 |
DEPARTMENT OF SENIOR PROGRAMS AND SERVICES |
|
|
|||
|
| TABLE 1: | TRADITIONAL MEDICARE, EMPIRE BLUE CROSS/BLUE SHIELD - BLUE CHOICE SENIORS HIP OF GREATER NEW YORK - LO-HIP PLAN |
| TABLE 2: | AETNA/US HEALTH CARE-US HEALTH CARE GOLDEN MEDICARE (PLAN V) |
TABLE 1
TRADITIONAL MEDICARE,
EMPIRE BLUE CROSS/BLUE SHIELD - BLUE CHOICE SENIORS
| DESCRIPTION OF BENEFITS | TRADITIONAL MEDICARE | Aetna/US
HEALTH CARE |
Aetna/US HEALTH CARE US HEALTHCARE GOLDEN MEDICARE (PLAN V) (800) 282-5366 | EMPIRE
BLUE CROSS |
HIP
OF GREATER NEW YORK |
| Monthly Premium (a) (in Addition to Part B Premium) | $0 | $85; Additional plans available | $85.00 | $75 | $120 |
| Choice of Physicians & Hospitals | Any Medicare physician or hospital | HMO physicians and hospitals only | HMO physicians and hospitals only | HMO physicians and hospitals only | HMO physicians and hospitals only |
| Hospital | You pay deductible and
co-insurance Day limit applies |
You pay $0 Unlimited days with referral or emergency admission |
You pay: $0 Check with plan for days covered |
Co-pay $250 Unlimited days with referral |
You pay $100 Unlimited days with referral or emergency admission |
| Physicians/Specialists
HMOs Require a Referral |
20% co-insurance and $100
deductible apply to both physicians and specialists No referral required |
You pay: $5/physician visit,
$10 after hours $15/specialist visit (referral required) |
You pay: $10/physician visit $15/specialist visit (referral required) |
You pay: $10/physician visit $15/specialist visit |
|
| Skilled Nursing Facility | Prior hospitalization
required Co-payment 100 day limit/benefit period |
Covered only with referral No charge; 100 day limit/benefit period |
Covered only with referral No charge 100 day limit/benefit period |
3 day prior hospitalization
required Covered only with referral No charge 100 day limit/benefit period |
|
| Home Health Care | Covered in full | Covered in full with approval | Covered in full with referral | Covered in full with referral | |
| Emergency Room Care In-Area Emergency Out-of-Area Emergency Worldwide |
You pay: 20%, $100 deductible 20%, $100 deductible Not covered |
You pay: $35 (waived if
admitted) $35 (waived if admitted) $35 (waived if admitted) Contact Plan for d etails |
You pay: $50 (waived if admitted) $50 (waived if admitted) Contact Plan for details |
You pay: $50 (waived if admitted) $50 (waived if admitted) Contact Plan for details $15 |
|
| Urgently needed services | 20%, $100 deductible | You pay $5 - one
annual physical $100 allowance every 2 years You pay $15 You pay $15 - one exam per year You pay $15 - one exam per year $500 per three years |
$50 (waived if admitted) | $15 | |
| Preventive Health Care Preventive Exam Eye Glasses Routine Vision Exam Routine Hearing Exam Hearing Aids |
Not covered Not covered Not covered Not covered |
You pay $10 generic
(30 day supply) $15 brand name See attached chart $500 annual limit for brand name plan-approved drugs |
You pay $10, unlimited number 1 pair every 2 years You pay $10, contact plan for details You pay $0 through HEARx $700 allowance every three years |
You pay $0, annual physical $check with plan You pay $15, one exam per year You pay $15 $500 allowance every 3 years, one aid allowed per 3 years |
|
| Pharmacy Benefit | Not covered | Contact Plan for details | You pay $5 generic (30 day
supply) $15 brand name (30 day supply) annual limit $450 (brand or generic plan-approved drugs) See additional information on attached chart |
You pay $10 generic
(unlimited) $20 brand name $500 annual limit on brand name for plan-approved drugs) See additional information on attached chart |
|
| Routine Dental | Not covered | No charge; 190 lifetime days You pay: $25/visit, group or individual session |
You pay $10 for a check-up and cleaning every six months | You pay $5 for each 6-month check-up; $10 for cleaning | |
| Mental Health Inpatient (psychiatric hospital) Outpatient |
Same as hospital
coverage |
$35 |
No charge; 190 lifetime days
|
$100 co-pay; 190 lifetime days You pay $25/visit |
|
| Point of Service Option | You can access any Medicare provider | Not currently available | Not currently available | ||
| Enrollment is open - November | Additional Plan available at $81 monthly premium. Call Plan for Information |