In-Network
Out-of-Network
Premium
In-Network
$55
Out-of-Network
$55
Medical Deductible
$500 annually for Medicare-covered in-network and out-of-network medical services
Eligible Age
65 or older (or under 65 with certain disabilities)
Eligible Service Areas
Reside within New York City’s five boroughs (The Bronx, Brooklyn, Manhattan, Queens, and Staten Island), Nassau, Suffolk, Rockland and Westchester counties.
Other Eligibility Requirements
Qualify for Medicare Part A.
Enroll in and continue to pay for Medicare Part B.
Maximum Out-of-Pocket
In-Network
$9,250 annually for Medicare‑covered services received from in‑network providers
Out-of-Network
$13,900 annually for Medicare‑covered services received from both in‑network and out‑of‑network providers
Annual Supplemental Physical Exam
In-Network
$0 copay
Out-of-Network
$50 copay
Dental
In-Network
Preventive $0 copay
Comprehensive $0 copay
Out-of-Network
$0‒$20 copay
$0‒$100 copay
Plan pays up to $1,500 per year for both preventive and comprehensive dental services combined
A $750 deductible applies for comprehensive dental services
Vision
$0 copay for routine vision exam, including refraction
$75 eyewear allowance every year for contact lenses or one pair of glasses (lenses and frames)
Hearing
$0 for one routine hearing exam per year
$0‒$1,475 copay per hearing aid
Plan covers one hearing aid per ear, per year
Nutrition Counseling
In-Network
$0 copay
Out-of-Network
$50 copay
Nutrition Counseling is offered for up to six preventive counseling and/or risk factor reduction visits annually
Acupuncture
In-Network
$0 copay
Out-of-Network
$50 copay for chronic lower back pain visits, after deductible
$50 copay for supplemental visits
Acupuncture is offered for up to 20 visits per year for chronic lower back pain and 12 supplemental visits per year for any condition, including chronic lower back pain
Telemedicine
In-Network
$0 copay for telemedicine services with in-network PCPs and mental health providers, or through Teladoc Health®
$0 copay for telemedicine services with network specialists, after deductible
Out-of-Network
$50 copay for telemedicine services with out-of-network PCPs;
$75 copay for telehealth services with out-of-network specialists
Nurse Help Line Access
In-Network
$0 copay
Out-of-Network
$0 copay
Meal Delivery
$0 copay for up to 84 meals delivered to your home for up to 28 days following a discharge from hospital to home or from a skilled nursing facility to home with a stay greater than two days, if recommended by a provider
Primary Care Provider (PCP) Visit
In-Network
$0 copay
Out-of-Network
$50 copay, after deductible
Specialist Visit
In-Network
$40 copay, after deductible
Out-of-Network
$75 copay, after deductible
Outpatient Lab Tests (including COVID-19)
In-Network
20% coinsurance for genetic labs, after deductible
$0 for all other labs, after deductible
Out-of-Network
$60 copay, after deductible
Retail Health Clinic
In-Network
$15 copay
Out-of-Network
$60 copay, after deductible
Urgent Care
In-Network
$40 copay
Out-of-Network
$40 copay
Emergency Room
In-Network
$115 copay
Out-of-Network
$115 copay
Ambulance
In-Network
$340 copay, after deductible
Out-of-Network
$340 copay, after deductible
Ambulatory Surgery Visit
In-Network
$0 copay for diagnostic colonoscopies and esophageal endoscopies, after deductible
$240 copay for all other ambulatory surgery center services, after deductible
Out-of-Network
30% coinsurance, after deductible
Outpatient Facility
In-Network
$0 copay for diagnostic colonoscopies and esophageal endoscopies, after deductible
20% coinsurance for all other outpatient hospital services, after deductible
Out-of-Network
30% coinsurance, after deductible
Inpatient Hospital Stay
In-Network
$490 copay per day for days 1‒4, after deductible;
$0 copay per day for days 5-999 and beyond
Out-of-Network
30% coinsurance per stay, after deductible
Skilled Nursing Facility
In-Network
$0 each day for days 1‒20, after deductible
$218 each day for days 21-100
Out-of-Network
50% coinsurance per stay, after deductible