2024 Encompass 65® Core HMO

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

$65

PRIMARY/SPECIALTY COPAY

(In-Network)

$0/$30

INPATIENT HOSPITAL COPAY

(In-Network)

Days 1-6: $295 per day. Additional days: $0. Unlimited Days for Medicare covered stays. ($1,770 Annual Member Copay Maximum).

PART D PRESCRIPTION BENEFIT

$50 deductible on tiers 3, 4 & 5 only. $0/$12/$42/50%/32% to initial coverage limit of $5,030.

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Plan Details

Monthly Premium

$65

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

$16.30

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

$50 deductible on tiers 3, 4 & 5 only. $0/$12/$42/50%/32% to initial coverage limit of $5,030.

Primary Copay

Specialty Copay

$30

Inpatient Hospital Copay

Days 1-6: $295 per day. Additional days: $0. Unlimited Days for Medicare covered stays. ($1,770 Annual Member Copay Maximum).

Home Delivered Meals

14 Days, up to 28 Meals post inpatient stay

Outpatient Mental Health Care Copay

$25

Worldwide Emergency / Urgent Care*

$100 / $55

Ambulance Copay

$225

Non-Emergency Transportation

$0 for 6 one-way trips

Personal Emergency Response System

Lab Copay**

General X-ray / Advanced Radiology Copay

$35 / $175

Outpatient Surgery

Ambulatory Surgical Center: $275

Hospital-based: $325

Skilled Nursing Facility

Days 1 - 20: $0

Days 21 - 100: $203 per day

Home Health

Physical, Speech and Occupational Therapy

$10

Part B Medications or Radiation Therapy

Part B Medications: 0% - 20%

Radiation Therapy: 20%

Annual Out-of-Pocket Maximum for Medicare Covered Services

$7,300

RedShirt Rewards

Earn up to $100 in RedShirt Rewards for taking healthy actions!
Learn More

Wellness Benefits†

Dental (from a network provider)

$2,000 combined maximum for preventive dental and comprehensive dental.

Preventive Dental: $0 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.

Comprehensive Dental: $0 deductible, 50% coinsurance.

Over-the-Counter (OTC)***

$25 per quarter

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

$0 copayment (Memberships will not roll over from 2023 to 2024 or 2024 to 2025. Memberships will restart on January 1st of each year.)

Vision (from a network provider)

$0 routine eye exam. $200 allowance for routine eyewear.

Hearing Aid Benefit (from a network provider)

$45 hearing aid evaluation exam. Member pays: $499 - $2,199 (per ear) for hearing aid device. The average cost for hearing aids without coverage is $2,445 - $3,125 per ear.

Telemedicine (with a Teladoc® provider)

$25 copay per session. Speak with a doctor anytime, anywhere by phone or online.

Enhanced Diabetes Benefits

These benefits will help members with diabetes manage their special needs, live healthier and save money. Learn More

Chiropractic Services Copay

$15 for Chiropractic evaluation, management and Medicare covered services

Additional Wellness Benefits

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

Disclaimers

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

** Member pays 20% of the cost of genetic testing.

***Allowance is made available by quarter. Allowance carries over quarter to quarter, however does not carry over plan year to plan year. Costs over the allowed amount are the member’s responsibility. This benefit can only be used for covered items through NationsOTC.®

† Limitations, copayments and restrictions may apply. Applicable copays may apply for these benefits. Member must use in-network providers to take advantage of these benefits (excluding Independent Health’s Medicare Passport Advantage PPO plan or Independent Health’s Medicare Passport Prime PPO plan). Must see a Start Hearing network provider to use the hearing aid benefit.

Benefits vary by plan and some plans do not include coverage for these benefits. Benefits, premiums, rewards and/or copayments may change on January 1 of each year. 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.

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

Y0042_C7173
Last Updated 10/1/2023

Individuals & Families

Individuals & Families

In the Community

Brokers

Providers

Employers

2024 Encompass 65® Core HMO

MONTHLY PREMIUM

PRIMARY/SPECIALTY COPAY

(In-Network)

INPATIENT HOSPITAL COPAY

(In-Network)

PART D PRESCRIPTION BENEFIT

(Tier 1 / 2 / 3 / 4 / 5)

MONTHLY PREMIUM

$65

PRIMARY/SPECIALTY COPAY

(In-Network)

$0/$30

INPATIENT HOSPITAL COPAY

(In-Network)

PART D PRESCRIPTION BENEFIT

Plan Details

Wellness Benefits†