Healthfirst Silver Leaf Plan - Benefits

What is covered by Healthfirst Family Health Plus?

Each Leaf Plan offers the same great health benefits, including checkups, maternity care, emergency services, hospitalization, prescription drugs, lab work, and more. The difference is that your monthly premium payment and other costs will vary based on the plan you choose. 

Depending on your income, you can get help to reduce the cost of your Silver Leaf Plan.This help is also referred to as a “subsidy.” Subsidies are available to families with incomes up to 250% of the Federal Poverty Level (FPL). Click here to view 2013 FPL amounts. 

Based on your where your income falls within the FPL guidelines, you can use the grid below to determine what your deductible, coinsurance, and maximum out-of-pocket cost will be for the Healthfirst Silver Leaf Plans. As an example, if your income is 200% of FPL, your deductible will be $1,750, your co-insurance will be 25%, and your yearly maximum out-of-pocket cost will be $4,000. 

For help understanding terms like deductible and co-insurance, please visit the Glossary.

Cost (Individual)

  Income over $34,471

Income up to: $34,470

Income up to: $22,980 Income up to: $17,235
Deductible

   $2,000

$1,750 $250 $0
Coinsurance 30% 25% 10% 5%
Maximum Out Of Pocket (MOOP) $5,500 $4,000 $2,000 $1,000

Cost (Family)

Federal Poverty Level (FPL) > 250% 200 - 250% 150 - 200% 100 - 150%
Deductible $4,000 $3,500 $500 $0
Coinsurance 30% 25% 10% 5%
Maximum Out Of Pocket (MOOP) $11,000 $8,000 $4,000 $2,000

Covered Benefits (Individual and Family)

Federal Poverty Level (FPL) >250% 200 - 250% 150 - 200% 100 - 150%
Preventive Care No deductible or cost sharing applies to preventive care visits or services as defined in section 2713 of the ACA
Primary Care Physician $30 copay $30 copay $15 copay $10 copay
Specialist $50 copay $50 copay $35 copay $20 copay

PT/OT/ST: Rehabilitative & Habilitative Services

$30 copay $30 copay $25 copay $15 copay
Urgent Care $70 copay $70 copay $50 copay $30 copay
Emergency Room $150 copay $150 copay $75 copay $50 copay
Ambulance $150 copay $150 copay $75 copay $50 copay
Surgeon, Anesthesiologist $100 copay $100 copay $75 copay $25 copay
Outpatient facility $100 copay $100 copay $75 copay $25 copay
Inpatient Facility /
Skilled Nursing Facility
$1,500
per admission
$1,500
per admission

$250
per admission

$100
per admission

Prescription Drugs (Individual and Family)

Federal Poverty Level (FPL) > 250% 200 - 250% 150 - 200% 100 - 150%
Generic $10 copay $10 copay $9 copay $6 copay
Brand Name (formulary) $35 copay $35 copay $20 copay $15 copay
Brand Name (not in formulary) $70 copay $70 copay $40 copay $30 copay
The benefit information provided herein is a brief summary, not a comprehensive description of benefits.  For more information contact the plan. - See more at: http://www.healthfirstny.org/2013-life-improvement-plan-hmo-snp-benefits.html#sthash.3Z9JoQ9M.dpuf

The benefit information provided above is a brief summary, not a comprehensive description of benefits.

For more information please click on the links below.