CDPHP Choice (HMO)
H3388 - 001 - 0
(4.5 / 5)
CDPHP Choice (HMO) is a Medicare Advantage (Part C) Plan by CDPHP Medicare Advantage.
This page features plan details for 2024 CDPHP Choice (HMO) H3388 – 001 – 0 available in Greater Capital Region of New York State.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
CDPHP Choice (HMO) is offered in the following locations.
Plan Overview
CDPHP Choice (HMO) offers the following coverage and cost-sharing.
| Insurer: | CDPHP Medicare Advantage |
| Health Plan Deductible: | $0.00 |
| MOOP: | $6,100 In-network |
| Drugs Covered: | No |
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Premium Breakdown
CDPHP Choice (HMO) has a monthly premium of $39.90. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $39.90 | $0.00 | $214.60 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
CDPHP Choice (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $6,100 In-network |
| No |
| In-network | No |
| $200 copay per visit (Authorization is required.) (Referral is required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $0-25 copay per visit (Authorization is required.) (Referral is required.) |
| $0 copay (Authorization is required.) (Referral is not required.) |
| Emergency | $90 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $45 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $0-25 copay (Authorization is required.) (Referral is required.) |
| Lab services | $0-5 copay (Authorization is required.) (Referral is required.) |
| Diagnostic radiology services (e.g., MRI) | $100 copay (Authorization is required.) (Referral is required.) |
| Outpatient x-rays | $25 copay (Authorization is required.) (Referral is required.) |
| Hearing exam | $25 copay (Authorization is not required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (There are no limits.) (Authorization is not required.) (Referral is not required.) |
| Hearing aids | $199-499 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Diagnostic services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Restorative services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Endodontics | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Periodontics | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Extractions | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| Occupational therapy visit | $25 copay (Authorization is not required.) (Referral is required.) |
| Physical therapy and speech and language therapy visit | $25 copay (Authorization is not required.) (Referral is required.) |
| $165 copay (Not applicable.) (Not applicable.) |
| $0 copay (There are no limits.) (Authorization is required.) (Referral is not required.) |
| Foot exams and treatment | $25 copay (Authorization is not required.) (Referral is required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | $35 copay or 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
| $260 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is required.) (Referral is required.) |
| Inpatient hospital – psychiatric | $260 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is not required.) (Referral is required.) |
| Outpatient group therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is required.) |
| Outpatient individual therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is required.) |
| Outpatient group therapy visit | $25 copay (Authorization is not required.) (Referral is required.) |
| Outpatient individual therapy visit | $25 copay (Authorization is not required.) (Referral is required.) |
| $0 per day for days 1 through 20 $120 per day for days 21 through 100 (Authorization is required.) (Referral is required.) |
Ready to sign up for CDPHP Choice (HMO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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