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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 $125.00. 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. In the initial coverage phase, your costs vary. For example, you will pay a $10 copay at a preferred pharmacy, or no copay for preferred mail-order for preferred generic drugs. For non-preferred drugs, you pay 29% coinsurance. After your total drug costs reach $2000, you enter the catastrophic coverage phase, where you will pay nothing for your Part D covered drugs.
Additional Benefits
The EmblemHealth VIP Gold (HMO) plan offers a range of benefits with varying costs. Hospital stays have a copay of $290 for the first seven days, and outpatient services range from no copay to $295. The plan includes coverage for primary care, specialist visits, and mental health services, with copays typically at $25. Additional benefits include hearing and vision services, with a $25 copay for eye exams and a maximum benefit of $300 for eyewear. Dental services cover a variety of procedures with copays, and the plan also covers home infusion, dialysis, and medical equipment with copays or coinsurance. However, certain services like cardiac rehabilitation, acupuncture, and some home-based care are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute, with a copay of $290 for days 1-7 and no copay for days 8-90, and Inpatient Hospital Psychiatric with a copay of $2036. Additional days for Inpatient Hospital-Acute are covered, but non-Medicare-covered stays 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 (ASC) services with no copay. Outpatient substance abuse services have a $25 copay for individual and group sessions, and outpatient blood services are also covered.
Partial Hospitalization See details
Partial Hospitalization is covered under the EmblemHealth VIP Gold (HMO) plan, with a $25 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the EmblemHealth VIP Gold (HMO) plan. 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 and Worldwide Emergency Coverage, Urgent Coverage, and Transportation have a $110 copay, while Urgently Needed Services have a $35 copay, and there is no coinsurance for any of these services.
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
Preventive Services include coverage for Medicare-covered preventive services, annual physical exams, health education, fitness benefits, enhanced disease management, remote access technologies, kidney disease education, glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit. However, 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, fitting/evaluation for hearing aids, and prescription hearing aids (all types) with a maximum benefit of $2,400 every three years. Prescription hearing aids for the inner ear, outer ear, and over the ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams, eyewear, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, and eyeglass frames. Eye exams have a $25 copay, and eyewear has a combined maximum plan benefit of $300 every year.
Dental Services See details
Dental Services are covered under the EmblemHealth VIP Gold (HMO) plan, including Oral Exams, Dental X-Rays, Other Diagnostic Dental Services, Prophylaxis (Cleaning), Fluoride Treatment, and Other Preventive Dental Services. Restorative Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), and Oral and Maxillofacial Surgery are covered with copays ranging from $0 to $150 depending on the service. Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Medicare Part B Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered under the EmblemHealth VIP Gold (HMO) plan. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the EmblemHealth VIP Gold (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered under the EmblemHealth VIP Gold (HMO) plan. Durable Medical Equipment (DME) has a coinsurance between 10% and 20%, and Prosthetics/Medical Supplies have a 20% coinsurance, while Diabetic Equipment is covered with no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered under the EmblemHealth VIP Gold (HMO) plan. Diagnostic Procedures/Tests have a copay between $0 and $45, while Lab Services have no copay. Diagnostic Radiological Services, Therapeutic Radiological Services, and Outpatient X-Ray Services have a coinsurance of at most 20%, with Outpatient X-Ray Services also having a $25 copay.
Home Health Services See details
Home Health Services are covered by the EmblemHealth VIP Gold (HMO) plan, with no copay or coinsurance. Additional hours of care and personal care services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the EmblemHealth VIP Gold (HMO) plan. This includes Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, and Additional Cardiac Rehabilitation Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the EmblemHealth VIP Gold (HMO) plan, with a $0 copay for days 1-20 and a $214 copay for days 21-100. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
The EmblemHealth VIP Gold (HMO) 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. Other services are not covered.
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