Empire MediBlue Freedom I for Nassau, NY

Empire MediBlue Freedom I
Summary Rating:This Medicare drug plan has an average rating of 3.0
Part C Premium:
$50.00
Part D Deductible:$125.00
ICL:$0.00
Mail Order:No
Gap Coverage:No Gap Coverage
LIS:No
Formulary Drugs:2998
Plan ID:H3342-012
Plan Year:2014
Residents of:NY Residents
Plan Type:Local PPO
Summary of Benefits:

Medicare Advantage Plan Summary & Benefits

Empire MediBlue Freedom I, NY Medicare Advantage PlanEmpire MediBlue Freedom I (H3342-012), Preferred Provider Organization Advantage Plan, Nassau County, NY

Empire MediBlue Freedom I is a Preferred Provider Organization (PPO) healthcare plan for seniors and other beneficiaries in Nassau County, NY with Medicare benefits. A Medicare Advantage PPO plan gives you freedom to choose which doctors, specialists, and hospitals you visit. You can lower your costs when you use network providers. Plus, predictable copayments and coinsurance make it easier for you to budget healthcare costs.

The plan information presented on this page is a summary, but not a complete description of available benefits. Comprehensive information about the plan benefits is available from your agent.

Summary of Benefits

When this page was published the Summary of Benefits document for this 2014 health plan was not available. Please Ask an Agent for the Summary of Benefits documentation before choosing this plan.

Monthly Premium

The monthly premium for this health insurance plan in Nassau County is $50.00 plus your monthly Medicare Part B premium. Most Medicare beneficiaries pay the standard monthly Part B premium in addition to their MA or MAPD plan premium. However, some beneficiaries are required to pay slightly higher Part B and Medicare Part D premiums because of their income (over $85,000 per year for singles or $170,000 for married couples), or due to late enrollment penalties.

Part D Prescription Drug Plan Information

This plan includes prescription drug coverage. The formulary (00014281) has a total of 2,998 prescription medications.

If you have Part D assistance, your premium will be adjusted based on your percentage.

Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
  — Drugs per Tier:360873655283408
  — Cost-Sharing in ICP:$3.00$11.00$40.00$90.00$95.00

The Medicare Part D deductible with this health plan is $125.00. This is the amount you will pay until the plan begins to pay its portion.

Maximum Out of Pocket (MOOP) Benefit

The new healthcare law allows for a maximum limit of $6,700 on your out of pocket medical costs for 2014 Medicare Advantage plans. This amount is commonly called the plan MOOP (Maximum Out of Pocket). A plan's MOOP does not include your prescription drugs or the monthly premiums you pay for your health plan. Although the mandatory MOOP limit is $6,700, the Affordable Care Act law allows for a “Voluntary MOOP” that can be as low as $3,400. The MOOP on this plan is $4,500 .

Doctor Visits

Most Medicare health plans require you to make a co-payment (aka, copay) when you visit your primary care physician or a doctor. Here's how this plan works:

  • $20 co-payment for each visit to your primary care physician.
  • $40 co-payment for each visit to a specialist covered by Medicare.
  • $40 co-payment for each visit to your primary care physician.
  • $65 co-payment for each visit to a specialist covered by Medicare.

Urgent Care Doctor Visits

Urgent care is the delivery of ambulatory medical care outside of a hospital emergency department on a walk-in basis without a scheduled appointment. Here's how Urgent Care works with this plan:

  • $40 co-payment for urgent care treatment covered by Medicare.

Emergency Care

Emergency care is medical attention for patients with acute illnesses or injuries which require immediate medical attention. Here's how Emergency Care works with this plan:

  • $65 co-payment for emergency room treatments covered by Medicare.
  • Worldwide coverage.

Ambulance Service

Most health plans do not cover transportation to and from medical services. The exception, of course, is when you have an emergency or when non-ambulatory. Here's how this plan covers ambulance service:

  • Pre-authorization rules apply.
  • $250 co-payment for ambulance benefits covered by Medicare.
  • $250 co-payment for ambulance benefits covered by Medicare.

Inpatient Treatment (Hospital Stays)

A patient who is admitted to a hospital or clinic for treatment that requires at least one overnight stay is an inpatient. Most health plans have a tiered cost structure for inpatient treatment. Here's how this plan covers hospital stays:

  • There is no limit to the number of days covered by the plan per stay in the hospital.
  • For hospital stay covered by Medicares:
  • Days 1 - 5: $245 co-payment per day.
  • .
  • Days 6 - 90: $0 co-payment per day.
.
  • $0 co-payment for additional non-Medicare-covered hospital days.
  • Except in the case of an emergency your physician must let the plan know when you are to be admitted into the hospital.
  • 30% of the cost for each hospital stay covered by Medicare.
  • Diagnostic Services

    Diagnostic services include X-rays, diagnostic tests, lab services, and radiology services. Here's how this plan covers diagnostic services:

    • Pre-authorization rules apply.
    • $15 co-payment for Medicare-covered lab services.
    • $0 to $25 co-payment for diagnostic procedures and tests covered by Medicare.
    • $50 to $150 co-payment for X-Rays covered by Medicare.
    • $50 to $150 co-payment for Medicare-covered diagnostic radiology services (not including X-rays).
    • 20% of the cost for therapeutic radiology treatments covered by Medicare.
    • If the physician provides you services in addition to Outpatient Diagnostic Procedures Tests and Lab Services separate cost sharing of $20 to $40 may apply.
    • If the physician provides you services in addition to Outpatient Diagnostic and Therapeutic Radiology Services separate cost sharing of $20 to $40 may apply.
    • 30% of the cost for therapeutic radiology treatments covered by Medicare.
    • $150 to $200 co-payment for Medicare-covered outpatient X-rays.
    • $150 to $200 co-payment for Medicare-covered diagnostic radiology services.
    • $50 to $75 co-payment for diagnostic procedures and tests covered by Medicare.
    • $50 to $75 co-payment for Medicare-covered lab services.
    • If the physician provides you services in addition to (Medicarecovered Diagnostic Procedures/Tests Medicarecovered Laboratory Services ) separate cost sharing of $40 to $65 may apply.
    • If the physician provides you services in addition to (Diagnostic Radiological Services Outpatient X-Rays ) separate cost sharing of $40 to $65 may apply.
    • If the physician provides you services in addition to (Therapeutic Radiological Services ) separate cost sharing of $40 to $65 may apply.

    Preventive Services

    Medicare covers a wide range of preventive services, including cardiovascular screenings, alcohol misuse screening and counseling, depression screen, and diabedes screening, to name just a few. Here's how this plan covers preventive services:

    • $0 co-payment for all preventive services covered by traditional Medicare at zero cost sharing. All additional preventive services approved by Medicare mid-year will be paid by the plan or by Medicare.
    • $0 to $100 co-payment for preventive treatment covered by Medicare.

    Skilled Nursing Facility

    Medicare covers skilled nursing care in a skilled nursing facility (SNF) under certain conditions for a limited time (no long-term care). Here's how this plan covers SNF services:

    • Pre-authorization rules apply.
    • The plan will cover up to 100 days per benefit period.
    • Prior inpatient treatment (hospital stay) is not required.
    • For SNF stays:
    • Days 1 - 20: $25 co-payment per day.
    • .
    • Days 21 - 100: $120 co-payment per day.
    .
  • For each Medicare-covered SNF stay:
  • Days 1 - 20: $125 co-payment per SNF day.
  • .
  • Days 21 - 100: $170 co-payment per SNF day.
  • .

    Mental Health

    Medicare covers both inpatient and outpatient mental health care services. Here's how this plan covers mental health

    Outpatient:

    • Pre-authorization rules apply.
    • $40 co-payment for each individual therapy visit covered by Medicare
    • $40 co-payment for each group therapy visit covered by Medicare
    • $40 co-payment for each individual therapy visit with a psychiatrist covered by Medicare.
    • $40 co-payment for each Medicare-covered group therapy visit with a psychiatrist.
    • $40 co-payment for partial hospitalization program services covered by Medicare.
    • $100 co-payment for Medicare-covered Mental Health visits with a psychiatrist.
    • $100 co-payment for Medicare-covered Mental Health visits.
    • $100 co-payment for partial hospitalization program services covered by Medicare.

    Inpatient:

    • You are allowed a maximum of 190 days of inpatient (hospitalized) psychiatric care in a lifetime. Inpatient services are applied to the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric care given in a general hospital.
    • For hospital stay covered by Medicares:
    • Days 1 - 5: $245 co-payment per day.
    • .
    • Days 6 - 90: $0 co-payment per day.
    .
  • The plan covers 60 lifetime reserve days. $0 co-payment per lifetime reserve day.
  • With the exception of emergencies, your physician must notify the plan that you are going to be admitted to the hospital.
  • 30% of the cost for each hospital stay covered by Medicare.
  • Dental

    In general, Original Medicare does not cover routine dental care. Currently, Medicare will pay for dental services that are an integral part either of a covered procedure (e.g., reconstruction of the jaw following accidental injury), or for extractions done in preparation for radiation treatment for neoplastic diseases involving the jaw. Here's how this plan covers dental care:

    • This plan covers some preventive dental benefits for an additional monthly fee.
    • $0 co-payment for dental benefits covered by Medicare.
    • 20% of the cost for comprehensive dental benefits covered by Medicare

    Vision

    In general, Original Medicare does not cover routine vision care. Currently, Medicare will pay for Glaucoma screenigs, eye prostheses, Astigmatism-Correcting Intraocular Lenses, and A conventional IOL is covered when implanted following cataract surgery. Here's how this plan covers vision services:

    • This plan covers some vision benefits for an extra cost (see "Optional Supplemental Benefits").
    • $0 to $40 co-payment for exams covered by Medicare to diagnose and treat diseases and conditions of the eye including an annual glaucoma screening for people at risk.
    • $0 co-payment for one pair of eyeglasses covered by Medicare (lenses and frames) or contact lenses after cataract surgery.
    • $65 co-payment for eye exams covered by Medicare.
    • $0 co-payment for corrective lenses covered by Medicare.

    Hearing

    Medicare doesn't cover routine hearing exams, hearing aids, or exams for fitting hearing aids. Medicare covers diagnostic hearing and balance exams if your doctor or other health care provider orders these tests to see if you need medical treatment. Here's how this plan covers hearing services:

    • In most cases, supplemental hearing exams and hearing aids are not covered.
    • $40 co-payment for diagnostic hearing exams covered by Medicare.
    • $65 co-payment for diagnostic hearing exams covered by Medicare.

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    This page was last updated on: 10/28/2013

    More Information

    About The Insurer Empire BlueCross BlueShield

    The summary (overall) rating for this plan is 3.0 out of 5 based on reviews from 41496 user ratings from the previous year. For more information about the review process, visit http://cms.gov.