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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 $54.00. 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, your cost will vary depending on the drug tier and the pharmacy you use. For a 30-day supply, you'll pay a $10 copay for preferred generic drugs at a preferred pharmacy, or no copay if you use preferred mail order. For specialty tier drugs, there is no copay.
Additional Benefits
The EmblemHealth VIP Gold (HMO) plan offers a range of benefits with varying costs. The plan covers inpatient hospital stays with a copay, outpatient services with copays ranging from $0-$295, and emergency services with copays. Primary care, hearing, vision, and dental services are also included, with set copays for each. This plan also provides coverage for ambulance services, home infusion, and medical equipment with copays or coinsurance. Preventive services, home health, and skilled nursing facility stays are covered, while certain services like cardiac rehabilitation, acupuncture, and over-the-counter items are not.
Inpatient Hospital See details
Inpatient Hospital coverage includes 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, while Non-Medicare-covered Stay and Upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient services are covered by the EmblemHealth VIP Gold (HMO) plan. Outpatient Hospital Services have a copay between $0 and $295, Observation Services have a $295 copay, and Ambulatory Surgical Center Services have no copay. Individual and Group Sessions for Outpatient Substance Abuse have a copay of $25. Outpatient Blood Services are also covered, including services not usually covered by Medicare plans.
Partial Hospitalization See details
Partial Hospitalization is covered by the EmblemHealth VIP Gold (HMO) plan, with a $25 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, 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, Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation are covered under the EmblemHealth VIP Gold (HMO) plan. Emergency Services have a $110 copay, Urgently Needed Services have a $35 copay, and Worldwide Emergency Services have a $110 copay.
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, mental health specialty services with a $25 copay, podiatry services with a $25 copay, other health care professional services with a $25 copay, psychiatric services with a $25 copay, 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 are covered under the EmblemHealth VIP Gold (HMO) plan, including Medicare-covered services, annual physical exams, health education, fitness benefits, enhanced disease management, remote access technologies, kidney disease education services, 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 of enrollees, additional sessions of smoking and tobacco cessation counseling, telemonitoring services, home and bathroom safety devices and modifications, and counseling services are not covered.
Hearing Services See details
Hearing services offered by the EmblemHealth VIP Gold (HMO) plan include hearing exams with a $25 copay, routine hearing exams (1 per year), and fitting/evaluation for hearing aids (1 per year). Prescription hearing aids are covered with a maximum plan benefit of $2,400 every three years, and the plan covers two hearing aid visits every three years, but 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
The EmblemHealth VIP Gold (HMO) plan covers vision services, including eye exams with a $25 copay. Eyewear is covered with a combined maximum benefit of $300 every year, while contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames are covered. Upgrades are not covered.
Dental Services See details
The EmblemHealth VIP Gold (HMO) plan covers a range of dental services. Oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, and other preventive dental services are covered. Restorative services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery are covered with varying copays. Orthodontic services, maxillofacial prosthetics, and implant services are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, with prior authorization required. 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 under the EmblemHealth VIP Gold (HMO) plan. You will pay a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment coverage includes Durable Medical Equipment (DME) with 10% to 20% coinsurance, Prosthetic Devices with 20% coinsurance, and Medical Supplies with 20% coinsurance; however, DME for use outside the home, Diabetic Supplies, and Diabetic Therapeutic Shoes/Inserts are not covered. There is no copay for these services.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by 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 and Therapeutic Radiological Services have a coinsurance of at most 20%, and Outpatient X-Ray Services have a $25 copay and a coinsurance of at most 20%.
Home Health Services See details
Home Health Services are covered under 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. Prior authorization is required for this service.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the EmblemHealth VIP Gold (HMO) plan, but require prior authorization. For days 1-20, there is no copay, and for days 21-100, the copay is $214 per day; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services, including acupuncture, over-the-counter items, and meal benefits, are not covered by the EmblemHealth VIP Gold (HMO) plan, and neither are 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. No authorization or referrals are required for these services.
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