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AgeWell New York CareWell (HMO I-SNP) By AgeWell New York



AgeWell New York CareWell (HMO I-SNP) H4922 004 0 is a 2023 Medicare Advantage Special Needs Plan plan by AgeWell New York. This plan from AgeWell New York works with Medicare to give you significant coverage beyond original Medicare. If you decide to sign up you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from AgeWell New York and not Original Medicare. All Medicare SNPs also provide Medicare additional Part-D drug coverage. AgeWell New York CareWell (HMO I-SNP) H4922-004 is an Institutional SNP (I-SNP). An Institutional SNP is for beneficiaries who live in an institution such as a nursing home or require nursing care at home. If you live in an institution like a nursing home or hospital you can join any Medicare SNP you qualify for or switch plans at any time.







2023 Medicare Special Needs Plan Details

Plan Name:AgeWell New York CareWell (HMO I-SNP)
Plan ID:H4922 004 0
Special Needs Type:Institutional
Provider:AgeWell New York
Plan Year:2023
Plan Type:Local HMO
Monthly Premium C+D:$38.90
Part C Premium:$0
Part D (Drug) Premium:$38.90
Part D Supplemental Premium$0
Total Part D Premium:$38.90
Drug Deductible:$505.00
Tiers with No Deductible:0
Benchmark:below the regional benchmark
Type of Medicare Health Plan:Defined Standard Benefit
Drug Benefit Type:Basic
Gap Coverage:No
Similar Plan: H4922-010


The AgeWell New York CareWell (HMO I-SNP) H4922-004 is available to residents to Medicare eligible seniors in New York. All Medicare SNPs must provide Medicare additional prescription drug (Part-D) coverage. AgeWell New York CareWell (HMO I-SNP) 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 need special care for a physician specialist, your primary care physician will make the arrangements and tell you where you can go in the network. You will need your PCPs okay, called a referral. Without getting a referral or services received from out-of-network providers are not typically covered by the plan.



How much does AgeWell New York CareWell (HMO I-SNP) cost?


Part-C Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. AgeWell New York charges a $0 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.


Part-D Deductible and Premium

An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. AgeWell New York CareWell (HMO I-SNP) has a monthly drug premium of $38.90 and a $505.00 drug deductible. This AgeWell New York plan offers a $38.90 Part-D Basic Premium that is below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0. This Premium covers any enhanced plan benefits offered by AgeWell New York above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $38.90. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.


AgeWell New York Gap Coverage

In 2023 once you and your plan provider have spent $4660 on covered drugs. (Combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This AgeWell New York plan does not offer additional coverage through the gap.


Extra Help Premium Assistance

The Low Income Subsidy (LIS) Extra Helps people with Medicare pay for prescription drugs and lowers the costs of Medicare prescription drug coverage. Income limits are based on the Federal Poverty Level (FPL), which changes every year in February or March. The 2022 income limit is $1,719 ($2,309 for couples) per month. Depending on your income level you may be eligible for a full 75%, 50%, 25% premium assistance. The AgeWell New York CareWell (HMO I-SNP) medicare insurance offers a $0 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $9.70 for 75% low-income subsidy $19.40 for 50% and $29.20 for 25%.


Full Assistance Premium:$0
75% Assistance Premium:$9.70
50% Assistance Premium:$19.40
25% Assistance Premium:$29.20


H4922-004 Formulary and Drug Coverage

AgeWell New York CareWell (HMO I-SNP) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Special Needs Plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.

Drug Tier Copay
Preferred
Pharmacy
Copay
Nonpreferred
Pharmacy
Tier 1 NA 25%
Tier 2 NA 25%
Tier 3 NA 25%
Tier 4 NA 25%
Tier 5 NA 25%
The complete AgeWell New York CareWell (HMO I-SNP) H4922-004 Formulary
*Initial Coverage Phase and 30 day supply





2023 Summary of Benefits

The benefit information provided is a summary of what AgeWell New York CareWell (HMO I-SNP) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from AgeWell New York helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

Wellness programs (e.g., fitness, nursing hotline)Covered



Contact lenses


VisionNot covered



Eyeglass frames


VisionNot covered



Eyeglass lenses


VisionNot covered



Eyeglasses (frames and lenses)


Vision$0 copay



Other


VisionNot covered



Routine eye exam


Vision$0 copay



Upgrades


VisionNot covered




TransportationNot covered
Skilled Nursing FacilityIn 2023 the amounts for each benefit period are:
$0 copay for days 1 through 20
$200 copay per day for days 21 through 100



Occupational therapy visit


Rehabilitation services20% coinsurance



Physical therapy and speech and language therapy visit


Rehabilitation services20% coinsurance



Cleaning


Preventive dentalNot covered



Dental x-ray(s)


Preventive dentalNot covered



Fluoride treatment


Preventive dentalNot covered



Oral exam


Preventive dentalNot covered




Preventive care$0 copay
Outpatient hospital coverage20% coinsurance per visit
In-Network Other health plan deductibles?No
Optional supplemental benefitsNo



Inpatient hospital - psychiatric


Mental health servicesIn 2023 the amounts for each benefit period are:
$1,600 deductible for days 1 through 60
$400 copay per day for days 61 through 90



Outpatient group therapy visit


Mental health services20% coinsurance



Outpatient group therapy visit with a psychiatrist


Mental health services20% coinsurance



Outpatient individual therapy visit


Mental health services20% coinsurance



Outpatient individual therapy visit with a psychiatrist


Mental health services20% coinsurance



Chemotherapy


Medicare Part B drugs20% coinsurance



Other Part B drugs


Medicare Part B drugs20% coinsurance



Diabetes supplies


Medical equipment/supplies20% coinsurance per item



Durable medical equipment (e.g., wheelchairs, oxygen)


Medical equipment/supplies20% coinsurance per item



Prosthetics (e.g., braces, artificial limbs)


Medical equipment/supplies20% coinsurance per item




Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$7,550 In-network
Inpatient hospital coverageIn 2023 the amounts for each benefit period are:
$1,600 deductible for days 1 through 60
$400 copay per day for days 61 through 90



Fitting/evaluation


Hearing$0 copay



Hearing aids


Hearing$0 copay



Hearing exam


Hearing20% coinsurance




Health plan deductible$226 per year for in-network services.
Ground ambulance20% coinsurance



Foot exams and treatment


Foot care (podiatry services)20% coinsurance



Routine foot care


Foot care (podiatry services)Not covered



Emergency


Emergency care/Urgent care20% coinsurance per visit (always covered)



Urgent care


Emergency care/Urgent care20% coinsurance per visit (always covered)



Primary


Doctor visits20% coinsurance per visit



Specialist


Doctor visits20% coinsurance per visit



Diagnostic radiology services (e.g., MRI)


Diagnostic procedures/lab services/imaging20% coinsurance



Diagnostic tests and procedures


Diagnostic procedures/lab services/imaging20% coinsurance



Lab services


Diagnostic procedures/lab services/imaging20% coinsurance



Outpatient x-rays


Diagnostic procedures/lab services/imaging20% coinsurance



Diagnostic services


Comprehensive dentalNot covered



Endodontics


Comprehensive dentalNot covered



Extractions


Comprehensive dentalNot covered



Non-routine services


Comprehensive dentalNot covered



Periodontics


Comprehensive dentalNot covered



Prosthodontics, other oral/maxillofacial surgery, other services


Comprehensive dental$0 copay



Restorative services


Comprehensive dentalNot covered




In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?No




Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Special Need Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for AgeWell New York CareWell (HMO I-SNP) requires you to live in that plan’s service area. The service area is listed below:





Source: CMS.

Plans as of Oct 1, 2022.

Last updated on

Notes: Data are subject to change. All contracts for 2023 have not been finalized. For 2023, enhanced alternative plans may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part Part D benefit.

Includes 2023 approved contracts/plans. Employer sponsored 800 series plans and plans under sanction are excluded.

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