2024 NYSHIP Plan Comparison
| Independent Health HMO - Medicare Advantage Plan | |
|---|---|
| Office Visits | $20 per visit |
| Annual Adult Routine Physicals | No copayment |
| Well Child Care | |
| Specialty Office Visits | $20 per visit [1] |
| Diagnostic/Therapeutic Services | |
| Radiology | $20 per visit |
| Lab Tests | No copayment [2] |
| Pathology | No copayment |
| EKG/EEG | $20 per visit |
| Radiation | $20 per visit |
| Chemotherapy | $20 per visit |
| Dialysis | 20% coinsurance [3] |
| Women's Health Care/Reproductive Health | |
| Pap Tests | No copayment |
| Mammograms | No copayment |
| Prenatal Visits | $20 per visit |
| Postnatal Visits | $20 per visit |
| Bone Density Tests | No copayment |
| Breastfeeding Services and Equipment | $20 copayment per education visit to PCP or specialist office, equipment subject to 20% coinsurance |
| External Mastectomy Prosthesis | 20% coinsurance |
| Family Planning Services | $20 per visit |
| Infertility Services | Not covered |
| Contraceptive Drugs | Applicable Rx copayment |
| Contraceptive Devices | Not covered |
| Inpatient Hospital Surgery | No copayment |
| Physician | |
| Facility | |
| Outpatient Surgery | |
| Hospital | $75 per visit |
| Physician's Office | $20 per visit |
| Outpatient Surgery Facility | $75 per visit |
| Weight Loss/Bariatric Surgery | Applicable surgery copayment for Medicare-covered surgeries |
| Emergency Department | $65 per visit (waived if admitted within 24 hours) |
| Urgent Care Facility | $35 per visit |
| Ambulance | $100 per trip [4] |
| Telehealth | Virtual Care PCP/Specialist: $20 per visit |
| Virtual Portal | |
| Outpatient Mental Health | |
| Individual | $40 per visit, unlimited |
| Group | $40 per visit, unlimited |
| Inpatient Mental Health | No copayment, 190 days max per lifetime |
| Outpatient Drug/Alcohol Rehab | $40 per visit, unlimited |
| Inpatient Drug/Alcohol Rehab | No copayment, unlimited |
| Durable Medical Equipment | 20% coinsurance |
| Prosthetics | 20% coinsurance |
| Orthotics | No copayment [5] |
| Rehabilitative Care, Physical, Speech and Occupational Therapy | |
| Inpatient | No copayment, unlimited |
| Outpatient Physical or Occupational Therapy | $20 per visit, unlimited |
| Outpatient Speech Therapy | $20 per visit, unlimited |
| Diabetic Supplies | |
| Retail | No copayment, 30-day supply |
| Mail Order | Not available |
| Insulin and Oral Agents | Applicable Rx copayment |
| Retail | |
| Mail Order | |
| Diabetic Shoes | No copayment, one pair per year when medically necessary |
| Hospice | Covered by Medicare |
| Skilled Nursing Facility | No copayment, up to 100 days per benefit period |
| Prescription Drugs | |
| Retail | $0 Tier 1, $15 Tier 2, $30 Tier 3, $50 Tier 4, $50 Tier 5, 30-day supply |
| Mail Order | $0 Tier 1, $37.50 Tier 2, $75 Tier 3, $125 Tier 4, 90-day supply |
| Additional Prescription Drug Related Information | Coverage includes injectable and self-injectable medications and enteral formulas. Medicare Encompass prescription drug coverage is an enhancement to Medicare Part D and is subject to any changes required by the Centers for Medicare & Medicaid Services for 2024. NYSHIP's prescription drug coverage under Medicare Encompass is a five-tier benefit that covers Part D prescription drugs through all four drug phases throughout the year. Medicare covered Part B drugs will be covered in full. |
| Specialty Drugs | $50 Tier 5 benefits are provided for specialty drugs by Reliance Rx Pharmacy and Walgreens Specialty Pharmacy. Specialty drugs include select high-cost injectables and oral agents, such as Part D oral oncology drugs. Specialty drugs require prior approval and are subject to the applicable Rx copayment based on the formulary status of the medication. Members pay one copayment for each 30-day supply. A 90-day supply is not available. |
| Additional Benefits | |
| Annual Out-of-Pocket Maximum (In-Network Benefits) | $3,450 per year |
| Dental | No copayment [6] |
| Vision | No copayment for routine eye exam |
| Hearing Aids | Hearing aids from $499 to $2,199 each from Start Hearing. Contact plan for details. |
| Out of Area | While traveling outside the service area, coverage is provided for renal dialysis and urgent and emergency situations only. |
| Additional Benefits HMOs (as applicable) | |
| Home Health Care | No copayment, unlimited, requires prior authorization |
| Eyeglasses | $200 annual allowance |
| Brook Personal Health Companion | Smart phone app for assistance with diabetes and hypertension management. |
| SilverSneakers Fitness Membership | No copayment |
| Plan Highlights for 2024 | Independent Health's Medicare Advantage Plan was awarded a 5-star rating in 2022 and 2023 by the Centers for Medicare & Medicaid Services. |
| Participating Physicians | Independent Health is affiliated with more than 3,000 providers throughout the eight counties of Western New York. |
| Affiliated Hospitals | Independent Health Medicare Encompass members are covered at all Western New York hospitals where their physicians have admitting privileges. Members may be directed to other hospitals when medically necessary. |
| Pharmacies and Prescriptions | All retail pharmacies in Western New York participate. Members may obtain prescriptions out of the service area by using our National Pharmacy Network, which includes 58,000 pharmacies nationwide. |
| Medicare Coverage | Medicare-primary NYSHIP enrollees are required to enroll in Medicare Encompass, Independent Health's Medicare Advantage Plan. Copayments differ from the copayments of a NYSHIP-primary enrollee. To qualify, you must be enrolled in Medicare Parts A and B and live in the service area. Call our Member Services Department for detailed information. |