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2025 Assure Advantage® HMO C-SNP Plan

Plan Highlights

MONTHLY PREMIUM
PRIMARY/SPECIALTY COPAY
(In-Network)
INPATIENT HOSPITAL COPAY
(In-Network)
PART D PRESCRIPTION BENEFIT
(Tier 1 / 2 / 3 / 4 / 5)
MONTHLY PREMIUM

$49

PRIMARY/SPECIALTY COPAY
(In-Network)

$0/$0 - $20

INPATIENT HOSPITAL COPAY
(In-Network)

Days 1-6: $250 per day. Additional days: $0 Unlimited Days for Medicare covered stays. ($1,500 Annual Member Copay Maximum).

PART D PRESCRIPTION BENEFIT

$200 deductible on tiers 3, 4 & 5 only. $0/$12/$47/50%/30% to out-of-pocket maximum of $2,000. $35 for insulins on our formulary.

Plan Details

Independent Health’s Assure Advantage (HMO-SNP) is a specialized Medicare Advantage Plan (a Medicare “Special Needs Plan”), which means its benefits are designed for people with special health care needs. Independent Health’s Assure Advantage is designed to provide additional health benefits that specifically help people who have chronic heart failure.

Our plan includes providers who specialize in treating chronic heart failure. It also includes health programs designed to serve the specialized needs of people with this condition. In addition, our plan covers prescription drugs to treat most medical conditions, including the drugs that are usually used to treat chronic heart failure. As a member of the plan, you get benefits specially tailored to your condition and have all your care coordinated through our plan.

Eligibility Requirements:
To be eligible, it’s important that you meet all of the following criteria:

  • Reside in Erie County.
  • Have chronic heart failure.
  • Must be entitled or enrolled in Medicare Parts A and B.

Note: Enrollment into Independent Health’s Assure Advantage HMO-SNP plan will automatically disenroll a person from any other Medicare Advantage plan.

For more information or to enroll speak with an Independent Health representative today at:
(716) 635-4900 or 1-800-958-4405 (TTY users call 711):
October 1 – March 31: Monday – Sunday, 8 a.m. – 8 p.m.
April 1 – September 30: Monday – Friday, 8 a.m. – 8 p.m.

Monthly Premium

$49

Plan Premium with Full 100% Low Income Subsidy (LIS)

$0.00

Part D Prescription Benefit Tier 1 / 2 / 3 / 4 / 5 / 6

$200 deductible on tiers 3, 4 and 5. $0/$12/$47/50%/30% to out-of-pocket maximum of $2,000.

Primary Copay

$0

Specialty Copay

$20 ($0 for cardiologist and nephrologist)

Preventive Services

$0

Inpatient Hospital Copay

Days 1-6: $250 per day. Additional days: $0 Unlimited Days for Medicare covered stays. ($1,500 Annual Member Copay Maximum).

Home Delivered Meals

14 days, up to 28 meals post acute inpatient stay

Plus, an additional 14 days, up to 28 meals anytime to help you manage your health.

Ambulance / Non-Emergency Transportation (from a network provider)

Ambulance: $245

Non-Emergency Transportation: $0 for up to 12 one-way trips to plan-approved locations (30-mile limit per trip).

Worldwide Emergency / Urgent Care**

$125 / $55

Lab Copay*

$0

General X-ray / Advanced Radiology Copay

General X-ray: $30

Advanced Radiology: $155

Speech, Physical, Occupational Therapy

$10

Skilled Nursing Facility

Days 1 - 20: $0

Days 21 - 100: $214 per day

Annual Out-of-Pocket Maximum for Medicare Covered Services

$6,750

RedShirt Rewards

Earn up to $100 in RedShirt Rewards for taking healthy actions!
Learn More

Wellness Benefits

Dental (from a network provider)

$2,000 combined maximum for preventive dental and comprehensive dental.

Preventive Dental: $0 per visit for preventive dental. Two routine cleanings, exams, fluoride treatments and bitewing X-rays per calendar year. One full-mouth series every 36 months.

Comprehensive Dental: $0 deductible and 50% coinsurance on covered services.

Over-the-Counter (OTC)***

$40 per quarter

SilverSneakers® Fitness Benefit (from a participating facility that offers SilverSneakers)

$0 copayment (Memberships will not roll over from 2024 to 2025 or 2025 to 2026. Memberships will restart on January 1st of each year.)

Vision (from a network provider)

$0 routine eye exam. $200 coverage allowance for routine eyewear.

Hearing Aid Benefit (from a network provider)

$45 hearing aid evaluation exam. Member pays: $499 - $1,949 (per ear) for hearing aid device. The average cost for hearing aids without coverage is $2,445 - $3,125 per ear.

Personal Emergency Response System (PERS)

$0

Enhanced Diabetes Benefits

These benefits will help members with diabetes manage their special needs, live healthier and save money. Learn more

Additional Wellness Benefits

All of our Medicare Advantage plans come with additional wellness benefits to help you maintain an active, healthy lifestyle. Learn More

Disclaimers

* Member pays 20% for genetic testing.

This plan requires the use of participating providers, except in the case of emergency care, urgent care or out of area renal dialysis. This information is not a complete description of benefits. Call (716) 250-4401 or 1-800-665-1502 (TTY users call 711) for more information.

** $10,000 annual maximum plan limit for emergency care, urgent care or ambulance outside the USA and its territories.

***Allowance is made available by quarter. Allowance carries over quarter to quarter, however does not carry over plan year to plan year. Costs over the allowed amount are the member’s responsibility. This benefit can only be used for covered items through NationsOTC.®

IN = In-Network, OON = Out-of-Network

Independent Health has been approved by the National Committee for Quality Assurance (NCQA) to operate as a Special Needs Plan (SNP) until December 31, 2025 based on a review of Independent Health’s Model of Care.

Y0042_C7173
Last Updated 10/1/2024

© Independent Health Association, Inc.

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