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Independent Health's Encompass 65 Basic (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Independent Health's Encompass 65 Basic (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 Basic (HMO) in 2025, please refer to our full plan details page.
Independent Health's Encompass 65 Basic (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 Basic (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 Independent Health's Encompass 65 Basic (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 Basic (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $134.00. 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 $250.00 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 $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
The Independent Health's Encompass 65 Basic (HMO) plan has a $250 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier. For example, you will pay a $13 copay for preferred generic drugs at a standard pharmacy. For standard generic drugs, you will pay a $42 copay. For preferred brand drugs, you pay 50% coinsurance, and for non-preferred drugs, you pay 30% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
Independent Health's Encompass 65 Basic (HMO) offers a range of benefits, including inpatient and outpatient hospital care, with varying copays. You'll find coverage for ambulance services, emergency services, and a selection of primary care services with copays. Other benefits include hearing, vision, and dental services, with some services having copays and coinsurance. This plan also covers home infusion, dialysis, medical equipment, diagnostic and radiological services, and home health services with copays and coinsurance. Additional benefits include an OTC allowance, and a meal benefit. However, services like cardiac rehabilitation, and some other services, are not covered.
Inpatient Hospital See details
Inpatient Hospital coverage includes acute and psychiatric care. For Inpatient Hospital-Acute, you pay a $250 copay for days 1-6, and no copay for days 7-90, with a service-specific out-of-pocket maximum of $1500. Inpatient Hospital-Psychiatric has a $350 copay for days 1-4, and no copay for days 5-90. Additional days for Inpatient Hospital-Acute are covered with no copay, 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 all outpatient hospital services, observation services, ambulatory surgical center services, outpatient substance abuse services, and outpatient blood services. Outpatient Hospital Services have a copay between $0 and $350, Observation Services have a $250 copay, Ambulatory Surgical Center Services have no copay, and both Individual and Group Sessions for Outpatient Substance Abuse have a $40 copay.
Partial Hospitalization See details
Partial Hospitalization is covered by Independent Health's Encompass 65 Basic (HMO) with a $55 copay, and prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, with prior authorization required. Ground ambulance services have a $240 copay, while air ambulance services have a 20% coinsurance. Transportation services to a plan-approved health-related location are covered for 12 one-way taxi trips per year.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered by Independent Health's Encompass 65 Basic (HMO). Emergency Services have a $125 copay, while Urgently Needed Services have a $55 copay. Worldwide Emergency Transportation has a 20% coinsurance and a $240 copay, while Worldwide Emergency Coverage has a $125 copay, and Worldwide Urgent Coverage has a $55 copay.
Primary Care See details
Primary Care benefits include coverage for Primary Care Physician Services, Chiropractic Services, Occupational Therapy Services, Physician Specialist Services, Mental Health Specialty Services, Other Health Care Professional, Psychiatric Services, Physical Therapy and Speech-Language Pathology Services, Additional Telehealth Benefits, and Opioid Treatment Program Services. Chiropractic Services and Other Chiropractic Services have a $15 copay, while Occupational Therapy Services, Physical Therapy and Speech-Language Pathology Services have a $10 copay, Physician Specialist Services have a $20 copay, Individual and Group Sessions for Mental Health and Psychiatric Services have a $20 copay, and Opioid Treatment Program Services have a $40 copay. Additional Telehealth Benefits have a copay between $0 and $55. Podiatry Services are not covered.
Preventive Services See details
Preventive Services include Medicare-covered services and additional preventive services. Health Education and Remote Access Technologies have a copay between $0 and $20 or $25, respectively. Other services such as Medical Nutrition Therapy, Home-Based Palliative Care, and others are not covered.
Hearing Services See details
Hearing services include routine hearing exams, fitting/evaluation for hearing aids, and prescription hearing aids. Routine hearing exams have a copay between $0 and $20, fitting/evaluation for hearing aids have a $45 copay, and prescription hearing aids have a copay between $499 and $1949. Prescription hearing aids - Inner Ear, Prescription hearing aids - Outer Ear, and Prescription hearing aids - Over the Ear are not covered, and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams with a copay of $0-$20, and eyewear with no copay. Eyeglasses (lenses and frames) and contact lenses are covered, while eyeglass lenses, eyeglass frames, and upgrades are not covered.
Dental Services See details
Dental Services include coverage for Medicare Dental Services with a copay between $20 and $350, and other dental services with no copay. Restorative, Adjunctive General, Endodontics, Periodontics, Prosthodontics (removable), and Oral and Maxillofacial Surgery services are covered with a 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 by Independent Health's Encompass 65 Basic (HMO), including Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs are also covered, with coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis services are covered by Independent Health's Encompass 65 Basic (HMO), with a coinsurance of 20%.
Medical Equipment See details
Medical equipment is covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a coinsurance of 10-20% with no copay, while Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies have a coinsurance for Medicare-covered supplies and no copay, while Medical Supplies are not covered. Diabetic Supplies have a 0-20% coinsurance, and Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services, including diagnostic procedures, lab services, and radiological services, are covered by Independent Health's Encompass 65 Basic (HMO). Diagnostic Procedures/Tests have a copay between $0 and $20, Lab Services have a coinsurance of up to 20%, Diagnostic Radiological Services have a copay of $125, Therapeutic Radiological Services have a coinsurance of up to 20%, and Outpatient X-Ray Services have a copay of $30.
Home Health Services See details
Home Health Services are covered by Independent Health's Encompass 65 Basic (HMO) with no copay and no coinsurance, but Additional Hours of Care and Personal Care Services are not covered. Prior authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Independent Health's Encompass 65 Basic (HMO) plan. This includes Additional Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered, but require prior authorization. There is no copay for days 1-20, and a $214 copay per day for days 21-100. Additional days beyond Medicare-covered for SNF, and non-Medicare-covered stays for SNF, are not covered.
Other Services See details
The Independent Health's Encompass 65 Basic (HMO) plan covers Over-the-Counter (OTC) Items with a maximum benefit of $35.00 every three months, including nicotine replacement therapy and naloxone. The plan does not cover 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. The plan also covers a meal benefit with prior authorization.
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