CDPHP Medicare Advantage plans are available to people looking for Medicare coverage in parts of New York state.
CDPHP offer various Medicare Advantage Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) plans, all with no annual deductible for medical expenses and some with no monthly premium.
Most of the plans also include prescription drug coverage.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare Advantage is a bundled plan that includes the two parts of original Medicare. These are Part A, which is inpatient hospital insurance, and Part B, which is outpatient medical insurance. Many Medicare Advantage plans also include prescription drug coverage.
Private insurance companies administer Medicare Advantage plans. Other names for Medicare Advantage include Part C, Medicare replacement plans, or MA plans.
Medicare Advantage plans typically have an annual out-of-pocket maximum, which is the most an individual will pay before the plan covers 100% of eligible costs.
Premiums, deductibles, and coinsurance vary among plans, and the plans usually include benefits not available with original Medicare, such as coverage for dental or vision care.
Types of Medicare Advantage plan
Several types of Medicare Advantage plan are available. The sections below will look at these in more detail.
Someone with an HMO plan must usually use healthcare providers within the plan’s network. An exception is when emergency care is necessary.
A person must also choose a primary care physician (PCP) and obtain a referral to see a specialist.
In this variation of an HMO plan, a person may use some services from out-of-network providers, though these services could cost more.
Someone with a PPO plan can save money by using providers in the plan’s network. They may also see out-of-network providers, but this will usually be at a higher cost.
In most cases, these plans do not require a person to obtain a referral to see a specialist or choose a PCP.
Learn more about PPO plans here.
A person can use any Medicare-approved healthcare provider who accepts the Private Fee-for-Service (PFFS) plan’s terms. Some PFFS plans have networks in which providers agree to provide treatment to plan members at set costs.
Someone with a PFFS plan is not required to choose a PCP or get a referral to see a specialist.
Special Needs Plans
Special Needs Plans (SPNs) provide tailored-made benefits if a person has a chronic health condition, such as cancer, diabetes, or dementia.
SNPs must provide prescription drug coverage.
Medical savings account plans
Medicare savings account (MSA) plans deposit money into a savings account, which a person uses to pay healthcare expenses before they have fully paid their deductible.
The plans do not include prescription drug coverage, and they generally do not require a person to choose a PCP or get a referral for a specialist.
CDPHP are a nonprofit health insurance company based in Albany, NY.
Founded by doctors in 1984, CDPHP stands for Capital District Physicians’ Health Plan. This was the company’s name in its early years.
CDPHP offer two types of Medicare Advantage plan: HMO and PPO.
The HMO plans are:
The PPO plans are:
CDPHP’s Medicare Advantage plans cover services such as doctor office visits, preventive care, inpatient and outpatient hospital care, surgeries, and diagnostic tests.
All of the company’s HMO and PPO plans include coverage for dental, vision, and hearing care. Many of these services require a copayment.
All of the HMO plans except for the Choice plan include prescription drug coverage.
The PPO plans Vital Rx and Flex Rx have prescription drug coverage, but the Flex plan does not.
Costs vary among CDPHP’s different Medicare Advantage plans. Learn more about costs in the sections below.
According to CDPHP’s summary of benefits, premiums for their HMO plans range from $0–$130 per month.
A person enrolled in one of the plans must still pay the Medicare Part B premium, and the standard monthly premium is $148.50 in 2021. Individuals who have an annual income above $88,000 may pay a higher Part B premium.
Also according to the summary of benefits, none of CDPHP’s HMO plans have deductibles. For their HMO plans, the maximum out-of-pocket costs range from $5,000–$7,500 for the year. Those amounts do not include out-of-pocket payments for prescription drugs.
CDPHP’s $0 plan has a $300 deductible for brand-name and specialty drugs, but the deductible does not apply to generic drug options.
The Basic Rx, Value Rx, and Choice Rx plans do not have prescription drug deductibles, but copayments vary by plan and medication tier.
The only PPO plan with a monthly premium is FlexRx. This plan costs $41.80 per month, and, as with the HMO plans, a person must still pay their Part B premium.
All three of the PPO plans have a $0 deductible for healthcare services. The Vital Rx plan has a $350 deductible for brand-name or specialty drugs.
Depending on the plan, the annual out-of-pocket maximum is $5,500 or $7,500 for in-network services. For in-network and out-of-network services combined, the out-of-pocket maximum is $10,000 or $11,300.
In-network services typically require a copayment, while out-of-network services require coinsurance of either 30% or 40% of the cost. The coinsurance applies to services such as:
- inpatient hospital care
- preventive care
- surgery at an ambulatory center
In 2021, CDPHP Medicare Advantage plans are available in 23 counties in New York state.
These counties are:
CDPHP plans have some additional features, including incentives to plan members for participating in wellness programs.
The company are also introducing new benefits for most members of their Medicare Advantage plans in 2021. These benefits include:
- two meals per day for 7 days with no copayment after an inpatient hospital stay
- free telemedicine services through the Doctor On Demand program
- primary care office appointments with no copayment
- certain mail-order generic drugs with no copayment
Medicare.gov has a plan finder tool that allows people to compare all the Medicare Advantage plans in their zip code. Search results include plan information, costs, and the plan provider’s contact information.
State Health Insurance Assistance Programs (SHIPs) provide free, unbiased counseling for those looking for a Medicare plan. If a person is looking for impartial advice, the SHIP telephone number is 877-839-2675. The website also has a directory of SHIP offices in each state.
The Medicare Rights Center have a list of questions for someone choosing a Medicare Advantage plan to consider. Some points to think about include:
- whether or not the person’s current healthcare providers will still be in-network
- which specialists and hospitals would be part of the network
- whether or not a referral is needed to make an appointment with a specialist
- out-of-pocket costs, such as premiums, deductibles, and copayments
- the out-of-pocket maximum
- which prescribed medications are in the plan’s formulary
- the pharmacies a person can choose from
Someone looking for a Medicare Advantage plan in New York state can find several different choices from CDPHP. The company’s plans include HMO and PPO options, with and without prescription drug coverage.
Like many Medicare Advantage plans, CDPHP plans include benefits that original Medicare does not provide, such as dental and vision care.