MetroPlus Platinum Plan (HMO) Plan Details for Kings County, NY
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*CMS rated this MetroPlus Health Plan plan (H0423-004-0) 3 (Average) out of 5 stars.
MetroPlus Platinum Plan (HMO) is a Medicare Advantage plan with prescription benefits. Eligibility and enrollment periods apply. Online enrollment available.
See more Medicare Advantage Plans in Kings County, New York.
MetroPlus Platinum Plan Basic Details
| Plan Basics | |
|---|---|
| Plan ID: | H0423-004-0 |
| Plan Type: | HMO |
| Plan Year: | 2025 |
| Premium: | $92.00/mo Plus your Medicare Part B premium. |
| Health Plan Deductible: | $0.00 |
| Out-of-Pocket Maximum: | 9,350.00 /yr (in-network) |
| Part B Reduction: | $0.00/mo |
| Drug Plan Benefit: | Basic, $590.00 deductible |
| Supplemental Benefits: | Hearing |
| Availability: | Kings County, NY |
| Insured By: | MetroPlus Health Plan |
| Summary of Benefits |
|---|
MetroPlus Health Plan Out-of-Pocket Costs
This MetroPlus Health Plan Part C plan has cost-sharing. These are costs you pay out-of-pocket when you use approved health services. The following table summarizes the most common in-network out-of-pocket costs in plan H0423-004-0.
NOTE: Certain preventive services are covered 100% by the plan as a Part B benefit.
Doctor's Office Visits
| Service | Enrollee Cost (in-network) |
|---|---|
| Primary: | Not Covered |
| Specialist: | $40 Copay Referral Required |
Emergency, Urgent, and Inpatient Hospital Coverage
| Service | Enrollee Cost |
|---|---|
| Emergency room care: | $100 Copay |
| Urgent care: | Not Covered |
| Ground ambulance: | $100 Copay |
| Inpatient hospital care: | $225.00 per day for days 1 through 8 $0.00 per day for days 9 and beyond |
| Skilled Nursing Facility: |
Foot Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Foot Exams and Treatments (Medicare-covered): | $30 Copay Referral Required |
| Routine Foot Care: | Not Covered |
Chiropractic Care
| Service | Enrollee Cost (in-network) |
|---|---|
| Medicare-covered chiropractic: | $15 Copay Prior Authorization Required, Referral Required |
| Routine chiropractic: | Not Covered |
Mental Health Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Outpatient individual therapy: | $40 Copay |
| Outpatient group therapy: | $40 Copay |
| Inpatient psychiatric hospital care: | $195.00 per day for days 1 through 8 $0.00 per day for days 9 and beyond |
Rehabilitation Services
| Service | Enrollee Cost (in-network) |
|---|---|
| Physical therapy and speech and language therapy: | $25 Copay Prior Authorization Required, Referral Required |
| Occupational therapy: | $25 Copay Prior Authorization Required, Referral Required |
Medical Equipment and Supplies
| Service | Enrollee Cost (in-network) |
|---|---|
| Diabetes supplies: | 20% Coinsurance Prior Authorization Required |
| Durable medical equipment: | 20% Coinsurance Prior Authorization Required |
| Prosthetics: | 20% Coinsurance |
Diagnostics, Lab Services, and Imaging
| Service | Enrollee Cost (in-network) |
|---|---|
| Diagnostic radiology services: | 20% Coinsurance Referral Required |
| Lab services: | 20% Coinsurance Referral Required |
| Outpatient x-rays: | 20% Coinsurance Referral Required |
| Diagnostic tests and procedures: | 20% Coinsurance Referral Required |
Medicare Part B Drugs
| Service | Enrollee Cost (in-network) |
|---|---|
| Chemotherapy: | 20% Coinsurance |
| Other Part B drugs (Medicare-covered): | 20% Coinsurance |
Dental Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare Covered Preventive Dental | Not Covered |
| Oral exam | Not Covered |
| Dental x-rays | Not Covered |
| Cleaning | Not Covered |
| Periodontics | Not Covered |
| Endodontics | Not Covered |
| Restorative Services | Not Covered |
Hearing Aids and Services
| Service | Member Cost (in-network) |
|---|---|
| Fitting/evaluation | Covered Limits may apply |
| Hearing aids | Not Covered |
| Hearing exam | Covered Limits may apply |
Vision Services
| Service | Member Cost (in-network) |
|---|---|
| Medicare-covered eye exam | |
| Routine eye exam | Not Covered |
| Eyewear benefits | None |
Feel free to download our MetroPlus Platinum Plan Summary of Benefits information.
Prescription Drug Costs & Benefits
MetroPlus Platinum Plan includes a basic benefit Medicare Part D plan (PDP). Basic plans meet the minimum coverage standards set by the Centers for Medicare & Medicaid Services (CMS). These plans may have higher cost-sharing, deductibles, or limited drug coverage compared to enhanced plans, but they still provide essential prescription drug coverage at a lower premium.
As of 2023, approximately 75% of people on Medicare are enrolled in enhanced plans.
Part D Prescription Drug Premium
The table below outlines the Part D premium costs for this MetroPlus Health Plan plan, showing the monthly portion of the total premium dedicated to prescription drug coverage. While the Part D premium is included in the overall plan cost, some plans may have supplemental charges or offer assistance through the Low-Income Subsidy (LIS) program. Also known as Extra Help, LIS is a Social Security initiative that helps individuals with limited income and resources reduce or eliminate Part D expenses.
| Basic Part D Premium: | $92.00 |
| Supplemental Part D Premium: | $0.00 |
| Total Part D Premium: | $92.00 |
| Low Income Premium Subsidy: | $72.34 |
| Low Income Premium Subsidy CMS Pays: | $72.30 |
| Low Income Subsidy Premium: | $19.70 |
If you would like more information about the Extra Help program, you can refer to the Social Security Extra Help page.
Prescription Drug Plan Deductible
The Medicare Part D annual deductible with this plan is $590.00. You must pay this amount at the pharmacy before MetroPlus Health Plan begins paying its share.
Prescription Drug Plan Out-of-Pocket Costs
In addition to the plan's monthly premium and deductible, MetroPlus Platinum Plan has out-of-pocket costs you must pay when you pick up your prescriptions.
| Drug Tier | Retail | Mail Order | |
|---|---|---|---|
| Cost data not available. | |||
| *The Part D deductible does not apply. | |||
CMS 5-Star Rating Marks
Each year the Centers for Medicare & Medicaid Services (CMS) rates health plans (Part C) in five broad categories and drug plans (Part D) in four broad categories using a 5-star rating system. Here are the most recent CMS ratings for MetroPlus Platinum Plan .
| CMS Measure | Star Rating |
|---|---|
| 2025 Overall Rating | |
| Staying Healthy: Screenings, Tests, Vaccines | |
| Managing Chronic (Long Term) Conditions | |
| Member Experience with Health Plan | Not enough data available |
| Complaints and Changes in Plans Performance | |
| Health Plan Customer Service | |
| Drug Plan Customer Service | |
| Complaints and Changes in the Drug Plan | |
| Member Experience with the Drug Plan | |
| Drug Safety and Accuracy of Drug Pricing |
Additional Plan Options
The Medicare Part C program offers a myriad of HMO, PPO, and PFFS plan options, including these plans:
If you are enrolled in a Part C plan with prescription drug coverage, you cannot be enrolled in a stand-alone Medicare Part D plan, regardless of your chosen insurance company.
You cannot be enrolled in a Part C health plan and simultaneously hold Medicare Supplement Insurance (Medigap). Medicare Supplement plans are only compatible with Medicare Parts A and B.
Contact MetroPlus Health Plan
| Website: | MetroPlus Health Plan Plan Page |
|---|---|
| Providers: | MetroPlus Health Plan Providers Page |
| Formulary: | MetroPlus Health Plan Formulary Page |
| Pharmacy: | MetroPlus Health Plan Pharmacy Page |
| New Member Health Plan Help: | (866)986-0356 |
| New Member Health Plan TTY: | 711 |
| New Member Part D Help: | (866)986-0356 |
| New Member Part D TTY Users: | 711 |
If you qualify for Medicare benefits but have not yet enrolled or verified your enrollment status, you can do so on the Social Security Administration website. You can learn more about the Medicare Part C program on www.medicare.gov or call 1-800-MEDICARE.
Citations & References
- MetroPlus Health Plan, http://www.metroplusmedicare.org, Last Accessed February 20, 2024
- Medicare.gov, "Medicare Advantage Plans cover all Medicare services", Last Accessed February 20, 2024
- Medicare.gov, "How Original Medicare Works", Last Accessed February 19, 2024
- Medicare.gov, "Medicare & You", Last Accessed February 19, 2024
- Medicare.gov, "What Medicare Covers", Last Accessed February 7, 2023
- CMS.gov, Landscape Source Files, Last Accessed February 21, 2024
- CMS.gov, Medicare Part C & D Performance, Last Accessed February 21, 2024
- CMS.gov, Plan Benefits Package, Last Accessed February 21, 2024
Plans Offered
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Baylor Scott & White Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, GlobalHealth, Health Care Service Corporation, Healthy Blue, HealthSun, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.