

    Learn more about what our over-the-counter debit card covers, how to get money back for a drug, our Medication Management Therapy program, how to get help paying for Part D drugs through the Extra Help program (as known as Low Income Subsidy) and much more.

    To view the Portable Document Format (PDF) files on this page, you need Adobe Acrobat Reader. If you do not already have this software, you can download a free copy from Adobe®. Download the Adobe Reader® now. Follow Adobe's instructions for download and installation. 



    Disclaimer

    HIP Health Plan of New York (HIP) is an HMO plan with a Medicare contract. Enrollment in HIP depends on contract renewal. HIP is an EmblemHealth company. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.

    Our Medicare Special Needs Plan is for people with both Medicare and Medicaid. Your eligibility to enroll in this plan may depend on your Medicaid status. Premium, copays, coinsurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

    The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary.

    The SilverSneakers® fitness program is provided by Tivity Health, Inc., an independent company. © 2018. All rights reserved.


    To view the Portable Document Format (PDF) files, you need Adobe Acrobat Reader . If you do not already have this software, you can download a free copy from Adobe®. Download the Adobe Reader® now . Follow Adobe's instructions for download and installation.

  • 2018 Plan Documents


    Summary of Benefits

    Evidence of Coverage

    Nondiscrimination Policy

    Annual Notice of Change


    Nondiscrimination Policy

    Download Directories -


    Monthly Provider Directory Updates

    This document includes recent additions, deletions and changes to the provider network. A group of health care professionals or facilities, such as hospitals, that contract with EmblemHealth for all the counties.


    2018 EmblemHealth HMO and PPO Drug Formulary

    Low-Income Subsidy Information

    Do you get extra help from Medicare to pay for your Medicare prescription drug plan costs? If so, your monthly plan premium will be lower than it would be if you did not get extra help from Medicare. The amount of help you get will determine your total monthly premium as a member of our plan.

    LIS Premium Summary

    EmblemHealth Medicare Plan Ratings

    Nondiscrimination Policy


    Disclaimer

    HIP Health Plan of New York (HIP) is an HMO plan with a Medicare contract. Enrollment in HIP depends on contract renewal. HIP is an EmblemHealth company. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.

    Our Medicare Special Needs Plan is for people with both Medicare and Medicaid. Your eligibility to enroll in this plan may depend on your Medicaid status. Premium, copays, coinsurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

    The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary.

    The SilverSneakers® fitness program is provided by Tivity Health, Inc., an independent company. © 2018. All rights reserved.


    To view the Portable Document Format (PDF) files, you need Adobe Acrobat Reader . If you do not already have this software, you can download a free copy from Adobe®. Download the Adobe Reader® now . Follow Adobe's instructions for download and installation.

  • Enroll in an EmblemHealth Medicare Advantage Plan

    You've looked at your options, and now you're ready to enroll. We want to make the process as easy as possible for you.

    There are four simple ways to enroll.

    Enroll Online

    Enroll Now

    You may also enroll in an EmblemHealth Medicare Plan through the CMS Medicare Online Enrollment Center.

    Make an In-Home Appointment

    Call us at 1-800-447-9169 (TTY: 711), 8 am to 8 pm, seven days a week to:

    • Schedule an in-home appointment with an EmblemHealth Sales Representative who will answer your questions and help you complete the enrollment application.
    • Request an enrollment kit.

    Call to Enroll

    You may enroll in an EmblemHealth Medicare Advantage Plan for 2018 over the phone beginning October 15th by calling us toll-free at 1-800-447-9169 (TTY:711), seven days a week, 8 am to 8 pm.

    Enroll by Mail

    We make it easy for you to become an EmblemHealth VIP Medicare Advantage plan member.

    • Fill in all the requested Medicare information on your enrollment form.
    • Sign and date your enrollment form.
    • Mail it to us at:
      EmblemHealth
      Attention: Medicare Marketing
      P.O. Box 2859
      New York, NY 10117-7894



    2018 EmblemHealth Medicare Enrollment Form


    Mail the form to:

    EmblemHealth
    Attention: Medicare Marketing
    PO Box 2859
    New York, NY 10117-7894


    Disclaimer

    HIP Health Plan of New York (HIP) is an HMO plan with a Medicare contract. Enrollment in HIP depends on contract renewal. HIP is an EmblemHealth company. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or co-payments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.

    Our Medicare Special Needs Plan is for people with both Medicare and Medicaid. Your eligibility to enroll in this plan may depend on your Medicaid status. Premium, copays, coinsurance, and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

    The formulary, pharmacy network and/or provider network may change at any time. You will receive notice when necessary.

    The SilverSneakers® fitness program is provided by Tivity Health, Inc., an independent company. © 2018. All rights reserved.


    To view the Portable Document Format (PDF) files, you need Adobe Acrobat Reader . If you do not already have this software, you can download a free copy from Adobe®. Download the Adobe Reader® now . Follow Adobe's instructions for download and installation.