2021 Medicare Family Choice® HMO I-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)
MONTHLY PREMIUM

$42.30

PRIMARY/SPECIALTY COPAY
(In-Network)

$0/$0

INPATIENT HOSPITAL COPAY
(In-Network)

$200 copay per admission. Unlimited Days for Medicare covered stays. ($600 Annual Member Copay Maximum).

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

No deductible. $4/$15/25%/25%/33% to initial coverage limit of $4,130.

Plan Details

If you reside in a participating nursing home or an assisted living facility, or are caring for someone who does, and want an extra level of care to address special needs you may be interested in this Medicare Advantage plan.

What extra level of care do plan members receive?

  • Specially Trained Nurse Practitioners/Physician Assistants
    Provide regular, frequent visits to the member; available 24 hours a day, 7 days a week.
  • Care Coordinators
    Work with nursing homes, physicians and hospitals to schedule specialist office visits, and coordinate transportation when authorized.
  • Family Choice Social Workers
    Available to help members and their families with difficult issues, access necessary resources and discuss care options.

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

  • Reside in an affiliated facility located in Western New York, and not live outside the affiliated facility for more than 30 days.
  • Reside as a permanent resident in an affiliated nursing home or assisted living facility or otherwise qualify for an institutional level of care under New York State regulation.
  • Must be entitled or enrolled in Medicare Parts A and B.

NOTE: Members must continue to pay any required Medicare premiums. Enrollment into Independent Health’s Family Choice 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 Medicare Family Choice HMO-SNP plan 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

$42.30

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

$0

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

No deductible. $4/$15/25%/25%/33% to initial coverage limit of $4,130.

Primary Copay

$0

Specialty Copay

$0

Inpatient Hospital Copay

$200 copay per admission. Unlimited Days for Medicare covered stays. ($600 Annual Member Copay Maximum).

Worldwide Emergency / Urgent Care**

$90 / $0

Lab Copay*

$0

General X-ray / Advanced Radiology Copay

10% coinsurance / 10% coinsurance

Transportation (from a network provider)

$0 copay for 36 one-way trips to plan-approved locations (30-mile limit per trip).

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.

Disclaimers

* Member pays 20% for genetic testing.
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.
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