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EmblemHealth VIP Gold (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for EmblemHealth VIP Gold (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on EmblemHealth VIP Gold (HMO) in 2025, please refer to our full plan details page.
EmblemHealth VIP Gold (HMO) is a HMO plan offered by EmblemHealth, Inc. available for enrollment in 2025 to people living in Bronx, Kings, NY, Queens, Long Island, Westchester. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that EmblemHealth VIP Gold (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 EmblemHealth VIP Gold (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 EmblemHealth VIP Gold (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $95.00. 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 $200.00 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 $8850.00 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 EmblemHealth VIP Gold (HMO) plan has a $200 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, you will pay a $10 copay at a preferred pharmacy and no copay for preferred mail order. Standard generic drugs have a $40 copay at a preferred pharmacy. Preferred brand drugs have a $95 copay at a preferred pharmacy, and non-preferred drugs have a 29% coinsurance. Specialty tier drugs have no copay.
Additional Benefits
The EmblemHealth VIP Gold (HMO) plan offers comprehensive coverage with a variety of benefits. The plan includes inpatient hospital stays, outpatient services, and partial hospitalization, each with varying copays. Emergency, primary care, preventive, hearing, vision, and dental services are also covered, with specific copays for each service. Additional benefits include ambulance services, home health services, and home infusion. The plan also covers diagnostic and radiological services, dialysis, and medical equipment, with some services requiring prior authorization and/or coinsurance. However, certain services such as cardiac rehabilitation, and other services like acupuncture, over-the-counter items and meal benefits are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute, you'll pay a $290 copay for days 1-7, and no copay for days 8-90. Inpatient Hospital Psychiatric has a copay of $2036. Additional days and upgrades for Inpatient Hospital-Acute, and additional days and non-Medicare covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a copay between $0 and $295, observation services with a $295 copay, and ambulatory surgical center services with no copay. Outpatient substance abuse services are covered with a $25 copay for both individual and group sessions. Outpatient blood services are also covered.
Partial Hospitalization See details
Partial hospitalization is covered by the EmblemHealth VIP Gold (HMO) plan, but requires prior authorization. You will have a $25 copay for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the EmblemHealth VIP Gold (HMO) plan, with prior authorization required for all ambulance services. Ground ambulance services have a $100 copay, while air ambulance services have a 20% coinsurance. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the EmblemHealth VIP Gold (HMO) plan. Emergency Services have a $110 copay, and Urgently Needed Services have a $35 copay. Worldwide Emergency Services, Worldwide Urgent Coverage, and Worldwide Emergency Transportation have a $110 copay, with a maximum plan benefit coverage of $50,000.
Primary Care See details
The EmblemHealth VIP Gold (HMO) plan covers primary care physician services, chiropractic services with a $10 copay, occupational therapy services with a $25 copay, physician specialist services with a $25 copay, and mental health specialty services with a $25 copay for individual and group sessions. The plan also covers podiatry services with a $25 copay, other health care professional services with a $25 copay, psychiatric services with a $25 copay for individual and group sessions, physical therapy and speech-language pathology services with a $25 copay, additional telehealth benefits with a $0-$25 copay, and opioid treatment program services with a $25 copay. Routine chiropractic care is not covered.
Preventive Services See details
The EmblemHealth VIP Gold (HMO) plan covers preventive services, including Medicare-covered services, annual physical exams, health education, fitness benefits (memory fitness), enhanced disease management, remote access technologies, kidney disease education services, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKG following a Welcome Visit. In-home safety assessments, personal emergency response systems, 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, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers, additional sessions of smoking and tobacco cessation counseling, telemonitoring services, home and bathroom safety devices, and counseling services are not covered.
Hearing Services See details
Hearing services under the EmblemHealth VIP Gold (HMO) plan include hearing exams with a $25 copay, and routine hearing exams and fitting/evaluation for hearing aids, each covered once per year. Prescription hearing aids are covered with a maximum benefit of $2400 every three years, but inner ear, outer ear, and over-the-ear hearing aids are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a $25 copay, and eyewear benefits including contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames, with a combined maximum benefit of $300 every year. Upgrades are not covered.
Dental Services See details
Dental Services are covered, including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, orthodontic services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery. Restorative, endodontics, periodontics, prosthodontics, and oral and maxillofacial surgery services have a copay ranging from $0 to $150, while oral and maxillofacial surgery has a copay from $0 to $50. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are also covered with a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the EmblemHealth VIP Gold (HMO) plan, with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment is covered by the EmblemHealth VIP Gold (HMO) plan. Durable Medical Equipment (DME) has a coinsurance between 10% and 20%, and Prosthetic Devices and Medical Supplies have a 20% coinsurance, but Durable Medical Equipment for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, with prior authorization required. Diagnostic Procedures/Tests have a copay between $0 and $45, while Lab Services have no copay. Diagnostic Radiological Services and Therapeutic Radiological Services have at most 20% coinsurance, and Outpatient X-Ray Services have a $25 copay and at most 20% coinsurance.
Home Health Services See details
Home Health Services are covered by the EmblemHealth VIP Gold (HMO) plan with no copay or coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the EmblemHealth VIP Gold (HMO) plan. Prior authorization is required.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) benefits are covered by the EmblemHealth VIP Gold (HMO) plan, requiring prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services, including acupuncture, over-the-counter items, meal benefits, and more, are not covered by the EmblemHealth VIP Gold (HMO) plan. No authorization or referral is required for additional services.
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