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Neighborhood Care

EmblemHealth Affinity Medicare Solutions (HMO SNP)

This plan does not require referrals. This is a special needs plan (SNP) for people enrolled in both Medicare and who have partial or full New York State Medicaid. You may pay as little as $0 each month for this plan based on your Low-Income Subsidy (LIS) level. You may pay $0 or low copays depending on your level of Medicaid for covered services in this plan. 

You will also get benefits Medicare does not cover, like preventive dental, hearing aids, vision, and 14 one-way transportation visits to approved health care locations.

 

Available in the following counties: Bronx, Kings, Queens, Richmond, New York, Nassau, Orange, Rockland, Suffolk and Westchester

 

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

 

Your level of extra help Premium
0% $39.30
25% $29.50
50% $19.60
75% $9.80
100% $0.00

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Plan Highlights

  • $0 up to $39.30
  • No referrals required
  • Transportation (14 one-way trips at no cost)
  • Preventive dental services

Plan Summary

Benefit Summary Amount
Primary care doctor visit: $0
Specialist doctor visit: $0 or $45
Preventive care (Services that keep you healthy): $0
Urgently needed services: $0 or $30
Emergency room: $0 or $90
Inpatient hospital coverage: $0 or $310 per day 1-6, $0 for each additional day
Lab services: $0 or $15
Benefit Summary Amount
Foot care: $0 or $40
Dental services: Preventive
Hearing aid: $350 allowance every year
Routine eyewear: $200 allowance every year
SilverSneakers®: Not covered
Prescription drug: Yes

Medicare Pharmacy

Having the medicines you need is an important part of staying healthy, which is why we take our pharmacy offerings very seriously. We strive to help you make sure you can afford the medicines you take. Our formulary gives you access to thousands of them, and our pharmacy network is large enough to provide the choices you need—close to home.

 

LIS Category (Subsidy Level) Out-of-pocket costs through the coverage gap Generic/Brand Catastrophic Level Drug Copay Over $5,100 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 $3.40/$8.50 or 5% of the total cost $39.30
Category 1 (100%) $3.40 / $8.50 $0 $0
Category 2 (100%) $1.25 / $3.80 $0 $0
Category 3 (100%) $0 (institutional) $0 $0
Category 4 (100%) $85 deductible/15% of the total cost $3.40 / $8.50 $0
Category 4 (75%) $85 deductible/15% of the total cost $3.40 / $8.50 $9.80
Category 4 (50%) $85 deductible/15% of the total cost $3.40 / $8.50 $19.60
Category 4 (25%) $85 deductible/15% of the total cost $3.40 / $8.50 $29.50

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 health services).

 

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 $85 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 pharmacy.

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through home delivery pharmacy) reach $5,100, you pay the greater of: 5% of the cost or you pay $3.40 for generic drugs (including brand drugs treated as generic). You pay $8.50 for all other drugs.

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

 

Plan Documents

 

Medicare Provider Directories

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. Call 877-344-7364/TTY: 711 for more information. Out-of-network/non-contracted providers are under no obligation to treat EmblemHealth members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

Y0026_127476 Accepted 10/1/18

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Last Updated 09/24/19

Y0026_127476 Accepted 10/1/18

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