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Independent Health's Encompass 65 Core (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Independent Health's Encompass 65 Core (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 Core (HMO) in 2025, please refer to our full plan details page.
Independent Health's Encompass 65 Core (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 Core (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 Core (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 Core (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $73.00. 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 $350.00 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
Independent Health's Encompass 65 Core (HMO) has a $350 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For example, you will pay a $15 copay for preferred generic drugs at a standard pharmacy, and 50% coinsurance for preferred brand drugs. After your total drug costs reach $2000, you will pay nothing for covered drugs.
Additional Benefits
Independent Health's Encompass 65 Core (HMO) plan offers a range of benefits, including coverage for inpatient and outpatient services, with varying copays. The plan includes coverage for primary care, preventive, hearing, vision, and dental services, with specific copays and coinsurance amounts depending on the service. The plan also covers home health, cardiac rehabilitation, and skilled nursing facility services.
Inpatient Hospital See details
Inpatient Hospital benefits, including acute and psychiatric care, are covered under Independent Health's Encompass 65 Core (HMO) plan. For acute inpatient hospital stays, there is a $275 copay for days 1-6, and no copay for days 7-90, with a service-specific out-of-pocket maximum of $1650. For inpatient hospital psychiatric stays, there is a $395 copay for days 1-4, and no copay for days 5-90.
Outpatient Services See details
Outpatient services include coverage for all outpatient hospital services with a copay between $0 and $365, observation services with a $275 copay, and ambulatory surgical center services with no copay. Outpatient substance abuse services are covered with a $40 copay for both individual and group sessions, and outpatient blood services are covered with a waived three-pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered under the Independent Health's Encompass 65 Core (HMO) plan, with a $55 copay. Prior authorization is required.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Independent Health's Encompass 65 Core (HMO). Ground ambulance services have a $250 copay, while air ambulance services have a 20% coinsurance. 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 Independent Health's Encompass 65 Core (HMO). Emergency Services have a $125 copay, and Urgently Needed Services have a $55 copay. Worldwide Emergency Transportation has a $250 copay and 20% coinsurance, while Worldwide Emergency Coverage has a $125 copay, and Worldwide Urgent Coverage has a $55 copay.
Primary Care See details
Independent Health's Encompass 65 Core (HMO) covers primary care physician services, chiropractic services with a $15 copay, occupational therapy services with a $15 copay, physician specialist services with a $30 copay, mental health specialty services with a $25 copay for both individual and group sessions, other health care professional services with a $30 copay, psychiatric services with a $25 copay for both individual and group sessions, physical therapy and speech-language pathology services with a $15 copay, additional telehealth benefits with a copay between $0 and $55, and opioid treatment program services with a $40 copay. Podiatry services are not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services with no copay, annual physical exams, and additional services like Health Education with a copay between $0 and $20. Other covered services include Nutritional/Dietary Benefit (4 sessions) and Fitness Benefit (Memory Fitness). Medical Nutrition Therapy (MNT), 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, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing Services includes coverage for hearing exams with no copay, and routine hearing exams with a copay between $0 and $30. Fitting/Evaluation for Hearing Aid has a copay of $45. Prescription hearing aids are covered with a copay between $499 and $1949, but prescription hearing aids - inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision Services include eye exams with a copay of $0 - $30, and eyewear with no copay, including contact lenses. 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 $30 and $365, and Other Dental Services with no copay. Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable), and Oral and Maxillofacial Surgery 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, including Medicare Part B Insulin Drugs, are covered under the Independent Health's Encompass 65 Core (HMO) plan. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under Independent Health's Encompass 65 Core (HMO), with a coinsurance of 20%.
Medical Equipment See details
Medical Equipment, including Durable Medical Equipment (DME), Prosthetics, and Diabetic Equipment, is covered by the plan. DME has a coinsurance between 10% and 20% and no copay, while Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices have a 20% coinsurance, and no copay. Diabetic Supplies have a coinsurance between 0% and 20%, and no copay, while Diabetic Therapeutic Shoes/Inserts are not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered by Independent Health's Encompass 65 Core (HMO) plan. Diagnostic Procedures/Tests have a copay between $0 and $30, while Lab Services have a coinsurance of at most 20%. Diagnostic Radiological Services have a copay of $175, and Therapeutic Radiological Services have a coinsurance of at most 20%. Outpatient X-Ray Services have a copay of $35.
Home Health Services See details
Home Health Services are covered by Independent Health's Encompass 65 Core (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 covered by Independent Health's Encompass 65 Core (HMO), but the plan does not cover Additional Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services. There is a copay for some Cardiac Rehabilitation Services, but the specific amount is not provided.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Independent Health's Encompass 65 Core (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 coverage for Over-the-Counter (OTC) Items, with a maximum benefit of $35.00 every three months, and Nicotine Replacement Therapy (NRT) as a Part C OTC benefit, but acupuncture, meal benefits, 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.
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