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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 2026, 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 2026.
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 $615.00 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 $9250.00 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) features an annual drug deductible of $615. Under this plan, you will pay no copay for Tier 1 preferred generic drugs filled at standard pharmacies or through standard mail order. Tier 2 generic drugs are also highly affordable, requiring a $3 copay for one-month and three-month supplies, or a $6 copay for a two-month supply. For brand-name and specialty medications, your out-of-pocket costs are determined by coinsurance. Tier 3 preferred brand drugs require a 21% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs carry a 25% coinsurance. These coinsurance rates apply to standard pharmacy fills and standard mail-order services.
Additional Benefits
The Healthfirst 65 Plus Plan (HMO) provides robust medical coverage featuring no copay for primary care visits, preventive services, and home health care. Specialist visits require a $35 copay, while acute inpatient hospital stays have a $489 copay for days one through five with no copay for subsequent days. Emergency room visits carry a $115 copay, which is waived if you are admitted, and urgent care is available with a $40 copay. This plan also includes valuable supplemental benefits like dental care up to $1,250 annually and routine vision exams with no copay, alongside a $150 annual limit for eyewear. Routine hearing exams are covered with a $35 copay, and prescription hearing aids feature no coinsurance with copays ranging up to $1,475. Additionally, members benefit from up to eight one-way transportation trips per year with no copay, alongside covered acupuncture and over-the-counter items.
Inpatient Hospital See details
Healthfirst 65 Plus Plan (HMO) inpatient hospital benefits are partially covered with no coinsurance, requiring a $489 copay for days 1 to 5 of acute stays and a $416 copay for days 1 to 5 of psychiatric stays, with no copay for subsequent covered days. Prior authorization is required, and non-Medicare-covered stays, upgrades, and additional psychiatric days are not covered.
Outpatient Services See details
Healthfirst 65 Plus Plan (HMO) covers outpatient services, offering ambulatory surgical center and blood services with no copay and no coinsurance, and outpatient hospital services with a copay and 0% to 20% coinsurance. Observation services require a $115 copay per stay with no coinsurance, and while some outpatient substance abuse services are covered, individual and group sessions are not covered.
Partial Hospitalization See details
Partial hospitalization is covered under the Healthfirst 65 Plus Plan (HMO) with no copay and no coinsurance, although prior authorization is required.
Ambulance and Transportation Services See details
Healthfirst 65 Plus Plan (HMO) covers Medicare-approved ground and air ambulance services with a $315 copay and no coinsurance. The plan also covers up to 8 one-way transportation trips per year to plan-approved health-related locations with no copay and no coinsurance, though transportation to any health-related location is not covered.
Emergency Services See details
Healthfirst 65 Plus Plan (HMO) covers emergency services with a $115 copay (waived if admitted to the hospital within 24 hours) and urgent care with a $40 copay, both with no coinsurance. Worldwide emergency, urgent, and transportation services are also covered with no coinsurance and copays ranging from $40 to $315, up to a maximum plan benefit of $200,000.
Primary Care See details
Healthfirst 65 Plus Plan (HMO) features primary care, telehealth, and opioid treatment with no copay and no coinsurance, while specialist and podiatry visits require a $35.00 copay and no coinsurance. Physical, occupational, and speech therapies require a $25.00 copay and no coinsurance, routine chiropractic is partially covered with a $15.00 copay and no coinsurance (other chiropractic services are not covered), and while some mental health and psychiatric services are covered, individual and group sessions are not.
Preventive Services See details
Preventive services are partially covered by the Healthfirst 65 Plus Plan (HMO) with no copay and no coinsurance for covered care, including annual physical exams, kidney disease education, and glaucoma screenings. While benefits like fitness, counseling, and personal emergency response systems are covered, other services such as health education, weight management, in-home safety assessments, alternative therapies, and medical nutrition therapy are not covered.
Hearing Services See details
Healthfirst 65 Plus Plan (HMO) covers annual hearing exams and evaluations with a $35 copay and no coinsurance. Prescription hearing aids are partially covered with no coinsurance and a copay ranging from no copay up to $1,475, but over-the-counter (OTC) hearing aids, as well as inner ear, outer ear, and over the ear prescription hearing aids, are not covered.
Vision Services See details
Healthfirst 65 Plus Plan (HMO) offers vision services with no copays, no coinsurance, and no deductibles, covering one routine eye exam and one contact lens fitting per year. Eyewear is partially covered with a $150 annual limit for contact lenses and one pair of eyeglasses, though individual eyeglass lenses, frames, and upgrades are not covered.
Dental Services See details
Dental services under the Healthfirst 65 Plus Plan (HMO) are partially covered with no copay and no coinsurance, up to a maximum annual benefit of $1,250. Covered services include cleanings, exams, and restorative treatments, but other diagnostic dental services, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by the Healthfirst 65 Plus Plan (HMO) with no copay and no coinsurance, subject to prior authorization and step therapy. Covered Medicare Part B chemotherapy, radiation, and other drugs have no copay and no coinsurance to 20% coinsurance, while Part B insulin has a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the Healthfirst 65 Plus Plan (HMO) with no copay and a 20% coinsurance, though prior authorization is required.
Medical Equipment See details
Medical equipment is partially covered under the Healthfirst 65 Plus Plan (HMO) with no copays, featuring 0% to 20% coinsurance for durable medical equipment and 20% coinsurance for prosthetics and medical supplies. Diabetic supplies and diabetic therapeutic shoes or inserts are not covered, while other diabetic equipment is covered with no copay and no coinsurance.
Diagnostic and Radiological Services See details
Healthfirst 65 Plus Plan (HMO) partially covers diagnostic and radiological services, as lab services are not covered. Diagnostic procedures require prior authorization with no coinsurance and a copay ranging from no copay to $40, while radiological services require prior authorization and range from no copay for diagnostic radiology to a $40 copay for X-rays and 20% coinsurance for therapeutic radiology.
Home Health Services See details
Home Health Services are covered under the Healthfirst 65 Plus Plan (HMO) with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered under the Healthfirst 65 Plus Plan (HMO) with no coinsurance and a $15 copay, though prior authorization is required. While some services are covered, standard cardiac, intensive cardiac, pulmonary, and supervised exercise therapy (SET) for symptomatic peripheral artery disease (PAD) services are not covered.
Skilled Nursing Facility (SNF) See details
Healthfirst 65 Plus Plan (HMO) partially covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring no copay for days 1 through 20 and a $218 copay for days 21 through 100. Prior authorization is required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
Healthfirst 65 Plus Plan (HMO) covers select other services with no copay and no coinsurance, including up to 12 acupuncture treatments per year, over-the-counter items, family planning, and chronic illness meals with prior authorization. Dual eligible SNPs with highly integrated services and certain other additional services are not covered under this benefit.
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