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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 2026, 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 2026.
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 $24.20. 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 Increased Benefits Plan (HMO) features a yearly prescription drug deductible of $615. For Tier 1 preferred generic drugs, members pay no copay for a one-, two-, or three-month supply at standard pharmacies and through standard mail order. Tier 2 generic drugs are available with a low copay of $6 for a one-month supply, $12 for a two-month supply, and $18 for a three-month supply. Higher-tier medications under this plan are subject to coinsurance rather than flat copays. Tier 3 preferred brand drugs require a 16% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs require a 25% coinsurance. These costs apply to standard retail pharmacy and standard mail-order services, helping you manage your prescription expenses.
Additional Benefits
The Healthfirst Increased Benefits Plan (HMO) features robust coverage with no copay and no coinsurance for primary care visits, preventive services, dental care, and home health services. For specialized medical needs, members pay copays ranging from $15 to $25 for specialist visits and physical therapy, with no coinsurance required. Inpatient hospital stays require a $489 copay for the first five days of acute care, while subsequent days up to day 90 are covered with no copay. Emergency care is available with a $115 copay, which is waived if admitted, and urgent care visits require a $40 copay. The plan also offers routine vision services with no copay, no coinsurance, and no deductible, including up to $250 annually for eyewear, alongside affordable hearing exams and prescription hearing aid options. Additionally, members can access up to 20 free one-way transportation trips per year to plan-approved locations, over-the-counter items, and acupuncture treatments with no copay.
Inpatient Hospital See details
Healthfirst Increased Benefits Plan (HMO) covers inpatient hospital services with no coinsurance, though prior authorization is required. You will pay a $489 copay for days 1-5 of acute care and a $416 copay for days 1-5 of psychiatric care, with no copay for days 6-90. Unlimited additional acute care days are covered at no copay, while psychiatric additional days and non-Medicare-covered stays are not covered.
Outpatient Services See details
Healthfirst Increased Benefits Plan (HMO) covers outpatient hospital services with a copay and 0% to 20% coinsurance, and observation services with a $115 copay per stay and coinsurance. Ambulatory surgical center and outpatient blood services are covered with no copay and no coinsurance, while some outpatient substance abuse services are covered with no copay and no coinsurance, though individual and group sessions are not covered.
Partial Hospitalization See details
Partial hospitalization is covered under the Healthfirst Increased Benefits Plan (HMO) with no copay and no coinsurance, though prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and transportation services are covered under the Healthfirst Increased Benefits Plan (HMO), featuring a $315 copay and no coinsurance for both ground and air ambulance services. Transportation services are partially covered, offering up to 20 one-way trips per year to plan-approved locations with no copay or coinsurance, while transportation to any other health-related location is not covered.
Emergency Services See details
Healthfirst Increased Benefits Plan (HMO) covers emergency services with a $115 copay (waived if admitted to the hospital within 24 hours) and urgently needed services with a $40 copay, both with no coinsurance. Worldwide emergency, urgent, and transportation services are also covered up to a $200,000 limit with no coinsurance, requiring copays of $115, $40, and $315 respectively.
Primary Care See details
Primary Care benefits under the Healthfirst Increased Benefits Plan (HMO) include primary care physician visits, telehealth, and opioid treatment with no copay and no coinsurance. Specialist visits, physical therapy, occupational therapy, routine chiropractic care, and podiatry are covered with copays ranging from $15 to $25 and no coinsurance, though individual and group mental health and psychiatric sessions are not covered.
Preventive Services See details
Preventive services under the Healthfirst Increased Benefits Plan (HMO) are covered with no copay and no coinsurance, including annual physical exams, kidney disease education, and diabetes self-management. While additional benefits like fitness programs and counseling are covered with no copay and no coinsurance, this category is only partially covered as services such as health education, weight management, and in-home safety assessments are not covered.
Hearing Services See details
Hearing services are partially covered by the Healthfirst Increased Benefits Plan (HMO), which offers annual routine exams and fittings for a $25 copay and no coinsurance. Prescription hearing aids require no coinsurance with copays ranging from $0 to $1,475, though OTC hearing aids as well as inner-ear, outer-ear, and over-the-ear prescription models are not covered.
Vision Services See details
Healthfirst Increased Benefits Plan (HMO) vision services are covered with no copay, no coinsurance, and no deductible, providing up to $250 annually for eyewear. This partially covered benefit includes yearly routine exams, contact lens fittings, and contact lenses or eyeglasses, but standalone eyeglass lenses, standalone eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental services are partially covered by the Healthfirst Increased Benefits Plan (HMO) with no copay and no coinsurance, though prior authorization is required for most procedures. Covered benefits include preventive and comprehensive care, 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 Increased Benefits Plan (HMO) with no copay, though prior authorization is required. Medicare Part B chemotherapy, radiation, and other drugs require no copay and no coinsurance to 20% coinsurance, while Medicare Part B insulin is covered with a $35 copay and no coinsurance to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the Healthfirst Increased Benefits Plan (HMO) with no copay and a 20% coinsurance. Prior authorization is required to receive these covered services.
Medical Equipment See details
Medical equipment is covered by the Healthfirst Increased Benefits Plan (HMO) with no copays and prior authorization required, featuring a 0% to 20% coinsurance for durable medical equipment and a 20% coinsurance for prosthetics and medical supplies. Diabetic equipment is partially covered with no copay or coinsurance, though diabetic supplies and therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are partially covered by the Healthfirst Increased Benefits Plan (HMO), as prior authorization is required and lab services are not covered. Diagnostic procedures and tests have no coinsurance and a copay of $0 to $35, diagnostic radiological services have no copay, outpatient X-rays require a $35 copay and coinsurance, and therapeutic radiological services carry a 20% coinsurance.
Home Health Services See details
Healthfirst Increased Benefits Plan (HMO) covers Home Health Services with no copay and no coinsurance, although prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services under the Healthfirst Increased Benefits Plan (HMO) require prior authorization and have no coinsurance, although standard cardiac, intensive cardiac, pulmonary, and SET for PAD rehabilitation services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled nursing facility (SNF) services are covered by the Healthfirst Increased Benefits Plan (HMO) with no coinsurance, featuring no copay for days 1 to 20 and a $218 daily copay for days 21 to 100. Prior authorization is required, and additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Other services are covered by the Healthfirst Increased Benefits Plan (HMO) with no copay and no coinsurance, including acupuncture up to 12 treatments per year, over-the-counter items, family planning, and chronic illness meal benefits. Prior authorization is required for the meal benefit, and some additional miscellaneous services are not covered.
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