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Healthfirst 65 Plus Plan (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Healthfirst 65 Plus Plan (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Healthfirst 65 Plus Plan (HMO) in 2025, please refer to our full plan details page.
Healthfirst 65 Plus Plan (HMO) is a HMO plan offered by Healthfirst, Inc. available for enrollment in 2025 to people living in New York City and Nassau County. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Healthfirst 65 Plus Plan (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 Healthfirst 65 Plus Plan (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 Healthfirst 65 Plus Plan (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.
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 $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 Healthfirst 65 Plus Plan (HMO) has a $590 deductible for prescription drugs. After the deductible is met, you will pay a copay or coinsurance for your prescriptions depending on the drug tier and the pharmacy you use. Preferred and standard generic drugs have a copay of $15 or $35, respectively. Preferred brand drugs have a 50% coinsurance, while non-preferred drugs have a 25% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Healthfirst 65 Plus Plan (HMO) offers a range of benefits with varying costs. Inpatient hospital stays have copays, while outpatient services may have coinsurance or copays, depending on the service. The plan covers ambulance, emergency, and primary care services, with copays for some services, and also provides coverage for hearing, vision, and dental services, each with their own specific limitations and costs. Additional covered services include home infusion, dialysis, medical equipment, and diagnostic services, with varying copays or coinsurance. The plan also covers home health services with no copay, and skilled nursing facility stays with copays for specific days. Other benefits include acupuncture and a meal benefit. However, some services like cardiac rehabilitation and certain vision and dental procedures are not covered.
Inpatient Hospital See details
Inpatient Hospital services for the Healthfirst 65 Plus Plan (HMO) include acute and psychiatric care. For Inpatient Hospital-Acute, you will pay a $460 copay for days 1-5 and no copay for days 6-90; additional days (91-999) have no copay. Inpatient Hospital Psychiatric care has a $390 copay for days 1-5 and no copay for days 6-90. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute and Additional days for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a coinsurance of 0% - 20%, and observation services with a $110 copay. Ambulatory Surgical Center (ASC) Services have no copay, and Outpatient Blood Services are covered. Outpatient Substance Abuse Services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Healthfirst 65 Plus Plan (HMO), but prior authorization is required. There is no information about the cost of this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Healthfirst 65 Plus Plan (HMO). Ground and Air Ambulance Services have a $275 copay, and Transportation Services to a plan-approved health-related location are covered for up to 10 one-way trips per year.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the Healthfirst 65 Plus Plan (HMO). Emergency Services and Worldwide Emergency Coverage have a $110 copay, Urgently Needed Services have a $45 copay, and Worldwide Emergency Transportation has a $275 copay, while all have no coinsurance.
Primary Care See details
The Healthfirst 65 Plus Plan (HMO) covers primary care physician services, chiropractic services with a $15 copay, occupational therapy services with a $15 copay, physician specialist services with a $25 copay, podiatry services with a $25 copay, other health care professional services with a $0 - $25 copay, physical therapy and speech-language pathology services with a $15 copay, additional telehealth benefits, and opioid treatment program services. Mental health specialty services and psychiatric services are partially covered, with individual and group sessions not being covered.
Preventive Services See details
The Healthfirst 65 Plus Plan (HMO) offers preventive services, including Medicare-covered services with prior authorization, annual physical exams, and additional preventive services, with coverage for services like nutritional/dietary benefits up to 6 visits and a fitness benefit offering memory fitness. However, health education, in-home safety assessments, and several other services are not covered.
Hearing Services See details
Hearing services include routine hearing exams with a $25 copay, and fitting/evaluation for hearing aids, each limited to once per year. Prescription hearing aids are covered with a copay between $0 and $1475, 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 Healthfirst 65 Plus Plan (HMO) covers vision services, including routine eye exams and other eye exam services, each limited to one visit per year, and contact lens fitting. Eyewear is covered with a combined maximum of $200 per year, and eyeglasses (lenses and frames) are covered, limited to one pair per year, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Healthfirst 65 Plus Plan (HMO) offers dental services with a maximum benefit of $2,000 per year. Oral exams, dental x-rays, cleaning, fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), maxillofacial prosthetics, and oral and maxillofacial surgery are covered, but implant services and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, but prior authorization is required. For Medicare Part B Insulin Drugs, there is a $35 copay and the coinsurance ranges from 0% to 20%. For Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, the coinsurance ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered, but require prior authorization. You will pay 20% coinsurance for this service.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a coinsurance between 0% and 20% with no copay, however, Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies have a 20% coinsurance and no copay, and Diabetic Equipment has no copay, but Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by the Healthfirst 65 Plus Plan (HMO). Diagnostic services have no copay, but Diagnostic Procedures/Tests and Lab Services are not covered. Diagnostic Radiological Services have a copay of at most $60, and Therapeutic Radiological Services have a coinsurance of at most 20%, while Outpatient X-Ray Services are not covered.
Home Health Services See details
Home Health Services are covered by the Healthfirst 65 Plus Plan (HMO), with no copay or coinsurance, although authorization is required. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Healthfirst 65 Plus Plan (HMO). Prior authorization is required for these services, but they are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Healthfirst 65 Plus Plan (HMO), with prior authorization required. You will pay no copay for days 1-20, and a $214 copay for days 21-100; additional days beyond Medicare-covered and non-Medicare-covered stays are not covered.
Other Services See details
Other Services includes coverage for acupuncture and a meal benefit, but over-the-counter items, 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 are not covered. Acupuncture requires prior authorization and is limited to 12 treatments per year.
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