EmblemHealth Affinity Medicare Ultimate (HMO SNP)

This plan does not require referrals. 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 Original Medicare does not cover, like an allowance toward comprehensive dental, hearing aids, vision, and a Medicare card for up to $720 in over-the-counter items,  depending on where you live.  

 

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

 

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

 

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

Plan Highlights

  • $0 monthly premium plan
  • No referrals required
  • $60 Monthly over-the-counter (OTC) card
  • Up to $425 for comprehensive dental services

Benefit Summary

Primary care doctor visit: $0
Specialist doctor visit: $0
Preventive care: $0
Urgently needed services: $0
Emergency room: $0
Inpatient hospital coverage: $0
Lab service: $0
Foot care: $0
Dental services: Up to $425 for comprehensive
Hearing aid: $750 every year
Routine eyewear: $100 plan limit per year
SilverSneakers®: Not covered
Prescription drug: Yes

Drugs Covered

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 s 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 $10
Category 4 (50%) $85 deductible/15% of the total cost $3.40 / $8.50 $20
Category 4 (25%) $85 deductible/15% of the total cost $3.40 / $8.50 $30

Drug Cost Calculator

Use our Cost Calculator tool to estimate your prescription drug costs. Enter the prescription drugs you take and we'll show you your monthly drug costs.


  • Summary of Plan Benefits

  • Evidence of Coverage

  • LIS Plan Summary

  • EmblemHealth Medicare Star Ratings

  • Comprehensive and Preventative Dental Benefits

  • HMO/PPO Pharmacy Directory

  • 2019 Annual Notice of Change


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