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Independent Health's Encompass 65 RED 043 (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Independent Health's Encompass 65 RED 043 (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 043 (HMO) in 2026, please refer to our full plan details page.
Independent Health's Encompass 65 RED 043 (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 043 (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 043 (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 043 (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $190.00. 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 $50.00 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 $7000.00 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 043 (HMO) features a low drug deductible of $50. Under this plan, Tier 1 preferred generic drugs are covered with no copay for 1-month or 3-month supplies at standard pharmacies and standard mail order. Tier 2 generic medications require a $10 copay for a 1-month supply or a $25 copay for a 3-month supply at standard pharmacies and standard mail order. For higher-tier medications, costs transition to coinsurance percentages at standard pharmacies and standard mail order. Tier 3 preferred brands require a 19% coinsurance, and Tier 4 non-preferred drugs carry a 42% coinsurance. Tier 5 specialty drugs are covered with a 32% coinsurance for a 1-month supply at standard pharmacies.
Additional Benefits
Independent Health's Encompass 65 RED 043 (HMO) offers comprehensive medical coverage with predictable costs, featuring no copay to a $20 copay for primary care visits and a $25 to $50 copay for specialists, both with no coinsurance. For hospital stays, inpatient acute care requires a $300 daily copay for the first six days and no copay thereafter, while outpatient hospital services carry copays between $375 and $550 with no coinsurance. Emergency care is also accessible with a $115 copay, which is waived if you are admitted to the hospital within 24 hours. Routine and preventive services are highly affordable, featuring no copay and no coinsurance for annual physicals, screenings, and home health services. Dental preventive care is covered with no copay up to a $1,500 annual limit, while routine eye and hearing exams feature no copay or low copays up to $25. Additionally, the plan covers skilled nursing facility stays with no copay for the first 20 days and offers a $35 quarterly allowance for over-the-counter items with no copay.
Inpatient Hospital See details
Independent Health's Encompass 65 RED 043 (HMO) partially covers inpatient hospital services with no coinsurance, requiring prior authorization for both acute and psychiatric stays. Acute stays carry a $300 daily copay for days 1 through 6 (with no copay for days 7 to 90), while psychiatric stays require a $350 daily copay for days 1 through 4 (with no copay for days 5 to 90). Upgrades, non-Medicare-covered stays, and additional psychiatric days are not covered.
Outpatient Services See details
Independent Health's Encompass 65 RED 043 (HMO) covers outpatient services with no coinsurance, featuring copays of $375 to $550 for outpatient hospital services, $300 to $485 per stay for observation services, and $325 for ambulatory surgical center services. Outpatient substance abuse sessions require a $40 copay with no coinsurance, while outpatient blood services are covered with no copay.
Partial Hospitalization See details
Independent Health's Encompass 65 RED 043 (HMO) covers partial hospitalization services with a $55.00 copay and no coinsurance. Prior authorization may be required for these services.
Ambulance and Transportation Services See details
Independent Health's Encompass 65 RED 043 (HMO) covers ambulance services with a $240 copay for ground transport and a 20% coinsurance for air transport, with prior authorization required. For transportation services, some services are covered but transportation to plan-approved health-related locations and any health-related locations are not covered.
Emergency Services See details
Emergency services are covered by Independent Health's Encompass 65 RED 043 (HMO) with a $115 copay and no coinsurance, with the copay waived if you are admitted to the hospital within 24 hours. Urgently needed services cost a $40 copay with no coinsurance, while worldwide emergency care is covered up to $10,000 and includes a $240 copay and 20% coinsurance for emergency transportation.
Primary Care See details
Independent Health's Encompass 65 RED 043 (HMO) covers primary care visits with no copay to a $20 copay, and specialist visits with a $25 to $50 copay, both with no coinsurance. Therapy services require a $10 copay with no coinsurance (prior authorization required), while chiropractic care is partially covered with a $15 copay and no coinsurance, excluding routine chiropractic care. Podiatry services are not covered under this plan.
Preventive Services See details
Preventive services are covered by Independent Health's Encompass 65 RED 043 (HMO) with no copay and no coinsurance for annual physicals, kidney disease education, and routine screenings. Additional preventive benefits are partially covered with no coinsurance, featuring memory fitness, health education (up to a $20 copay), and remote access (up to a $25 copay), while sub-services like medical nutrition therapy, weight management, and in-home safety assessments are not covered.
Hearing Services See details
Independent Health's Encompass 65 RED 043 (HMO) partially covers hearing services with no coinsurance, offering Medicare-covered hearing exams with no copay, routine exams with a $0 to $25 copay, and fitting evaluations for a $45 copay. Covered prescription hearing aids require a $499 to $1,949 copay with up to a $200 annual benefit per ear, but OTC hearing aids and inner ear, outer ear, and over-the-ear prescription hearing aids are not covered.
Vision Services See details
Independent Health's Encompass 65 RED 043 (HMO) covers vision services with no coinsurance, including one routine eye exam per year with no copay and other eye exams with a $0 to $25 copay, though other eye exam services are not covered. Eyewear is partially covered with no copay up to a $200 annual maximum for contacts and eyeglasses, but upgrades, individual eyeglass lenses, and individual frames are not covered.
Dental Services See details
Independent Health's Encompass 65 RED 043 (HMO) covers Medicare dental services with a $25 to $550 copay and no coinsurance. Preventive services are partially covered with no copay and no coinsurance up to a $1,500 annual limit, though other diagnostic and other preventive services are not covered. Comprehensive services are also partially covered with no copay and 50% coinsurance, excluding orthodontics, implants, fixed prosthodontics, and maxillofacial prosthetics.
Home Infusion bundled Services See details
Home infusion bundled services are covered by Independent Health's Encompass 65 RED 043 (HMO) with no copay, requiring prior authorization and step therapy. Medicare Part B insulin drugs have a $35 copay and no coinsurance, while chemotherapy and other Part B drugs require no copay and a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis services are covered under Independent Health's Encompass 65 RED 043 (HMO) with no copay and a 20% coinsurance.
Medical Equipment See details
Independent Health's Encompass 65 RED 043 (HMO) partially covers medical equipment with no copays, featuring a 10% to 20% coinsurance for durable medical equipment, 20% coinsurance for prosthetics, and no coinsurance to 20% coinsurance for diabetic supplies. Prior authorization is required for certain items, and medical supplies as well as diabetic therapeutic shoes or inserts are not covered.
Diagnostic and Radiological Services See details
Independent Health's Encompass 65 RED 043 (HMO) covers diagnostic and radiological services with prior authorization, featuring no copay to a $50 copay plus coinsurance for diagnostic tests, and lab services with a copay and no coinsurance. Outpatient X-rays require a $30 copay and coinsurance, while diagnostic radiology has a minimum $150 copay, and therapeutic radiology incurs a minimum 20% coinsurance alongside copays.
Home Health Services See details
Independent Health's Encompass 65 RED 043 (HMO) covers home health services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
Independent Health's Encompass 65 RED 043 (HMO) partially covers cardiac rehabilitation services, with only additional cardiac rehabilitation services covered at a $20 copayment and no coinsurance. 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 043 (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, requiring prior authorization and no preceding three-day hospital stay. There is no copay for days 1 through 20 and a $218 daily copay for days 21 through 100, though additional days beyond the Medicare-covered limit are not covered.
Other Services See details
Independent Health's Encompass 65 RED 043 (HMO) partially covers other services, offering over-the-counter (OTC) items with no copay and no coinsurance up to a maximum of $35 every three months, with unused balances carrying forward. Acupuncture, meal benefits, and other additional services are not covered under this plan benefit.
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