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Independent Health's Encompass 65 RED 042 (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Independent Health's Encompass 65 RED 042 (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 RED 042 (HMO) in 2026, please refer to our full plan details page.
Independent Health's Encompass 65 RED 042 (HMO) is a HMO plan offered by Independent Health Association, Inc. available for enrollment in 2026 to people living in Western New York. This plan received an overall rating of 5 out of 5 stars in 2026.
It's important to know that Independent Health's Encompass 65 RED 042 (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 RED 042 (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 RED 042 (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $40.00. 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 $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
Independent Health's Encompass 65 RED 042 (HMO) prescription drug plan features an annual drug deductible of $250. You will pay no copay for Tier 1 preferred generic drugs, whether choosing a 1-month or 3-month supply at standard pharmacies or via standard mail order. For Tier 2 generic drugs, the cost is a $7.00 copay for a 1-month supply and a $17.50 copay for a 3-month supply. Higher-tier medications under this plan require coinsurance instead of flat copays. Tier 3 preferred brand drugs have a 16% coinsurance, while Tier 4 non-preferred drugs carry a 37% coinsurance for both 1-month and 3-month supplies. Specialty Tier 5 drugs are covered with a 30% coinsurance for a 1-month supply.
Additional Benefits
Independent Health's Encompass 65 RED 042 (HMO) offers comprehensive medical coverage with no copay to a $20 copay for primary care visits and a $55 copay for specialist consultations. For inpatient hospital stays, members pay a $500 daily copay for the first three days, with no copay for days four through 90. Emergency room visits require a $115 copay, which is waived if admitted within 24 hours, while urgent care services carry a $40 copay. Preventive dental care and annual physical exams are covered with no copay, and the plan includes a $200 annual allowance for eyewear. Skilled nursing facility stays feature no copay for the first 20 days, and home health services are fully covered with no copay or coinsurance. Diagnostic lab tests and home infusion services are also available with no copay, helping to minimize out-of-pocket costs for essential care.
Inpatient Hospital See details
Independent Health's Encompass 65 RED 042 (HMO) covers inpatient acute hospital stays with no coinsurance, requiring a $500 daily copay for days 1 through 3 and no copay for days 4 through 90. Inpatient psychiatric care is also covered with no coinsurance, requiring a $395 daily copay for days 1 through 4 and no copay for days 5 through 90, while upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Outpatient services are covered by Independent Health's Encompass 65 RED 042 (HMO) with no coinsurance, featuring a $500 to $743 copay for outpatient hospital and observation services, and a $350 copay for ambulatory surgical center services. Outpatient substance abuse sessions require a $40 copay with no coinsurance, while outpatient blood services are available with no copay and no coinsurance.
Partial Hospitalization See details
Independent Health's Encompass 65 RED 042 (HMO) covers partial hospitalization services with a $55.00 copay and no coinsurance. Prior authorization is required for some of these covered services.
Ambulance and Transportation Services See details
Ambulance and transportation services are partially covered under Independent Health's Encompass 65 RED 042 (HMO), where Medicare-covered ground ambulance services require a $300 copay with no coinsurance, and air ambulance services require a 20% coinsurance with no copay. Prior authorization is required for all ambulance services, and transportation services to plan-approved or any other health-related locations are not covered.
Emergency Services See details
Independent Health's Encompass 65 RED 042 (HMO) covers emergency services with a $115 copay, which is waived if admitted to the hospital within 24 hours, and urgently needed services with a $40 copay, both with no coinsurance. Worldwide emergency and urgent services are covered up to a $10,000 maximum benefit, requiring a $115 copay for emergencies, a $40 copay for urgent care, and a $300 copay plus 20% coinsurance for emergency transportation.
Primary Care See details
Independent Health's Encompass 65 RED 042 (HMO) covers primary care physician services with no copay to a $20 copay and no coinsurance, while specialist visits require a $55 copay and no coinsurance. Physical, occupational, and speech therapy services have a $20 copay, mental health and psychiatric services have a $35 copay, and chiropractic care has a $15 copay, all with no coinsurance, though podiatry and routine chiropractic services are not covered.
Preventive Services See details
Independent Health's Encompass 65 RED 042 (HMO) covers preventive services, including annual physical exams and kidney disease education, with no copay and no coinsurance. Additional preventive services are partially covered with no coinsurance, offering health education with copays up to $20 and remote access technologies with copays up to $25, while sub-services like in-home safety assessments, personal emergency response systems, and medical nutrition therapy are not covered.
Hearing Services See details
Hearing services are partially covered by Independent Health's Encompass 65 RED 042 (HMO) with no deductible and no coinsurance, offering Medicare-covered exams with no copay, routine exams with no copay to a $55 copay, and fitting evaluations for a $45 copay. Prescription hearing aids are covered up to $200 per ear annually with a $499 to $1,949 copay and no coinsurance, while OTC, inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision services are partially covered by Independent Health's Encompass 65 RED 042 (HMO), offering eye exams with a $0 to $55 copay and no coinsurance, which includes one annual routine exam with no copay while other eye exams are not covered. Eyewear is covered with no copay or coinsurance up to a $200 annual maximum for contact lenses and eyeglasses (lenses and frames), though upgrades, individual eyeglass lenses, and individual eyeglass frames are not covered.
Dental Services See details
Independent Health's Encompass 65 RED 042 (HMO) partially covers dental services, offering preventive care with no copay and no coinsurance up to a $1,500 annual limit, and Medicare-covered dental with a $40 to $743 copay and no coinsurance. Covered comprehensive services like endodontics and oral surgery require no copay and 50% coinsurance, but other diagnostic, other preventive, implants, orthodontics, fixed prosthodontics, and maxillofacial prosthetics are not covered.
Home Infusion bundled Services See details
Independent Health's Encompass 65 RED 042 (HMO) covers home infusion bundled services with no copay, though prior authorization is required. Covered Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy, radiation, and other Part B drugs require a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under Independent Health's Encompass 65 RED 042 (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Independent Health's Encompass 65 RED 042 (HMO) partially covers medical equipment with no copays, featuring 10% to 20% coinsurance for durable medical equipment and 20% coinsurance for prosthetic devices, both requiring prior authorization. Diabetic supplies are covered with no copay and up to 20% coinsurance, but medical supplies and diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Independent Health's Encompass 65 RED 042 (HMO) covers diagnostic and radiological services with prior authorization, featuring no coinsurance for lab services and copays ranging from no copay to $55 for diagnostic tests. Outpatient X-rays require a $55 copay, while diagnostic radiological services have a $290 copay and therapeutic radiological services carry a 20% coinsurance.
Home Health Services See details
Independent Health's Encompass 65 RED 042 (HMO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Cardiac rehabilitation services are partially covered by Independent Health's Encompass 65 RED 042 (HMO) with no coinsurance and a $20 copay for additional cardiac rehabilitation services. Standard cardiac rehabilitation, intensive cardiac rehabilitation, pulmonary rehabilitation, and SET for PAD services are not covered.
Skilled Nursing Facility (SNF) See details
Independent Health's Encompass 65 RED 042 (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization but no prior three-day inpatient hospital stay. There is no copay for days 1 through 20, followed by a $218 daily copay for days 21 through 100, though additional days beyond the standard 100-day limit are not covered.
Other Services See details
Other Services are not covered under Independent Health's Encompass 65 RED 042 (HMO), as there is no coverage for acupuncture, over-the-counter (OTC) items, or meal benefits.
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