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MetroPlus Platinum Plan (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for MetroPlus Platinum Plan (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on MetroPlus Platinum Plan (HMO) in 2025, please refer to our full plan details page.
MetroPlus Platinum Plan (HMO) is a HMO 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 Platinum Plan (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about MetroPlus Platinum Plan (HMO).
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 Platinum Plan (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $92.00. 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 $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 Platinum Plan (HMO) has a $590 deductible for prescription drugs. After the deductible is met, you will pay the costs for drugs in each tier until your total drug costs reach $2000, at which point you enter the next coverage phase. If you qualify for the low-income subsidy (LIS), your monthly premium will be reduced to $19.70. Once your yearly out-of-pocket drug costs reach $2000, you pay nothing for Medicare Part D covered drugs.
Additional Benefits
The MetroPlus Platinum Plan (HMO) offers a range of benefits with varying cost-sharing. Hospital stays have copays, and outpatient services have copays or coinsurance depending on the specific service. The plan also covers primary care, hearing, vision, and dental services to varying degrees, with copays for some services and no copay for others. This plan includes coverage for ambulance services with a copay, and emergency services with a copay. The plan also offers coverage for home infusion, dialysis, medical equipment, and diagnostic services, but some services such as home health and skilled nursing facilities may require prior authorization. However, it's important to note that certain services like preventive care, specific dental services, and other services are not covered by this plan.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, you will pay a $225 copay for days 1-8, and no copay for days 9-90. For Inpatient Hospital Psychiatric services, you will pay a $195 copay for days 1-8, and no copay for days 9-90.
Outpatient Services See details
Outpatient services include a 20% coinsurance for outpatient hospital and observation services, a $50 copay for ambulatory surgical center (ASC) services, and a $40 copay for both individual and group outpatient substance abuse sessions. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the MetroPlus Platinum Plan (HMO) with a $40 copay. Prior authorization and a doctor referral are required.
Ambulance and Transportation Services See details
The MetroPlus Platinum Plan (HMO) covers ambulance services with no coinsurance, but has a $100 copay for both ground and air ambulance services. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services, are covered by the MetroPlus Platinum Plan (HMO), with a $100 copay and no coinsurance for Emergency Services, and no copay or coinsurance for Urgently Needed Services. Worldwide Emergency Services, including Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation are not covered.
Primary Care See details
The MetroPlus Platinum Plan (HMO) covers primary care physician services, chiropractic services with a $15 copay, occupational therapy services with a $25 copay, physician specialist services with a $40 copay, and mental health specialty services with a $40 copay for individual and group sessions. Physical therapy and speech-language pathology services have a $25 copay, and additional telehealth benefits are available. Other Health Care Professional services have 20% coinsurance, and psychiatric services have a $40 copay for individual and group sessions. Podiatry services are not covered.
Preventive Services See details
Preventive Services are covered, with no copay or coinsurance. However, Annual Physical Exams, Health Education, In-Home Safety Assessments, Personal Emergency Response Systems (PERS), Medical Nutrition Therapy (MNT), Post discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Weight Management Programs, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Nutritional/Dietary Benefit, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Fitness Benefit, Enhanced Disease Management, Telemonitoring Services, Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline), Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
The MetroPlus Platinum Plan (HMO) covers hearing exams with a $20 copay, routine hearing exams, and fitting/evaluation for hearing aids, with a $20 copay for each, once per year. The plan also covers prescription hearing aids (all types), with a maximum benefit of $500 every three years, but does not cover prescription hearing aids for the inner, outer, or over the ear, or OTC hearing aids.
Vision Services See details
Vision services are partially covered under the MetroPlus Platinum Plan (HMO), with no deductible. Eye exams are covered, but routine eye exams are not covered. Eyewear is also covered, but contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services are partially covered by the MetroPlus Platinum Plan (HMO), with coverage for Medicare Dental Services, but not for Orthodontic Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable), Maxillofacial Prosthetics, Implant Services, Prosthodontics (fixed), Oral and Maxillofacial Surgery, or Orthodontics. This plan has no copay or coinsurance for the covered services.
Home Infusion bundled Services See details
The MetroPlus Platinum Plan (HMO) covers Home Infusion bundled Services, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required for this benefit.
Dialysis Services See details
Dialysis Services are covered under the MetroPlus Platinum Plan (HMO) with a doctor referral. There is no copay or coinsurance for this benefit.
Medical Equipment See details
Medical equipment is covered by the MetroPlus Platinum Plan (HMO), with a 20% coinsurance for Durable Medical Equipment, Prosthetic Devices, and Medical Supplies, and no copay. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
The MetroPlus Platinum Plan (HMO) covers diagnostic and radiological services, with no copay. Diagnostic Procedures/Tests, Lab Services, Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services have a coinsurance of at most 20%.
Home Health Services See details
Home Health Services are covered by the MetroPlus Platinum Plan (HMO) with no copay and no coinsurance, but additional hours of care and personal care services are not covered. This benefit requires both authorization and a referral.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are technically covered, but none of the sub-services, including Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services, are covered. Prior authorization and a doctor referral are required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered under the MetroPlus Platinum Plan (HMO), but additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered. Prior authorization is required and the plan charges the Medicare-defined cost share for tier 1, so check with the plan for more details.
Other Services See details
Other Services are not covered by the MetroPlus Platinum Plan (HMO). The plan does not cover acupuncture, over-the-counter items, meal benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services.
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