Empire MediBlue Service (HMO)
H8432 - 037 - 1
(3.5 / 5)
Empire MediBlue Service (HMO) is a Medicare Advantage Plan by Empire BlueCross BlueShield.
This page features plan details for 2023 Empire MediBlue Service (HMO) H8432 – 037 – 1 available in Select Counties in New York.
IMPORTANT: This page features the 2023 version of this plan. See the 2025 version using the link below:
No 2025 version found. You can use the location links below to find 2025 plans in your area.
Locations
Empire MediBlue Service (HMO) is offered in the following locations.
Plan Overview
Empire MediBlue Service (HMO) offers the following coverage and cost-sharing.
| Insurer: | Empire BlueCross BlueShield |
| Health Plan Deductible: | $0.00 |
| MOOP: | $8,300 In-network |
| Drugs Covered: | No |
Ready to sign up for Empire MediBlue Service (HMO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Premium Breakdown
Empire MediBlue Service (HMO) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $164.90 | $0.00 | $0.00 | $ |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Empire MediBlue Service (HMO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Endodontics: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Extractions: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Non-routine services: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Periodontics: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Restorative services: | $0 copay (limits may apply) (authorization required) (referral not required) |
Dental (preventive)
| Cleaning: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Dental x-ray(s): | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Fluoride treatment: | Not covered (no limits) |
| Oral exam: | $0 copay (limits may apply) (authorization not required) (referral not required) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | $200-250 copay (authorization required) (referral required) |
| Diagnostic tests and procedures: | $0-150 copay (authorization required) (referral required) |
| Lab services: | $0 copay (authorization required) (referral required) |
| Outpatient x-rays: | $60-100 copay (authorization required) (referral required) |
Doctor visits
| Primary: | $20 copay per visit |
| Primary: | $0 copay |
| Specialist: | $50 copay per visit (authorization required) (referral required) |
Emergency care/Urgent care
| Emergency: | $90 copay per visit (always covered) |
| Urgent care: | $60 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | $50 copay (authorization required) (referral required) |
| Routine foot care: | Not covered |
Ground ambulance
| $325 copay | |
| $300 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | Not covered (no limits) |
| Hearing aids – inner ear: | Not covered (no limits) |
| Hearing aids – outer ear: | Not covered (no limits) |
| Hearing aids – over the ear: | Not covered (no limits) |
| Hearing exam: | $50 copay (authorization required) (referral required) |
Hospital coverage (inpatient)
| $400 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral not required) |
Hospital coverage (outpatient)
| $0 copay or 30% coinsurance per visit (authorization required) (referral required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $8,300 In-network | |
| $6,500 In-network |
Medical equipment/supplies
| Diabetes supplies: | $0 copay (authorization not required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 0-20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 20% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | $465 per day for days 1 through 4 $0 per day for days 5 through 90 (authorization required) (referral not required) |
| Outpatient group therapy visit: | $40 copay (authorization required) (referral required) |
| Outpatient group therapy visit with a psychiatrist: | $40 copay (authorization required) (referral required) |
| Outpatient individual therapy visit: | $40 copay (authorization required) (referral required) |
| Outpatient individual therapy visit with a psychiatrist: | $40 copay (authorization required) (referral required) |
Optional supplemental benefits
| Yes |
Preventive care
| $0 copay (authorization not required) (referral not required) |
Rehabilitation services
| Occupational therapy visit: | $40 copay (authorization required) (referral required) |
| Physical therapy and speech and language therapy visit: | $40 copay (authorization required) (referral required) |
Skilled Nursing Facility
| $0 per day for days 1 through 20 $196 per day for days 21 through 100 (authorization required) (referral not required) |
Transportation
| Not covered |
Vision
| Contact lenses: | Not covered (no limits) |
| Eyeglass frames: | Not covered (no limits) |
| Eyeglass lenses: | Not covered (no limits) |
| Eyeglasses (frames and lenses): | Not covered (no limits) |
| Other: | Not covered (no limits) |
| Routine eye exam: | $0 copay (limits may apply) (authorization not required) (referral not required) |
| Upgrades: | Not covered |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization not required) (referral not required) |
Optional Benefits
Package #1
| Preventive dental: | Monthly Premium: | $14.00 |
| Preventive dental: | Deductible: | N/A |
Package #2
| Eyewear: | Monthly Premium: | $22.00 |
| Eyewear: | Deductible: | N/A |
| Preventive dental: | Monthly Premium: | $22.00 |
| Preventive dental: | Deductible: | N/A |
| Comprehensive dental: | Monthly Premium: | $22.00 |
| Comprehensive dental: | Deductible: | N/A |
Package #3
| Preventive dental: | Monthly Premium: | $43.00 |
| Preventive dental: | Deductible: | N/A |
| Comprehensive dental: | Monthly Premium: | $43.00 |
| Comprehensive dental: | Deductible: | N/A |
| Eyewear: | Monthly Premium: | $43.00 |
| Eyewear: | Deductible: | N/A |
Ready to sign up for Empire MediBlue Service (HMO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST