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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 2026, 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 3.5 out of 5 stars in 2026.
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 $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 Platinum Plan (HMO) has an annual prescription drug deductible of $615. This means you must pay $615 out-of-pocket for your medications before the plan's coverage begins to pay. Specific drug tier details, including copayments and coinsurance rates for different medication levels, are currently not available for this plan. When evaluating the MetroPlus Platinum Plan (HMO) for your medicare needs, keep this $615 drug deductible in mind for your yearly healthcare budget. To best understand your potential out-of-pocket expenses, you should verify how your specific prescriptions are covered under the plan's formulary.
Additional Benefits
The MetroPlus Platinum Plan (HMO) provides robust coverage for core medical services, featuring no copay and no coinsurance for primary care visits, telehealth, and home health care. Specialist visits and outpatient mental health services require a $40 copay, while acute inpatient hospital stays require a $225 daily copay for the first eight days. Emergency room visits and ambulance services are covered with a $100 copay, which is waived if you are admitted to the hospital. For specialty care, the plan offers a $500 annual allowance with no copay or coinsurance for covered eyewear, as well as a $500 hearing aid benefit every three years. Diagnostic tests, X-rays, and durable medical equipment are covered with no copay and a 20% coinsurance. Routine dental services, fitness benefits, acupuncture, and over-the-counter items are not covered under this plan.
Inpatient Hospital See details
MetroPlus Platinum Plan (HMO) covers inpatient hospital services with no coinsurance, requiring a daily copay of $225 for days 1-8 of acute stays and $195 for days 1-8 of psychiatric stays, followed by no copay for days 9-90. Prior authorization is required, and additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
MetroPlus Platinum Plan (HMO) covers outpatient services, featuring outpatient hospital and observation services with no copay and 20% coinsurance, and ambulatory surgical center services with a $95 copay and no coinsurance. Outpatient substance abuse services require a $40 copay and no coinsurance, while outpatient blood services are covered with no copay and no coinsurance.
Partial Hospitalization See details
MetroPlus Platinum Plan (HMO) covers partial hospitalization services with a $40.00 copay and no coinsurance. Prior authorization and a referral are required to access this covered benefit.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered by MetroPlus Platinum Plan (HMO), featuring a $100 copay and no coinsurance for ground and air ambulance services, with the copay waived if you are admitted to the hospital. Prior authorization is required for ambulance services, and transportation services to health-related locations are not covered.
Emergency Services See details
MetroPlus Platinum Plan (HMO) covers emergency services with a $100 copay and no coinsurance, which is waived if you are admitted to the hospital within three days. Urgently needed services are covered with no copay and no coinsurance, but worldwide emergency services are not covered.
Primary Care See details
MetroPlus Platinum Plan (HMO) covers primary care, telehealth, and opioid treatment with no copay and no coinsurance, while specialists and mental health services require a $40 copay with no coinsurance. Physical, occupational, and speech therapy require a $25 copay with no coinsurance, other health professionals require a 20% coinsurance with no copay, and chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are partially covered under the MetroPlus Platinum Plan (HMO) with no copay and no coinsurance for covered benefits like kidney disease education, glaucoma screenings, and diabetes self-management training. However, several services are not covered, including annual physical exams, fitness benefits, health education, and in-home safety assessments.
Hearing Services See details
Hearing services covered by the MetroPlus Platinum Plan (HMO) include annual routine exams and fitting evaluations for a $20 copay and no coinsurance. Prescription hearing aids are partially covered with no copay and no coinsurance up to a $500 maximum every three years, but inner ear, outer ear, over the ear, and over-the-counter hearing aids are not covered.
Vision Services See details
Vision services are partially covered by MetroPlus Platinum Plan (HMO) with no copay and no coinsurance, though a referral is required and routine eye exams and other eye exam services are not covered. Covered eyewear, including contact lenses, eyeglasses, frames, lenses, and upgrades, is available with no copay or coinsurance up to a $500 combined maximum benefit limit every year.
Dental Services See details
MetroPlus Platinum Plan (HMO) partially covers dental services, offering Medicare-covered dental services with no copay and no coinsurance. Routine and comprehensive services—including oral exams, cleanings, x-rays, fluoride, restorative services, endodontics, periodontics, prosthodontics, implants, oral surgery, and orthodontics—are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by the MetroPlus Platinum Plan (HMO) with no copay, though prior authorization and step therapy are required. Under this benefit, Medicare Part B insulin is covered with a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs require a coinsurance of 0% to 20%.
Dialysis Services See details
Dialysis Services are covered under the MetroPlus Platinum Plan (HMO) with no copay and no coinsurance, although a referral is required to receive care.
Medical Equipment See details
MetroPlus Platinum Plan (HMO) covers durable medical equipment, prosthetics, medical supplies, and diabetic equipment with no copay and a 20% coinsurance. Prior authorization is required for these benefits, and diabetic supplies are limited to specified manufacturers.
Diagnostic and Radiological Services See details
MetroPlus Platinum Plan (HMO) covers diagnostic and radiological services, including lab tests and X-rays, with no copay and a 20% coinsurance. Diagnostic services require a referral, while radiological services require both a referral and prior authorization.
Home Health Services See details
MetroPlus Platinum Plan (HMO) covers Home Health Services with no copay and no coinsurance, though prior authorization and a referral are required to receive these services.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the MetroPlus Platinum Plan (HMO) with no copay and no coinsurance, requiring both prior authorization and a referral. However, only some services are covered in practice, as Cardiac Rehabilitation, Intensive Cardiac Rehabilitation, Pulmonary Rehabilitation, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
MetroPlus Platinum Plan (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, though Medicare-defined copays apply and prior authorization is required. Admission requires a prior three-day inpatient hospital stay, and the plan does not cover additional days beyond the standard Medicare-covered limit.
Other Services See details
MetroPlus Platinum Plan (HMO) does not cover other supplemental services, meaning there is no coverage or cost-sharing available for acupuncture, over-the-counter (OTC) items, or meal benefits.
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