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Independent Health's Encompass 65 (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Independent Health's Encompass 65 (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Independent Health's Encompass 65 (HMO) in 2025, please refer to our full plan details page.
Independent Health's Encompass 65 (HMO) is a HMO plan offered by Independent Health Association, Inc. available for enrollment in 2025 to people living in Western New York. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that Independent Health's Encompass 65 (HMO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Independent Health's Encompass 65 (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 Independent Health's Encompass 65 (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. Additionally, this plan comes with a Part B Premium reduction of $20.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6750.00 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
Prescription drugs are not covered by Independent Health's Encompass 65 (HMO).
Additional Benefits
Independent Health's Encompass 65 (HMO) offers a range of benefits, including inpatient hospital stays with copays, outpatient services with varying copays, and coverage for ambulance and emergency services. The plan also covers primary care, preventive, hearing, vision, and dental services with a mix of copays and coinsurance. Additionally, it covers home infusion, dialysis, medical equipment, diagnostic services, home health, and skilled nursing facility stays with copays or coinsurance. Other notable benefits include no copay for preventive services and eyewear, and the plan provides coverage for over-the-counter items and meal benefits. However, some services like cardiac rehabilitation, certain hearing aids, and specific dental and vision services are not covered. Prior authorization is required for some services, such as ambulance services and home infusion.
Inpatient Hospital See details
Inpatient Hospital coverage includes Inpatient Hospital-Acute, with a $150 copay for days 1-5, and no copay for days 6-90, and Inpatient Hospital Psychiatric, with a $250 copay for days 1-6, and no copay for days 7-90. Additional Days for Inpatient Hospital-Acute are covered with no copay, while Non-Medicare-covered Stay for Inpatient Hospital-Acute, Upgrades for Inpatient Hospital-Acute, Additional Days for Inpatient Hospital Psychiatric, and Non-Medicare-covered Stay for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services includes coverage for outpatient hospital services with a copay between $0 and $100, observation services with a $150 copay, and ambulatory surgical center services with no copay. Outpatient substance abuse services, including individual and group sessions, have a copay of $40. Outpatient blood services are also covered, including services not usually covered by Medicare plans.
Partial Hospitalization See details
Partial Hospitalization is covered by Independent Health's Encompass 65 (HMO) with a $40 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required. Ground ambulance services have a $150 copay, while air ambulance services have a 20% coinsurance. Transportation services to a plan-approved health-related location are covered for 24 one-way trips per year via taxi, but 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. Emergency Services has a $125 copay, and Urgently Needed Services has a $55 copay. Worldwide Emergency Transportation has a $150 copay and 20% coinsurance, while Worldwide Emergency Coverage and Worldwide Urgent Coverage have a $125 and $55 copay, respectively.
Primary Care See details
Independent Health's Encompass 65 (HMO) covers primary care physician services, chiropractic services with a $10 copay, occupational therapy services with a $10 copay, physician specialist services with a $10 copay, mental health specialty services with a $20 copay, other health care professional services with a $10 copay, psychiatric services with a $20 copay, physical therapy and speech-language pathology services with a $10 copay, additional telehealth benefits with a $0-$55 copay, and opioid treatment program services with a $40 copay. Podiatry services are not covered.
Preventive Services See details
The Independent Health's Encompass 65 (HMO) plan covers preventive services, including no copay for Medicare-covered services and an annual physical exam. Additional preventive services, such as health education and remote access technologies, have a copay between $0 and $25, while services like medical nutrition therapy and home-based palliative care are not covered.
Hearing Services See details
Hearing Services include coverage for hearing exams with no copay, and routine hearing exams and fitting/evaluation for hearing aids are covered. Prescription hearing aids are covered, with a copay between $499 and $1949 depending on the type, however, inner ear, outer ear, and over the ear hearing aids are not covered, and OTC hearing aids are also not covered.
Vision Services See details
Vision Services include eye exams with a copay of $0-$10, and eyewear with no copay. Eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services includes coverage for Medicare Dental Services with a copay between $10 and $125, and other dental services with no copay. Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable), and Oral and Maxillofacial Surgery are covered with 50% coinsurance. Maxillofacial Prosthetics, Implant Services, Prosthodontics (fixed), and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay, and Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with 0-20% coinsurance. Prior authorization is required.
Dialysis Services See details
Dialysis Services are covered by Independent Health's Encompass 65 (HMO), with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with a coinsurance between 10% and 20% and no copay, but Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies - Non-Medicare benefit has no copay, and Diabetic Equipment has no copay, with a coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests with a copay between $0 and $10, Lab Services with up to 20% coinsurance, Diagnostic Radiological Services with a copay of $50, Therapeutic Radiological Services with up to 20% coinsurance, and Outpatient X-Ray Services with a $25 copay.
Home Health Services See details
Home Health Services are covered by Independent Health's Encompass 65 (HMO), 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 Independent Health's Encompass 65 (HMO). Specifically, Additional Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services are not covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Independent Health's Encompass 65 (HMO) with prior authorization. There is 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
Under the Independent Health's Encompass 65 (HMO) plan, Acupuncture, 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. Over-the-Counter (OTC) Items and Meal Benefits are covered, with a maximum OTC benefit of $100 every three months.
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