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CDPHP Core (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for CDPHP Core (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on CDPHP Core (HMO) in 2025, please refer to our full plan details page.
CDPHP Core (HMO) is a HMO plan offered by Capital District Physicians' Health Plan, Inc. available for enrollment in 2025 to people living in Greater Capital Region of New York State. This plan received an overall rating of 4.5 out of 5 stars in 2025.
It's important to know that CDPHP Core (HMO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about CDPHP 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 CDPHP Core (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.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $6100.00 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
Prescription drugs are not covered by CDPHP Core (HMO).
Additional Benefits
The CDPHP Core (HMO) plan offers a range of benefits with varying costs. Inpatient hospital stays have a copay, while many outpatient services have copays as well. Emergency and urgent care services have copays, and primary care visits have no copay. The plan includes coverage for hearing, vision, and dental services, with copays for exams and some procedures. The plan also offers home health services with no copay, and covers medical equipment, dialysis, and diagnostic services with copays or coinsurance. Other benefits include acupuncture, an over-the-counter item allowance, and a meal benefit for those with chronic illnesses.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, with a copay of $260 for days 1-6, and no copay for days 7-90; however, non-Medicare-covered stays and upgrades are not covered. Additional days for both Inpatient Hospital-Acute and Inpatient Hospital Psychiatric are covered with no copay.
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 and observation services have a $200 copay, ambulatory surgical center services have a $150 copay, and outpatient blood services have no copay. Individual and group sessions for outpatient substance abuse have a copay between $25 and $25.
Partial Hospitalization See details
Partial Hospitalization is covered under the CDPHP Core (HMO) plan, and requires a doctor referral. You will have a $55 copay for this benefit.
Ambulance and Transportation Services See details
The CDPHP Core (HMO) plan covers ambulance and transportation services, including ground and air ambulance services with a $165 copay. Transportation services to a plan-approved health-related location are also covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Services are covered under the CDPHP Core (HMO) plan. Emergency Services have a $90 copay, and Urgently Needed Services have a $45 copay, both with no coinsurance. Worldwide Emergency Coverage has a $90 copay, Worldwide Urgent Coverage has a $45 copay, and Worldwide Emergency Transportation has a $165 copay.
Primary Care See details
The CDPHP Core (HMO) plan covers primary care physician services with no copay, chiropractic services with a $20 copay, and occupational therapy services with a $25 copay. This plan also covers physician specialist services, mental health specialty services, psychiatric services, physical therapy, speech-language pathology services, additional telehealth benefits, and opioid treatment program services, all with varying copays.
Preventive Services See details
Preventive services, including services not usually covered by Medicare plans, are covered under the CDPHP Core (HMO) plan. Kidney Disease Education Services, Glaucoma Screenings, Diabetes Self-Management Training, and EKGs following a Welcome Visit have no copay. Other covered services include Health Education, Weight Management Programs, Nutritional/Dietary Benefits, In-Home Support Services, Additional Sessions of Smoking and Tobacco Cessation Counseling, and Fitness Benefits. In-Home Safety Assessments, Personal Emergency Response Systems, Medical Nutrition Therapy, Post-discharge In-Home Medication Reconciliation, Re-admission Prevention, Wigs for Hair Loss Related to Chemotherapy, Alternative Therapies, Therapeutic Massage, Adult Day Health Services, Home-Based Palliative Care, Support for Caregivers of Enrollees, Telemonitoring Services, Remote Access Technologies, Home and Bathroom Safety Devices and Modifications, and Counseling Services are not covered.
Hearing Services See details
Hearing exams are covered with a $25 copay, and include routine hearing exams and fitting/evaluation for hearing aids. Prescription hearing aids are partially covered, with a copay between $199 and $499 for all types, but inner ear, outer ear, and over the ear hearing aids are not covered.
Vision Services See details
Vision Services include eye exams with a $25 copay, and routine eye exams with no copay. Eyewear has a 20% coinsurance, and contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames are covered. Upgrades are not covered.
Dental Services See details
Dental services include a $25 copay for Medicare dental services. Other dental services have a maximum plan benefit coverage of $1,500 every year.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered and require prior authorization. Insulin has a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have between 0% and 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered by the CDPHP Core (HMO) plan. The coinsurance for Dialysis Services is 20%.
Medical Equipment See details
Medical equipment is covered under the CDPHP Core (HMO) plan. Durable Medical Equipment (DME) has a 20% coinsurance, and you pay the lesser of 20% of the allowed amount or a $250 maximum per covered item; however, Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies have a 20% coinsurance, and Diabetic Supplies have a $10 copay with 0-20% coinsurance, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures/tests with a copay between $0 and $25, and lab services with no copay. Diagnostic Radiological Services have a minimum copay of $100, and Therapeutic Radiological Services have a minimum coinsurance of 20%. Outpatient X-Ray Services have a $25 copay.
Home Health Services See details
Home Health Services are covered by the CDPHP Core (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but not the sub-services including Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, and SET for PAD Services. There is a copay for some of the services, but the exact amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the CDPHP Core (HMO) plan, but require prior authorization and a doctor's referral. There is no copay for days 1-20, and a $120 copay for days 21-100. Additional days beyond Medicare-covered for SNF are not covered.
Other Services See details
The CDPHP Core (HMO) plan covers acupuncture with 50% coinsurance, up to 10 treatments per year, and also covers over-the-counter items with a maximum benefit of $100 every three months. The plan also offers a meal benefit for chronic illnesses or medical conditions that require the enrollee to remain at home. However, services like Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, and others are not covered.
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