2022 Empire MediBlue Service (HMO)

Empire MediBlue Service (HMO) H8432-037 is a 2022 Medicare Advantage Plan or Part-C by Empire BlueCross BlueShield available to residents in New York. This plan does not provide additional prescription drug (Part-D) coverage. The Empire MediBlue Service (HMO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $7,550 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $7,550 out-of-pocket. This can be a extremely nice safety net.

Empire MediBlue Service (HMO) is a Local HMO *. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your PCP will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your PCPs okay, called a referral. Services received from an out-of-network provider are not typically covered.

Empire BlueCross BlueShield works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Empire MediBlue Service (HMO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Empire BlueCross BlueShield and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Empire BlueCross BlueShield except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

2022 Empire BlueCross BlueShield Medicare Advantage Plan Costs

2021 Empire MediBlue Service (HMO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	$0 copay
Endodontics	$0 copay
Extractions	$0 copay
Non-routine services	$0 copay
Periodontics	$0 copay
Prosthodontics, other oral/maxillofacial surgery, other services	$0 copay
Restorative services	$0 copay

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$200-250 copay
Diagnostic tests and procedures	$0-150 copay
Lab services	$0 copay
Outpatient x-rays	$60-100 copay

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Doctor Visits

Primary	$20 copay per visit
Specialist	$50 copay per visit

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$65 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$50 copay
Routine foot care	Not covered

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Ground Ambulance

$300 copay

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Hearing

Fitting/evaluation	Not covered
Hearing aids - inner ear	Not covered
Hearing aids - outer ear	Not covered
Hearing aids - over the ear	Not covered
Hearing exam	$50 copay

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Inpatient Hospital Coverage

$400 per day for days 1 through 5 $0 per day for days 6 through 90

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Medical Equipment/Supplies

Diabetes supplies	$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)	0-20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item

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Medicare Part B Drugs

Chemotherapy	20% coinsurance
Other Part B drugs	20% coinsurance

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Mental Health Services

Inpatient hospital - psychiatric	$465 per day for days 1 through 4 $0 per day for days 5 through 90
Outpatient group therapy visit	$40 copay
Outpatient group therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit	$40 copay
Outpatient individual therapy visit with a psychiatrist	$40 copay

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MOOP

$6,950 In-network

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Option

No

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Optional supplemental benefits

Yes

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Outpatient Hospital Coverage

$0 copay or 30% coinsurance per visit

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Package #1

Deductible
Monthly Premium	$15.00

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Package #2

Deductible
Monthly Premium	$24.00

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Package #3

Deductible
Monthly Premium	$43.00

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Preventive Care

$0 copay

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Preventive Dental

Cleaning	$0 copay
Dental x-ray(s)	$0 copay
Fluoride treatment	Not covered
Oral exam	$0 copay

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Rehabilitation Services

Occupational therapy visit	$40 copay
Physical therapy and speech and language therapy visit	$40 copay

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Skilled Nursing Facility

$0 per day for days 1 through 20 $184 per day for days 21 through 100

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Transportation

Not covered

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Vision

Contact lenses	Not covered
Eyeglass frames	Not covered
Eyeglass lenses	Not covered
Eyeglasses (frames and lenses)	Not covered
Other	Not covered
Routine eye exam	$0 copay
Upgrades	Not covered

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for Empire MediBlue Service (HMO) H8432

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in Empire MediBlue Service (HMO) Plans Performance

Health Plan Customer Service Rating for Empire MediBlue Service (HMO)

Empire MediBlue Service (HMO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Empire MediBlue Service (HMO)

(Click county to compare all available Advantage plans)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.