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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: Richmond, Nassau, Orange, Rockland, Westchester, Dutchess, Putnam, Sullivan, Ulster.

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

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 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

 

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

You will need the Adobe® Acrobat Reader software to view files in the Portable Document Format (PDF). If you don’t already have it, you can download a copy from Adobe® here.

Last Updated 09/24/19

Y0026_127476 Accepted 10/1/18

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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.