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Independent Health's Encompass 65 Direct (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Independent Health's Encompass 65 Direct (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 Direct (HMO) in 2025, please refer to our full plan details page.
Independent Health's Encompass 65 Direct (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 Direct (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 Direct (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 Direct (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.
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 $450.00 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 Direct (HMO) plan has an enhanced alternative drug benefit. The plan has a $450 deductible. In the initial coverage phase, you will pay a $20 copay for preferred generic drugs, and a $47 copay for standard generic drugs. For preferred brand drugs, you pay 50% coinsurance, and for non-preferred drugs, you pay 27% coinsurance. After your yearly out-of-pocket drug costs reach $2000, you pay nothing for covered drugs.
Additional Benefits
Independent Health's Encompass 65 Direct (HMO) offers a range of benefits with varying costs. Inpatient hospital stays have a copay, with no copay after the first six days for acute care and after the first four days for psychiatric care. Outpatient services have copays depending on the service, while primary care and specialist visits have copays between $20 and $35. The plan provides coverage for emergency services, ambulance services, and home health services with either a copay or coinsurance. Hearing and vision services are covered, with hearing exams and eyewear having no copay. Dental services include coverage for Medicare dental services and other dental services with varying costs.
Inpatient Hospital See details
Inpatient Hospital coverage under Independent Health's Encompass 65 Direct (HMO) includes acute care with a $325 copay for days 1-6 and no copay for days 7-90, and psychiatric care with a $395 copay for days 1-4 and no copay for days 5-90. Additional days for inpatient hospital-acute are covered, while non-Medicare-covered stays and upgrades are not covered, and additional days and non-Medicare-covered stays for inpatient hospital psychiatric are not covered.
Outpatient Services See details
Outpatient Services are covered, including outpatient hospital services with a $400 copay, observation services with a $325 copay, ambulatory surgical center services with a $350 copay, and outpatient substance abuse services with a $40 copay for both individual and group sessions. Outpatient blood services are also covered, with a waived three-pint deductible.
Partial Hospitalization See details
Partial Hospitalization is covered by Independent Health's Encompass 65 Direct (HMO), with a $55 copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by Independent Health's Encompass 65 Direct (HMO). Ground ambulance services have a $225 copay, while air ambulance services have 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. Emergency Services have a $125 copay, and Urgently Needed Services have a $55 copay. Worldwide Emergency Transportation has a $225 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 Direct (HMO) covers primary care physician services, chiropractic services with a $20 copay, occupational therapy services with a $20 copay, physician specialist services with a $35 copay, mental health specialty services with a $35 copay for individual or group sessions, other health care professional services with a $35 copay, psychiatric services with a $35 copay for individual or group sessions, physical therapy and speech-language pathology services with a $20 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 preventive services, annual physical exams, additional preventive services, kidney disease education services, and other preventive services. Health education has a copay between $0 and $20, while Personal Emergency Response System (PERS), 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 include hearing exams with no copay, routine hearing exams with a copay between $0 and $35, and fitting/evaluation for hearing aids with a copay of $45. Prescription hearing aids are covered, with a copay between $499 and $1949 for all types, but inner ear, outer ear, and over the ear hearing aids are not covered. OTC hearing aids are not covered.
Vision Services See details
Vision Services include eye exams with a copay of $0-$35, and eyewear with no copay. 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 $35 and $400, 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, while 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. 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 Direct (HMO) with a 20% coinsurance. There is no copay for this service.
Medical Equipment See details
Medical equipment, including Durable Medical Equipment (DME), Prosthetics, and Diabetic Equipment are covered. DME has a 10-20% coinsurance, and Prosthetic Devices have a 20% coinsurance, and Diabetic Supplies have a 0-20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for Diagnostic Procedures/Tests with a copay between $0 and $35, Lab Services with no copay and a 20% coinsurance, and Outpatient X-Ray Services with a $40 copay. Diagnostic Radiological Services have a copay of $200, and Therapeutic Radiological Services have a 20% coinsurance.
Home Health Services See details
Home Health Services are covered by Independent Health's Encompass 65 Direct (HMO) with no copay and no coinsurance, but authorization is required. 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 Direct (HMO). None of the sub-services, including Additional Cardiac Rehabilitation Services, Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services, are covered.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by Independent Health's Encompass 65 Direct (HMO) with prior authorization. You will have 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
Other Services offered by Independent Health's Encompass 65 Direct (HMO) include Over-the-Counter (OTC) Items, with a maximum benefit coverage amount of $40 every three months. Acupuncture, Meal Benefit, 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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