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MetroPlus Advantage Plan (HMO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for MetroPlus Advantage Plan (HMO D-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on MetroPlus Advantage Plan (HMO D-SNP) in 2025, please refer to our full plan details page.
MetroPlus Advantage Plan (HMO D-SNP) is a HMO D-SNP plan offered by New York City Health and Hospitals Corporation available for enrollment in 2025 to people living in NYC - All five boroughs. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that MetroPlus Advantage Plan (HMO D-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
MetroPlus Advantage Plan (HMO D-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about MetroPlus Advantage Plan (HMO D-SNP).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For MetroPlus Advantage Plan (HMO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $71.20. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $0.80. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $590.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $9350.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The MetroPlus Advantage Plan (HMO D-SNP) has a $590 deductible for prescription drugs. After you meet your deductible, you will pay costs for your drugs depending on the drug tier, until your total drug costs reach $2000. If you qualify for the low-income subsidy, you will pay $71.20. After your yearly out-of-pocket drug costs reach $2000, you pay nothing for Medicare Part D covered drugs.
Additional Benefits
The MetroPlus Advantage Plan (HMO D-SNP) offers a range of benefits, including coverage for outpatient services, primary care, preventive services, vision, dental, and home health services, all with varying cost-sharing arrangements, such as coinsurance of 20% for many services. The plan also includes coverage for emergency services, ambulance services, and transportation to health-related locations. Additionally, the plan provides extra benefits such as hearing aids, medical equipment, and home infusion services, and covers some over-the-counter items, acupuncture, and a meal benefit.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered, but the specific cost-sharing details are not provided. Additional days, upgrades, and non-Medicare-covered stays for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services, including outpatient hospital services and observation services, are covered with a 20% coinsurance. Ambulatory Surgical Center (ASC) Services and Outpatient Substance Abuse Services are also covered with a coinsurance of 20%. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the MetroPlus Advantage Plan (HMO D-SNP), requiring prior authorization and a doctor referral. You will pay 20% coinsurance for this benefit.
Ambulance and Transportation Services See details
The MetroPlus Advantage Plan (HMO D-SNP) covers ambulance services with a 20% coinsurance for both ground and air ambulance services, and no copay. Transportation Services to a plan-approved health-related location are covered for up to 48 one-way trips per year using bus/subway, while transportation to any health-related location is not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the MetroPlus Advantage Plan (HMO D-SNP). Emergency Services and Urgently Needed Services have a 20% coinsurance. Worldwide Emergency Coverage is covered, while Worldwide Urgent Coverage and Worldwide Emergency Transportation are not covered.
Primary Care See details
Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Podiatry Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services are covered, with a 20% coinsurance for most services. Routine Chiropractic Care is not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with no copay, annual physical exams, and other preventive services. Kidney Disease Education Services, Glaucoma Screening, Diabetes Self-Management Training, Barium Enemas, Digital Rectal Exams, and EKG following Welcome Visit have a 20% coinsurance. Other covered services include Personal Emergency Response System (PERS) with no cost sharing, and Nutritional/Dietary Benefit with 6 visits.
Hearing Services See details
Hearing services are partially covered, with a doctor referral required for hearing exams that have a coinsurance of at least 20%, and prescription hearing aids covered up to $500 per year. Routine hearing exams, fitting/evaluation for hearing aids, prescription hearing aids for inner ear, outer ear, and over the ear, and OTC hearing aids are not covered.
Vision Services See details
Vision services are covered, including eye exams and eyewear. Eye exams have a 20% coinsurance, while routine eye exams are not covered. Eyewear, including contact lenses, eyeglasses, eyeglass lenses, and eyeglass frames, are covered with a 20% coinsurance and a combined maximum benefit of $450 every year.
Dental Services See details
The MetroPlus Advantage Plan (HMO D-SNP) covers dental services, including Medicare Dental Services with 20% coinsurance. Other dental services include oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, orthodontics, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the MetroPlus Advantage Plan (HMO D-SNP). Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the MetroPlus Advantage Plan (HMO D-SNP), requiring a doctor's referral. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment is covered by the MetroPlus Advantage Plan (HMO D-SNP), with a 20% coinsurance for durable medical equipment, prosthetic devices, medical supplies, diabetic supplies, and diabetic therapeutic shoes/inserts; there is no copay. Durable medical equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with a doctor referral required. Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services have a coinsurance of at most 20%, and there is no copay.
Home Health Services See details
Home Health Services are covered by the MetroPlus Advantage Plan (HMO D-SNP) with no copay and no coinsurance. Additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but not in practice because Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. Prior authorization and a doctor referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the MetroPlus Advantage Plan (HMO D-SNP), but prior authorization is required. The plan follows Medicare-defined cost sharing for tier 1, but additional days beyond Medicare-covered for SNF, and non-Medicare-covered stays for SNF, are not covered.
Other Services See details
The MetroPlus Advantage Plan (HMO D-SNP) covers acupuncture with prior authorization, up to 20 treatments per year, and includes Over-the-Counter (OTC) Items, offering nicotine replacement therapy, but not Naloxone coverage. The plan also provides a meal benefit for chronic illnesses. Other services such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management, and others are not covered.
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Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
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