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MetroPlus UltraCare (HMO D-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for MetroPlus UltraCare (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 UltraCare (HMO D-SNP) in 2025, please refer to our full plan details page.
MetroPlus UltraCare (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 UltraCare (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 UltraCare (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 UltraCare (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 UltraCare (HMO D-SNP), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $72.30. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $2.10. 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 UltraCare (HMO D-SNP) plan has a $590 deductible for prescription drugs. If you qualify for the low-income subsidy (LIS), you will pay $72.30 for your Part D premium. During the initial coverage phase, you pay the costs for drugs in each tier until your total drug costs reach $2,000. Once your yearly out-of-pocket drug costs reach $2,000, you enter the catastrophic coverage phase and pay nothing for Medicare Part D covered drugs.
Additional Benefits
The MetroPlus UltraCare (HMO D-SNP) plan offers a range of benefits with varying cost-sharing. Many services have a 20% coinsurance, including outpatient services, partial hospitalization, emergency services, primary care, vision, dental, and medical equipment. Ambulance services have a 20% coinsurance, while transportation services to a health-related location are covered for up to 48 one-way trips per year. Preventive services and hearing exams also have a 20% coinsurance, with prescription hearing aids covered up to $500 per year. Home health services have no copay or coinsurance, and there is a $35 copay for Medicare Part B Insulin Drugs. The plan covers a variety of other services, including acupuncture (with a limit of 20 treatments per year) and OTC items.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered and require prior authorization. Additional days, non-Medicare-covered stays, and upgrades for both Acute and Psychiatric Inpatient Hospital services are not covered.
Outpatient Services See details
Outpatient Services include coverage for Outpatient Hospital Services, Observation Services, Ambulatory Surgical Center (ASC) Services, and Outpatient Substance Abuse Services. Outpatient Hospital Services and Observation Services have a 20% coinsurance. Ambulatory Surgical Center (ASC) Services and Outpatient Substance Abuse Services also have a 20% coinsurance. Outpatient Blood Services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the MetroPlus UltraCare (HMO D-SNP) plan, with a 20% coinsurance. Prior authorization and a doctor's referral are required for coverage.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the MetroPlus UltraCare (HMO D-SNP) plan, with no copay for ambulance services. Ground and air ambulance services have a 20% coinsurance, while transportation services to any health-related location are not covered, but transportation services to a plan-approved health-related location are covered for up to 48 one-way trips per year via bus/subway.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the MetroPlus UltraCare (HMO D-SNP) plan. Emergency Services and Urgently Needed Services have a 20% coinsurance, and Worldwide Emergency Coverage has no coinsurance. Worldwide Urgent Coverage and Worldwide Emergency Transportation are not covered.
Primary Care See details
The MetroPlus UltraCare (HMO D-SNP) plan covers 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. The plan has a 20% coinsurance for Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, Individual and Group Sessions for Mental Health and Psychiatric Services, and Routine Foot Care. Routine Chiropractic Care is not covered.
Preventive Services See details
Preventive services are covered, including annual physical exams and additional preventive services, but health education, in-home safety assessments, medical nutrition therapy, 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, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, and telemonitoring services are not covered. Glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit have a 20% coinsurance, and nutritional/dietary benefits are covered for up to 6 visits.
Hearing Services See details
Hearing Services are partially covered by the MetroPlus UltraCare (HMO D-SNP) plan, with a coinsurance of at most 20% for hearing exams. Prescription hearing aids are covered, with a plan-specified amount of $500 per year, but routine hearing exams, fitting/evaluation for hearing aids, and OTC hearing aids are not covered.
Vision Services See details
Vision services include coverage for eye exams and eyewear; however, routine eye exams are not covered. Eye exams and eyewear have a 20% coinsurance, and eyewear has a combined maximum plan benefit of $450 every year.
Dental Services See details
Dental Services are covered, with a 20% coinsurance for Medicare Dental Services. Other services include oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, implant services, oral and maxillofacial surgery, and orthodontics, and all of these require prior authorization.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, 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 these services.
Dialysis Services See details
Dialysis Services are covered under the MetroPlus UltraCare (HMO D-SNP) plan, requiring a doctor's referral. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical equipment is covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. Durable Medical Equipment has a 20% coinsurance, and requires authorization. Prosthetic Devices, Medical Supplies, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts also have a 20% coinsurance. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the MetroPlus UltraCare (HMO D-SNP) plan. Diagnostic Procedures/Tests and Lab Services have a coinsurance of at most 20%, while Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services also have a coinsurance of at most 20%; all services have no copay.
Home Health Services See details
Home Health Services are covered by the MetroPlus UltraCare (HMO D-SNP) plan with no copay or coinsurance, but require authorization and a referral. Additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered. Prior authorization and a doctor referral are required for Cardiac Rehabilitation Services, and there is coinsurance for covered services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but the plan does not cover additional days beyond Medicare-covered SNF stays or non-Medicare-covered SNF stays. Prior authorization is required, and the plan charges the Medicare-defined cost share for tier 1, but the copay is not specified.
Other Services See details
The MetroPlus UltraCare (HMO D-SNP) plan covers acupuncture, with a limit of 20 treatments per year, but requires prior authorization. Over-the-counter (OTC) items, including nicotine replacement therapy, are covered. Meal benefits are covered for chronic illnesses. Other services, including Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, are not covered.
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