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Health First Emerald Plus H1099-026 (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Health First Emerald Plus H1099-026 (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Health First Emerald Plus H1099-026 (HMO) in 2026, please refer to our full plan details page.
Health First Emerald Plus H1099-026 (HMO) is a HMO plan offered by Health First Shared Services, Inc. available for enrollment in 2025 to people living in Indian River. This plan received an overall rating of 4 out of 5 stars in 2026.
It's important to know that Health First Emerald Plus H1099-026 (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 Health First Emerald Plus H1099-026 (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 Health First Emerald Plus H1099-026 (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $153.00. 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 $350.00 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 $4150.00 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 Health First Emerald Plus H1099-026 (HMO) plan features an annual drug deductible of $350. Tier 1 preferred generic drugs are fully covered with no copay for one-, two-, or three-month supplies at both preferred and standard pharmacies. Tier 2 generic drug copays start as low as $5 at preferred pharmacies, and there is no copay required for a three-month standard mail-order supply. For Tier 3 preferred brand drugs, copays start at $42 at preferred pharmacies and $47 at standard pharmacies for a one-month supply. Tier 4 non-preferred drugs carry a flat 25% coinsurance across standard and preferred pharmacies, while Tier 5 specialty drugs require a 28% coinsurance for a one-month supply.
Additional Benefits
The Health First Emerald Plus H1099-026 (HMO) plan offers comprehensive medical coverage featuring no copay for primary care visits, annual physicals, and home health services. Specialists, urgent care, and physical therapies require a low $20 to $25 copay, while emergency room visits carry a $150 copay. For inpatient hospital stays, members pay a $200 daily copay for the first eight days and no copay for subsequent days up to 90 days. Routine vision, hearing, and preventive dental services are covered with no copay, including up to $200 annually for eyewear and a $500 annual allowance for prescription hearing aids. Skilled nursing facility stays feature no copay for the first 20 days, followed by a $180 daily copay for days 21 through 100. Additionally, the plan includes up to 20 one-way transportation trips per year and a $40 quarterly allowance for over-the-counter items with no copay.
Inpatient Hospital See details
Inpatient hospital services are partially covered by Health First Emerald Plus H1099-026 (HMO) with no coinsurance, requiring a $200 daily copay for days 1 through 8 and no copay for days 9 through 90 for acute and psychiatric stays. Prior authorization is required, and additional days, upgrades, and non-Medicare-covered stays are not covered.
Outpatient Services See details
Health First Emerald Plus H1099-026 (HMO) covers outpatient services with no coinsurance, featuring a $0 to $150 copay for outpatient hospital services and a $200 copay per stay for observation services. Ambulatory surgical center and outpatient blood services have no copay and no coinsurance, while outpatient substance abuse individual and group sessions require a $25 copay and no coinsurance.
Partial Hospitalization See details
Health First Emerald Plus H1099-026 (HMO) covers partial hospitalization services with a $45.00 copay and no coinsurance. Prior authorization is required to receive coverage for this benefit.
Ambulance and Transportation Services See details
Health First Emerald Plus H1099-026 (HMO) covers ground and air ambulance services with a $260 copay and no coinsurance, subject to prior authorization. Transportation services are partially covered with no copay or coinsurance for up to 20 one-way bus or subway trips per year to any health-related location, though transport to plan-approved health-related locations is not covered.
Emergency Services See details
Emergency services are covered by Health First Emerald Plus H1099-026 (HMO) with a $150 copay and no coinsurance, which is waived if you are admitted to the hospital within 24 hours. Urgently needed services require a $25 copay and no coinsurance, while worldwide emergency services are covered up to a $50,000 maximum with no coinsurance and copays ranging from $150 to $260.
Primary Care See details
Health First Emerald Plus H1099-026 (HMO) provides primary care physician services with no copay and no coinsurance, while specialist visits and physical, occupational, and speech therapies require a $20 copay and no coinsurance. Mental health and psychiatric sessions have a $25 copay with no coinsurance, but podiatry and routine chiropractic services are not covered.
Preventive Services See details
Preventive Services are covered by Health First Emerald Plus H1099-026 (HMO) with no copay and no coinsurance for annual physicals, glaucoma screenings, and diabetes training, though an EKG following a welcome visit requires a $40 copay and no coinsurance. Additional preventive benefits are partially covered with no copay and no coinsurance under prior authorization, including fitness and in-home safety assessments. However, several sub-services are not covered, including health education, personal emergency response systems, medication reconciliation, readmission prevention, wigs, weight management, alternative therapies, therapeutic massage, adult day health, nutritional benefits, palliative care, caregiver support, smoking cessation, telemonitoring, remote access, safety devices, and counseling.
Hearing Services See details
Health First Emerald Plus H1099-026 (HMO) covers Medicare-covered hearing exams with a $35 copay and no coinsurance, while routine hearing exams and fitting evaluations have no copay or coinsurance. Prescription hearing aids are partially covered up to a $500 annual limit with no copay or coinsurance, though inner ear, outer ear, over the ear, and over-the-counter (OTC) hearing aids are not covered.
Vision Services See details
Health First Emerald Plus H1099-026 (HMO) partially covers vision services with no deductible, offering eye exams with a $25 copay and no coinsurance—with no copay and no coinsurance for one routine annual exam—and up to $200 yearly for eyewear with no copay and no coinsurance. Other eye exam services and eyewear upgrades are not covered.
Dental Services See details
Health First Emerald Plus H1099-026 (HMO) partially covers dental services, offering Medicare-covered dental with a $40 copay and no coinsurance, alongside select preventive services like exams, cleanings, x-rays, and fluoride with no copay and no coinsurance. Comprehensive dental services, including restorative, endodontics, periodontics, and orthodontics, are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Health First Emerald Plus H1099-026 (HMO) with no copay, though prior authorization is required. Associated Medicare Part B chemotherapy, radiation, and other drugs require between no coinsurance and 20% coinsurance, while Part B insulin has a $35 copay and between no coinsurance and 20% coinsurance.
Dialysis Services See details
Dialysis services are covered by Health First Emerald Plus H1099-026 (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment benefits under the Health First Emerald Plus H1099-026 (HMO) plan are covered with no copay and require prior authorization. Members will pay a 20% coinsurance for durable medical equipment, prosthetics, medical supplies, and diabetic therapeutic shoes, while diabetic supplies feature no coinsurance to 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and radiological services covered by Health First Emerald Plus H1099-026 (HMO) require prior authorization, featuring a $40 copay for diagnostic procedures and outpatient X-rays. Diagnostic radiological services require a $175 copay, therapeutic radiology has a 20% coinsurance, and lab services are covered with no coinsurance.
Home Health Services See details
Health First Emerald Plus H1099-026 (HMO) covers Home Health Services with no copay and no coinsurance. Prior authorization is required to access these covered services.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are covered under the Health First Emerald Plus H1099-026 (HMO) plan with no coinsurance, meaning some services are covered while standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered and require a $20 copay.
Skilled Nursing Facility (SNF) See details
Health First Emerald Plus H1099-026 (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day hospital stay. Patients pay no copay for days 1 through 20 and a $180 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other Services are partially covered by Health First Emerald Plus H1099-026 (HMO), which offers over-the-counter (OTC) items with no copay and no coinsurance up to a maximum of $40 every three months. Acupuncture, meal benefits, and Dual Eligible SNPs are not covered.
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