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Healthfirst Increased Benefits Plan (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Healthfirst Increased Benefits Plan (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Healthfirst Increased Benefits Plan (HMO) in 2025, please refer to our full plan details page.
Healthfirst Increased Benefits Plan (HMO) is a HMO plan offered by Healthfirst, Inc. available for enrollment in 2025 to people living in NYC, Long Island, and Some Lower Hudson Valley. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Healthfirst Increased Benefits 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 Increased Benefits 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 Increased Benefits Plan (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $36.10. 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 Increased Benefits Plan (HMO) has a $590 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, you'll pay a $20 copay for preferred generic drugs at a standard pharmacy. For preferred brand drugs, you pay 50% coinsurance at a standard pharmacy, and for non-preferred drugs, you pay 25% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered Part D drugs.
Additional Benefits
The Healthfirst Increased Benefits Plan (HMO) offers a range of benefits, including inpatient hospital stays with copays, outpatient services with coinsurance or no copay, and ambulance services with a $250 copay. Emergency services have varying copays, while primary care, chiropractic, and specialist visits have copays ranging from $15 to $20. Preventive services, hearing exams, and vision exams are covered, along with dental, home infusion, and dialysis services. The plan also includes coverage for durable medical equipment, home health services with no copay, and skilled nursing facility stays with copays. Other covered services encompass acupuncture, over-the-counter items, and a meal benefit. However, some services like outpatient substance abuse, implant services, and cardiac rehabilitation are not covered.
Inpatient Hospital See details
Inpatient Hospital benefits are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with a copay of $440 for days 1-5 and $0 for days 6-90 for Inpatient Hospital-Acute, and a copay of $400 for days 1-5 and $0 for days 6-90 for Inpatient Hospital Psychiatric. Additional Days for Inpatient Hospital-Acute are covered with no copay for days 91-999, while Non-Medicare-covered stays and Upgrades for Inpatient Hospital-Acute are not covered, 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 0% - 20% coinsurance, observation services with a $110 copay, and ambulatory surgical center services with no copay. Outpatient substance abuse services are not covered.
Partial Hospitalization See details
Partial Hospitalization is covered by the Healthfirst Increased Benefits Plan (HMO), but requires prior authorization.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Healthfirst Increased Benefits Plan (HMO), including both ground and air ambulance services, each with a $250 copay. Transportation services to plan-approved health-related locations are covered for up to 40 one-way trips per year via taxi, rideshare services, or medical transport. 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 by the Healthfirst Increased Benefits Plan (HMO). Emergency Services have a $110 copay, Urgently Needed Services have a $40 copay, and Worldwide Emergency Services have different copays depending on the service: Worldwide Emergency Coverage has a $110 copay, Worldwide Urgent Coverage has a $40 copay, and Worldwide Emergency Transportation has a $250 copay.
Primary Care See details
The Healthfirst Increased Benefits Plan (HMO) covers primary care services, chiropractic services with a $15 copay, occupational therapy with a $15 copay, physician specialist services with a $20 copay, podiatry services with a $20 copay, other health care professional services, 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 not covered for individual and group sessions.
Preventive Services See details
Preventive Services, including Medicare-covered services, annual physical exams, and additional preventive services, are covered. Health Education, In-Home Safety Assessments, 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, Home-Based Palliative Care, In-Home Support Services, Support for Caregivers of Enrollees, Additional Sessions of Smoking and Tobacco Cessation Counseling, Enhanced Disease Management, Telemonitoring Services, and Counseling Services are not covered.
Hearing Services See details
Hearing services include hearing exams with a $20 copay, and routine hearing exams and fitting/evaluation for hearing aids, each covered once per year. Prescription hearing aids are covered with a copay between $0 and $1,475, 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
The Healthfirst Increased Benefits Plan (HMO) covers vision services, including routine eye exams once per year and other eye exam services, including contact lens fittings, once per year. Eyewear is covered with a combined maximum of $250 per year, and contact lenses are covered. Eyeglasses (lenses and frames) are covered once per year, but eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
The Healthfirst Increased Benefits Plan (HMO) covers a range of dental services, including oral exams, dental x-rays, cleanings, fluoride treatments, other preventative dental services, restorative services, and more. Implant services and orthodontics 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 and coinsurance between 0% and 20%, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered with prior authorization, and the coinsurance is 20%.
Medical Equipment See details
The Healthfirst Increased Benefits Plan (HMO) covers Durable Medical Equipment (DME) with a coinsurance between 0% and 20% and no copay, but does not cover DME for use outside the home. Prosthetic Devices and Medical Supplies have a 20% coinsurance and no copay. Diabetic Equipment is covered but Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are partially covered by the Healthfirst Increased Benefits Plan (HMO). Diagnostic Procedures/Tests, Lab Services, and Outpatient X-Ray 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%.
Home Health Services See details
Home Health Services are covered by the Healthfirst Increased Benefits Plan (HMO) with no copay and no 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 Healthfirst Increased Benefits Plan (HMO). Prior authorization is required for Cardiac Rehabilitation Services, but the plan does not cover any of the listed sub-services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered under the Healthfirst Increased Benefits Plan (HMO) with prior authorization required. For days 1-20, there is no copay, and for days 21-100, the copay is $214. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services include acupuncture, over-the-counter (OTC) items, and a meal benefit. Acupuncture is covered with prior authorization, and limited to 12 treatments per year. OTC items are covered up to $110 every three months, and include nicotine replacement therapy and Naloxone. The meal benefit is covered for chronic illnesses with prior authorization. Services such as Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and private duty nursing services are not covered.
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