Independent Health's
Medicare Family Choice® HMO-SNP
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Here is an outline of some of the specific changes in your current plan for 2018.

You can also review your Annual Notice of Change / Evidence of Coverage for a complete list of plan changes and 2018 benefits:
2017 2018
Monthly Premium $41 $39
Part D Prescription Benefit
Tiers 1 / 2 / 3 / 4 / 5
No deductible
$4 / $15 / 25% / 25% / 33% to
initial coverage limit of $3,700
No deductible
$4 / $15 / 25% / 25% / 33%
to initial coverage limit of $3,750
Primary Copay $0 $0
Specialty Copay $0 $0
Inpatient Hospital Copay $100 copay per admission
$50 copay per admission
Worldwide Emergency and Urgent Care* $35 / $0 $35 / $0
Lab Copay* $0 $0
General X-ray / Advanced Radiology Copay General X-ray: 10% coinsurance
Advanced radiology: 10% coinsurance
General X-ray: 10% coinsurance
Advanced radiology: 10% coinsurance
Vision $20 routine eye exam, up to $100 coverage limit for routine eyewear $0 routine eye exam, up to $100 coverage limit for routine eyewear
Transportation   
(non-emergency)
$0 for up to 20 one-way trips plan-approved locations $0 for up to 20 one-way trips plan-approved locations



Disclaimers
*Member pays 20% for genetic testing.
Independent Health is a Medicare Advantage organization with a Medicare contract offering HMO, HMO-SNP, HMO-POS, and PPO plans. Enrollment in Independent Health depends on contract renewal. This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care requirement and resides in a participating nursing home for 90 days or more. Or, members must qualify for an institutional level of care as defined by the state of New York. Must be a resident of a participating assisted living facility located in Western New York, and not live outside the affiliated facility for more than 30 days.
Independent Health’s Medicare Family Choice HMO-SNP has been approved by the National Committee for Quality Assurance (NCQA), a non-profit organization dedicated to improving health care quality until December 31, 2020. This plan is available to all Medicare eligibles that are entitled to Medicare Part A and enrolled in Part B, except those with ESRD unless already enrolled with Independent Health. This plan requires the use of participating providers, except in the case of emergency care, urgent care or out of area renal dialysis. Members must continue to pay Part B premiums if not otherwise paid for under Medicaid or by another third party. This information is not a complete description of benefits.
Contact the plan for more information. Limitations, copayments and restrictions may apply. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year.
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Y0042_C5900 Approved 11052017
Last Updated 11/8/2017