2021 Assure Advantage® HMO C-SNP Plan

Plan Highlights

MONTHLY PREMIUM
PRIMARY/SPECIALTY COPAY
(In-Network)
INPATIENT HOSPITAL COPAY
(In-Network)
PART D PRESCRIPTION BENEFIT (Tier 1 / 2 / 3 / 4 / 5 / 6)
MONTHLY PREMIUM

$60

PRIMARY/SPECIALTY COPAY
(In-Network)

$0/$30

INPATIENT HOSPITAL COPAY
(In-Network)

Days 1-6: $275 per day. Additional days: $0 Unlimited Days for Medicare covered stays. ($1,925 Annual Member Copay Maximum).

PART D PRESCRIPTION BENEFIT (Tier 1 / 2 / 3 / 4 / 5 / 6)

No deductible. $0/$20/$47/40%/33%/$11 to initial coverage limit of $4,130.

Plan Details

Independent Health’s Assure Advantage (HMO-SNP) is a specialized Medicare Advantage Plan (a Medicare “Special Needs Plan”), which means its benefits are designed for people with special health care needs. Independent Health’s Assure Advantage is designed to provide additional health benefits that specifically help people who have chronic heart failure and diabetes.

Our plan includes providers who specialize in treating chronic heart failure and diabetes. It also includes health programs designed to serve the specialized needs of people with these conditions. In addition, our plan covers prescription drugs to treat most medical conditions, including the drugs that are usually used to treat chronic heart failure and diabetes. As a member of the plan, you get benefits specially tailored to your condition and have all your care coordinated through our plan.

Eligibility Requirements:
To be eligible, it’s important that you meet all of the following criteria:

  • Reside in Erie County.
  • Have chronic heart failure and diabetes.
  • Must be entitled or enrolled in Medicare Parts A and B.
  • Cannot currently have end stage renal disease (ESRD). (Please note: This does not apply if you are currently enrolled in another Independent Health plan.)

Note: Enrollment into Independent Health’s Assure Advantage HMO-SNP plan will automatically disenroll a person from any other Medicare Advantage plan.

For more information or to enroll speak with an Independent Health representative today at:
(716) 635-4900 or 1-800-958-4405 (TTY users call 711):
October 1 – December 7: Monday – Sunday, 8 a.m. – 8 p.m.
December 8 – September 30: Monday – Friday, 8 a.m. – 8 p.m.

Monthly Premium

$60

Plan Premium with Full 100% Low Income Subsidy (LIS)

$17.70

Part D Prescription Benefit Tier 1 / 2 / 3 / 4 / 5 / 6

No deductible. $0/$20/$47/40%/33%/$11 to initial coverage limit of $4,130.

Primary Copay

$0

Specialty Copay

$30

Inpatient Hospital Copay

Days 1-6: $275 per day. Additional days: $0 Unlimited Days for Medicare covered stays. ($1,925 Annual Member Copay Maximum).

Worldwide Emergency / Urgent Care**

$90 / $65

Lab Copay*

$0

General X-ray / Advanced Radiology Copay

$30 / $200

Transportation (from a network provider)

$0 for up to 12 one-way trips to plan-approved locations (30-mile limit per trip).

Wellness Benefits

Vision (from a network provider)

$0 routine eye exam. $150 coverage limit for routine eyewear. $0 for diabetic retinopathy exam for diabetics. $0 for Ophthalmologist too.

Dental (from a network provider)

$20 per visit for preventive dental: Two routine cleanings, exams, fluoride treatments and bitewing X-rays per calendar year. One full-mouth series every 36 months. Optional supplemental dental: 1 option offered for additional $25 premium billed separately. $750 every 3 months - Jan, April, July, Oct. $3,000 max limit, $0 deductible,  50% coinsurance.

SilverSneakers® Fitness Benefit (from a participating facility that offers SilverSneakers)

$0 copayment (memberships will not roll over from 2020 to 2021 or 2021 to 2022. Memberships will restart on January 1st of each year).

Hearing Aid Benefit (from a network provider)

$45 hearing aid evaluation exam. Member pays: $499 - $2,799 (per ear) for hearing aid device. The average cost for hearing aids without coverage is $2,445 or $3,125 per ear.

Enhanced Annual Wellness Visit (EAV)

$0

All of our Medicare Advantage plans come with additional benefits to help you maintain an active, healthy lifestyle.

Disclaimers

* Member pays 20% for genetic testing.

This plan requires the use of participating providers, except in the case of emergency care, urgent care or out of area renal dialysis. This information is not a complete description of benefits. Call (716) 250-4401 or 1-800-665-1502 (TTY users call 711) for more information.

** $10,000 annual maximum plan limit for emergency care, urgent care or ambulance outside the USA and its territories.

IN = In-Network, OON = Out-of-Network

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Last Updated 10/01/2021