2019 EmblemHealth VIP Dual (HMO SNP) | EmblemHealth

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EmblemHealth VIP DUAL (HMO SNP)

This is a special needs plan (SNP) for people enrolled in both Medicare and 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 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 Medicare card for up to $1,500 in over-the-counter items, depending on where you live.

Available in the following counties: Bronx, Kings, Queens and New York

Monthly Plan Premium (Amount you pay for your insurance every month):

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

Plan Highlights

Benefit Summary

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 allowance every 3 years
Routine eyewear: $200 allowance every 2 years
24-Hour nurse hotline: Yes
SilverSneakers®: Yes
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.

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 $5,100 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


Plan Documents


Provider Directory

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. 

The SilverSneakers® fitness program is provided by Tivity Health, Inc., an independent company. © 2019. All rights reserved.

Last Updated 10/1/18

Y0026_127476 Accepted 10/1/18

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Last Updated 09/24/19

Y0026_127476 Accepted 10/1/18