MetroPlus UltraCare (HMO D-SNP)
Available to residents of Richmond County, NY for 2026. Contract H0423, plan 007, segment 0.
- ✉ Email a copy of the plan benefit details
- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Richmond County
- Plan website
- Browse the MetroPlus UltraCare (HMO D-SNP) formulary
Renewed for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $58.80 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $58.80? |
| Drug premium in CMS's quarterly plan file | $0.00The CMS Landscape file above lists $58.80 for the drug part; the two CMS files differ for this plan. |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | None |
| In-network out-of-pocket maximum | $9,250.00? |
| Drug deductible | $615.00 |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO D-SNP? |
| Special needs plan | Dual-eligible SNP |
| Contract / plan | H0423-007-0 |
| Offered by | MetroPlus Health Plan |
| Parent organization | New York City Health and Hospitals Corporation |
| Formulary drugs | 3,424 |
| Pharmacy search | www.caremark.com |
| Member services | (866)986-0356TTY 711 |
CMS star ratings
- Overall
- 4 out of 5 stars for Overall
- Health plan (Part C)
- 3.5 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 3.5 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H0423 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | 20% coinsurance |
| Specialist | 20% coinsurance(referral required) |
| Other health care professional | 20% coinsurance(referral required) |
| Additional telehealth services | 20% coinsurance(referral required) |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | $0 copay |
| Kidney disease education | 20% coinsurance |
| Glaucoma screening | 20% coinsurance |
| Diabetes self-management training | 20% coinsurance |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | 20% coinsurance(referral required) |
| Lab services | 20% coinsurance(referral required) |
| Diagnostic radiology (e.g. MRI, CT) | 20% coinsurance(authorization and referral required) |
| Therapeutic radiology | 20% coinsurance(authorization and referral required) |
| Outpatient x-rays | 20% coinsurance(authorization and referral required) |
| Emergency and urgent care | |
| Emergency room | 20% coinsurance |
| Urgent care | 20% coinsurance |
| Worldwide emergency coverage | $0 copay |
| Worldwide urgent care | Not covered |
| Worldwide emergency transportation | Not covered |
| Hospital care | |
| Inpatient hospital stay | Original Medicare cost-sharing(authorization required) |
| Outpatient hospital services | 20% coinsurance |
| Outpatient observation | 20% coinsurance |
| Ambulatory surgical center | 20% coinsurance(referral required) |
| Outpatient blood services | 20% coinsurance(referral required) |
| Skilled nursing and home health | |
| Skilled nursing facility | Original Medicare cost-sharing(authorization required) |
| Home health care | $0 copay(authorization and referral required) |
| Kidney dialysis | 20% coinsurance(referral required) |
| Rehabilitation | |
| Occupational therapy | 20% coinsurance(authorization and referral required) |
| Physical therapy and speech-language therapy | 20% coinsurance(authorization and referral required) |
| Cardiac rehabilitation | 20% coinsurance(authorization and referral required) |
| Pulmonary rehabilitation | 20% coinsurance(authorization and referral required) |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | Original Medicare cost-sharing(authorization required) |
| Outpatient mental health, individual session | 20% coinsurance |
| Outpatient mental health, group session | 20% coinsurance |
| Psychiatrist, individual session | 20% coinsurance |
| Psychiatrist, group session | 20% coinsurance |
| Partial hospitalization | 20% coinsurance(authorization and referral required) |
| Intensive outpatient program | 20% coinsurance |
| Outpatient substance use, individual session | 20% coinsurance |
| Outpatient substance use, group session | 20% coinsurance |
| Opioid treatment program | 20% coinsurance(authorization required) |
| Ambulance and transportation | |
| Ground ambulance | 20% coinsurance(authorization required) |
| Air ambulance | 20% coinsurance(authorization required) |
| Transportation to plan-approved locations | $0 copay |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | 20% coinsurance(authorization required) |
| Diabetic therapeutic shoes or inserts | 20% coinsurance(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | 20% coinsurance(authorization and referral required) |
| Routine chiropractic care | $0 copay(authorization and referral required) |
| Acupuncture | $0 copay(authorization required, limits apply) |
| Foot exams and treatment (Medicare-covered) | 20% coinsurance(referral required) |
| Routine foot care | $0 copay(referral required, limits apply) |
| Dental? | |
| Medicare-covered dental services | 20% coinsurance |
| Oral exams | $0 copay(authorization required, limits apply) |
| Cleanings | $0 copay(authorization required, limits apply) |
| Fluoride treatment | $0 copay(authorization required, limits apply) |
| Dental x-rays | $0 copay(authorization required, limits apply) |
| Other diagnostic dental services | $0 copay(authorization required, limits apply) |
| Other preventive dental services | $0 copay(authorization required, limits apply) |
| Restorative services (fillings, crowns) | $0 copay(authorization required, limits apply) |
| Endodontics (root canals) | $0 copay(authorization required, limits apply) |
| Periodontics (gum disease) | $0 copay(authorization required, limits apply) |
| Dentures and other removable prosthodontics | $0 copay(authorization required, limits apply) |
| Maxillofacial prosthetics | $0 copay(authorization required, limits apply) |
| Implants | $0 copay(authorization required, limits apply) |
| Bridges and other fixed prosthodontics | $0 copay(authorization required, limits apply) |
| Oral and maxillofacial surgery | $0 copay(authorization required, limits apply) |
| Orthodontics | $0 copay(authorization required, limits apply) |
| Adjunctive general services | $0 copay(authorization required, limits apply) |
| Vision? | |
| Eye exam (Medicare-covered) | 20% coinsurance(referral required) |
| Routine eye exam | Not covered |
| Eyewear after cataract surgery (Medicare-covered) | 20% coinsurance(referral required, limits apply) |
| Eyewear plan limit | $500 plan limit every year |
| Contact lenses | $0 copay(referral required, limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(referral required, limits apply) |
| Eyeglass lenses | $0 copay(referral required, limits apply) |
| Eyeglass frames | $0 copay(referral required, limits apply) |
| Eyewear upgrades | $0 copay(referral required, limits apply) |
| Hearing? | |
| Hearing exam (Medicare-covered) | 20% coinsurance(referral required) |
| Routine hearing exam | Not covered |
| Hearing aid fitting and evaluation | Not covered |
| Hearing aid plan limit | $500 plan limit every year |
| Hearing aids (all types) | $0 copay(authorization required, limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | $35 copay(authorization required, step therapy may apply) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | Covered (allowance not stated) |
| Meals after a hospital stay or for a chronic condition | $0 copay |
| Fitness benefit | $0 copay(limits apply) |
| Health education | Not covered |
| Nutritional / dietary benefit | $0 copay(limits apply) |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | Not covered |
| Home and bathroom safety devices | $0 copay(limits apply) |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | $0 copay(limits apply) |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 4 other NY counties
Benefits in plain text
MetroPlus UltraCare (HMO D-SNP) (H0423-007-0) is a 2026 HMO D-SNP Medicare Advantage plan offered by MetroPlus Health Plan, available to residents of Richmond County, NY.
The monthly premium is $58.80 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
Its in-network out-of-pocket maximum is $9,250.00.
The drug deductible is $615.00.
It is a special needs plan (Dual-eligible SNP).
The plan's formulary lists 3,424 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00.
CMS gives the plan's contract (H0423) an overall rating of 4 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.