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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 2026, 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 3.5 out of 5 stars in 2026.
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 $58.80. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your 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 $615.00 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 $9250.00 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) features an annual prescription drug deductible of $615. Members enjoy no copay for Tier 1 preferred generic and Tier 2 generic drugs when filled at standard pharmacies or through standard mail order. This cost-saving benefit applies to one-, two-, and three-month supplies of these generic medications. For higher-tier medications, the plan utilizes a coinsurance structure for standard pharmacy and mail order fills. You will pay a 25% coinsurance for Tier 3 preferred brand drugs and Tier 5 specialty drugs, while Tier 4 non-preferred drugs require a 27% coinsurance. These cost-sharing percentages apply to one-, two-, and three-month supplies depending on the drug tier and delivery method.
Additional Benefits
The MetroPlus Advantage Plan (HMO D-SNP) offers comprehensive medical coverage where most outpatient services, specialist visits, and diagnostic tests feature no copay and a standard 20% coinsurance. Inpatient hospital stays and skilled nursing facility care require no coinsurance, though Medicare-defined copays do apply. Additionally, emergency services, ambulance transportation, and dialysis are covered with no copay and a 20% coinsurance. This plan also provides valuable supplemental benefits, including preventive and comprehensive dental care, home health services, and over-the-counter items with no copay and no coinsurance. Vision benefits include no copay and a $450 annual allowance for eyewear, while hearing aid coverage offers no copay up to a $500 annual limit. Members also benefit from up to 48 routine one-way transportation trips per year and acupuncture treatments with no copay or coinsurance.
Inpatient Hospital See details
MetroPlus Advantage Plan (HMO D-SNP) partially covers inpatient hospital care with no coinsurance, though Medicare-defined copays and prior authorization are required. Additional hospital days, room upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
MetroPlus Advantage Plan (HMO D-SNP) covers outpatient services, including outpatient hospital, ambulatory surgical center, substance abuse, and blood services, with no copay and a 20% coinsurance. A referral is required for ambulatory surgical center and outpatient blood services.
Partial Hospitalization See details
MetroPlus Advantage Plan (HMO D-SNP) covers partial hospitalization services with no copay and a 20% coinsurance. Prior authorization and a referral are required to access this benefit.
Ambulance and Transportation Services See details
MetroPlus Advantage Plan (HMO D-SNP) covers ground and air ambulance services with a 20% coinsurance and no copay, subject to prior authorization. Transportation services are partially covered with no copay or coinsurance, offering up to 48 one-way trips per year via bus or subway to plan-approved health-related locations, while transportation to other health-related locations is not covered.
Emergency Services See details
MetroPlus Advantage Plan (HMO D-SNP) covers emergency services and urgently needed services with a 20% coinsurance and no copay, with the coinsurance waived if you are admitted to the hospital within 3 days. Worldwide emergency services are partially covered with no copay and no coinsurance, though worldwide urgent care and worldwide emergency transportation are not covered.
Primary Care See details
MetroPlus Advantage Plan (HMO D-SNP) covers primary care, specialist, therapy, and mental health services with no copay and 20% coinsurance. Chiropractic services are partially covered, with routine care included but other chiropractic services excluded, while routine podiatry is covered for up to 8 visits per year with no copay and 20% coinsurance.
Preventive Services See details
Preventive services are partially covered under the MetroPlus Advantage Plan (HMO D-SNP), offering an annual physical exam with no copay and no coinsurance, while kidney disease education and other screenings have no copay and a 20% coinsurance. While some supplemental benefits like PERS and home safety devices are covered, several sub-services are not covered, including health education, in-home safety assessments, medical nutrition therapy, medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, home-based palliative care, in-home support, caregiver support, smoking cessation, disease management, telemonitoring, remote access, and counseling.
Hearing Services See details
MetroPlus Advantage Plan (HMO D-SNP) covers diagnostic hearing exams with no copay and no deductible, though routine hearing exams and fitting evaluations are not covered. Prescription hearing aids are covered with no copay and no coinsurance up to a $500 annual limit, but OTC hearing aids and inner, outer, or over-the-ear hearing aid types are not covered.
Vision Services See details
MetroPlus Advantage Plan (HMO D-SNP) vision services feature no copay and a $450 annual limit for eyewear, which has no coinsurance for eyeglasses and a 20% coinsurance for contact lenses. While some eye exam services are covered with no copay and a 20% coinsurance, routine eye exams and other eye exam services are not covered.
Dental Services See details
MetroPlus Advantage Plan (HMO D-SNP) covers Medicare-covered dental services with no copay and a 20% coinsurance. Preventive and comprehensive dental services, including exams, cleanings, and orthodontic care, are covered with no copay and no coinsurance, though prior authorization is required.
Home Infusion bundled Services See details
Home infusion bundled services are covered by the MetroPlus Advantage Plan (HMO D-SNP) with no copay, though prior authorization is required. Covered Medicare Part B insulin drugs require a $35 copay and no coinsurance, while chemotherapy and other Part B drugs have a coinsurance ranging from 0% to 20%.
Dialysis Services See details
Dialysis services are covered by the MetroPlus Advantage Plan (HMO D-SNP) with no copay and a 20% coinsurance, and a referral is required.
Medical Equipment See details
Medical equipment is covered by the MetroPlus Advantage Plan (HMO D-SNP) with no copay and a 20% coinsurance for durable medical equipment, prosthetics, medical supplies, and diabetic supplies or therapeutic shoes. Prior authorization is required for these benefits, and diabetic supplies are limited to specified manufacturers.
Diagnostic and Radiological Services See details
MetroPlus Advantage Plan (HMO D-SNP) covers diagnostic and radiological services with no copay and a 20% coinsurance. Referrals are required for all services, and prior authorization is also required for radiological services.
Home Health Services See details
Home Health Services are covered by the MetroPlus Advantage Plan (HMO D-SNP) with no copay and no coinsurance, although prior authorization and a referral are required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services under the MetroPlus Advantage Plan (HMO D-SNP) are technically covered with no copay and a 20% coinsurance, but in practice only some services are covered as cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
MetroPlus Advantage Plan (HMO D-SNP) covers Skilled Nursing Facility (SNF) services with no coinsurance, though Medicare-defined daily copayments apply and prior authorization is required. A prior three-day inpatient hospital stay is required for admission, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Other services covered by the MetroPlus Advantage Plan (HMO D-SNP) include acupuncture, over-the-counter (OTC) items, and meal benefits for chronic illnesses, all with no copay and no coinsurance. Acupuncture is limited to 20 treatments per year and requires prior authorization, while OTC items are available through reimbursement.
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