Trinity Health Plan New York Cash Back (HMO)
Available to residents of Lewis County, NY for 2027. Contract H9827, plan 004, 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 Lewis County
- Plan website
- Browse the Trinity Health Plan New York Cash Back (HMO) formulary
2027 drug-by-drug coverage is not published by CMS yet. The drug lookup covers 2026, whose formulary is live.
Renewed for 2027. CMS carries this plan forward from 2026. Every NY plan’s 2026–2027 changes →
Plan details
| Monthly premium (Part C + D) | $0.00 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $0.00? |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | $70.00 a month?You must continue to pay your Medicare Part B premium. |
| Health plan deductible (in-network) | $550.00 |
| In-network out-of-pocket maximum | $9,250.00? |
| Drug deductible | $450.00Tier 1 and 2 exempt |
| Drug out-of-pocket threshold | $2,400.00 |
| Plan type | HMO? |
| Contract / plan | H9827-004-0 |
| Offered by | Trinity Health Plan New York |
| Parent organization | Trinity Health Corporation |
| Formulary tiers | 5 |
| Formulary exception tier | 5? |
| Pharmacy search | www.medigold.com/tools-and-resources/drug-benefits/ |
| Member services | (800)964-4525TTY 711 |
CMS star ratings
- Overall
- 3 out of 5 stars for Overall
- Health plan (Part C)
- 3 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 2.5 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H9827 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $45 copay |
| Other health care professional | $0–$45 copay |
| Additional telehealth services | $0–$45 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | $0 copay |
| Kidney disease education | $0 copay |
| Glaucoma screening | $0 copay |
| Diabetes self-management training | $0 copay |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | $40 copay |
| Lab services | $0 copay |
| Diagnostic radiology (e.g. MRI, CT) | $395 copay |
| Therapeutic radiology | 20% coinsurance |
| Outpatient x-rays | $55 copay |
| Emergency and urgent care | |
| Emergency room | $115 copay |
| Urgent care | $40 copay |
| Worldwide emergency coverage | $115 copay |
| Worldwide urgent care | $115 copay |
| Worldwide emergency transportation | $300–$350 copay |
| Hospital care | |
| Inpatient hospital stay | $450 per day for days 1–5; $0 per day for days 6–90(authorization required) |
| Outpatient hospital services | $0–$475 copay |
| Outpatient observation | $405 copay |
| Ambulatory surgical center | $475 copay |
| Outpatient blood services | $0 copay |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $221 per day for days 21–65; $0 per day for days 66–100 |
| Home health care | $0 copay |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | $35 copay |
| Physical therapy and speech-language therapy | $35 copay |
| Cardiac rehabilitation | $30 copay |
| Pulmonary rehabilitation | $15 copay |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $415 per day for days 1–5; $0 per day for days 6–90 |
| Outpatient mental health, individual session | $40 copay |
| Outpatient mental health, group session | $40 copay |
| Psychiatrist, individual session | $40 copay |
| Psychiatrist, group session | $40 copay |
| Partial hospitalization | $60 copay |
| Intensive outpatient program | $60 copay |
| Outpatient substance use, individual session | $40 copay |
| Outpatient substance use, group session | $40 copay |
| Opioid treatment program | $40 copay |
| Ambulance and transportation | |
| Ground ambulance | $300 copay(authorization required) |
| Air ambulance | $350 copay(authorization required) |
| Transportation to plan-approved locations | Not covered |
| 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 | $0 copay(authorization required) |
| Diabetic therapeutic shoes or inserts | 20% coinsurance(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $15 copay(authorization required) |
| Routine chiropractic care | Not covered |
| Acupuncture | $20 copay(authorization required, limits apply) |
| Foot exams and treatment (Medicare-covered) | $45 copay |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | $45 copay |
| Preventive dental plan limit | $1,000 plan limit every year |
| Oral exams | $0 copay(limits apply) |
| Cleanings | $0 copay(limits apply) |
| Fluoride treatment | $0 copay(limits apply) |
| Dental x-rays | $0 copay(limits apply) |
| Other diagnostic dental services | $0 copay(limits apply) |
| Other preventive dental services | $0 copay(limits apply) |
| Restorative services (fillings, crowns) | Not covered |
| Endodontics (root canals) | Not covered |
| Periodontics (gum disease) | Not covered |
| Dentures and other removable prosthodontics | Not covered |
| Maxillofacial prosthetics | Not covered |
| Implants | Not covered |
| Bridges and other fixed prosthodontics | Not covered |
| Oral and maxillofacial surgery | Not covered |
| Orthodontics | Not covered |
| Adjunctive general services | Not covered |
| Vision? | |
| Eye exam (Medicare-covered) | $0–$45 copay |
| Routine eye exam | $0 copay(limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(limits apply) |
| Eyewear plan limit | $150 plan limit every year |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | $0 copay(limits apply) |
| Eyeglass frames | $0 copay(limits apply) |
| Eyewear upgrades | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | $45 copay |
| Routine hearing exam | $0 copay(limits apply) |
| Hearing aid fitting and evaluation | $0 copay |
| Hearing aids (all types) | $599–$899 copay(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 | $25 allowance every three months |
| Meals after a hospital stay or for a chronic condition | $0 copay |
| Fitness benefit | $0 copay |
| Health education | Not covered |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | $0 copay |
| Home and bathroom safety devices | Not covered |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | Not covered |
| 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, CY2027). 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 · Preferred Generic | $0.00 |
| Tier 2 · Generic | $5.00 |
| Tier 3 · Preferred Brand | 25% |
| Tier 4 · Non-Preferred Drug | 35% |
| Tier 5 · Specialty Tier | 28% |
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 |
| Tier 2: Generic | $5.00 | $5.00 | $0.00 | $15.00 | $15.00 | $0.00 |
| Tier 3: Preferred Brand | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 4: Non-Preferred Drug | 35% | 35% | 35% | 35% | 35% | 35% |
| Tier 5: Specialty Tier | 28% | 28% | 28% | n/a | n/a | n/a |
These are the initial coverage phase amounts, as the plan filed them in its benefit package. The deductible and post-threshold phases are not stated per tier in that filing, so they are not shown here rather than being inferred; the plan's annual out-of-pocket threshold is $2,400.00.
Star rating measures
| Measure | 2027 | 2026 |
|---|---|---|
| Staying Healthy: Screenings, Tests and Vaccines | ||
| Breast Cancer Screening · C01 | 3 out of 5 stars for Breast Cancer Screening | Plan too small to be measured |
| Colorectal Cancer Screening · C02 | 4 out of 5 stars for Colorectal Cancer Screening | Plan too small to be measured |
| Annual Flu Vaccine · C03 | 3 out of 5 stars for Annual Flu Vaccine | Plan too small to be measured |
| Monitoring Physical Activity · C06 | 3 out of 5 stars for Monitoring Physical Activity | Plan too small to be measured |
| Managing Chronic (Long Term) Conditions | ||
| Diabetes Care – Eye Exam · C11 | 2 out of 5 stars for Diabetes Care – Eye Exam | Plan too small to be measured |
| Diabetes Care – Blood Sugar Controlled · C12 | 3 out of 5 stars for Diabetes Care – Blood Sugar Controlled | Plan too small to be measured |
| Kidney Health Evaluation for Patients with Diabetes · C13 | 2 out of 5 stars for Kidney Health Evaluation for Patients with Diabetes | Plan too small to be measured |
| Controlling High Blood Pressure · C14 | 3 out of 5 stars for Controlling High Blood Pressure | Plan too small to be measured |
| Reducing the Risk of Falling · C15 | 1 out of 5 stars for Reducing the Risk of Falling | Plan too small to be measured |
| Improving Bladder Control · C16 | 2 out of 5 stars for Improving Bladder Control | Plan too small to be measured |
| Transitions of Care · C19 | 3 out of 5 stars for Transitions of Care | Plan too small to be measured |
| Member Experience with Health Plan | ||
| Getting Needed Care · C21 | 4 out of 5 stars for Getting Needed Care | Plan too small to be measured |
| Getting Appointments and Care Quickly · C22 | 4 out of 5 stars for Getting Appointments and Care Quickly | Plan too small to be measured |
| Customer Service · C23 | 3 out of 5 stars for Customer Service | Plan too small to be measured |
| Rating of Health Care Quality · C24 | 1 out of 5 stars for Rating of Health Care Quality | Plan too small to be measured |
| Rating of Health Plan · C25 | 1 out of 5 stars for Rating of Health Plan | Plan too small to be measured |
| Care Coordination · C26 | 4 out of 5 stars for Care Coordination | Plan too small to be measured |
| Member Complaints and Changes in the Health Plan's Performance | ||
| Complaints about the Health Plan · C27 | 2 out of 5 stars for Complaints about the Health Plan | not enough data |
| Members Choosing to Leave the Plan · C28 | 3 out of 5 stars for Members Choosing to Leave the Plan | not enough data |
| Health Plan Customer Service | ||
| Plan Makes Timely Decisions about Appeals · C30 | 5 out of 5 stars for Plan Makes Timely Decisions about Appeals | not enough data |
| Reviewing Appeals Decisions · C31 | 5 out of 5 stars for Reviewing Appeals Decisions | not enough data |
| Call Center – Foreign Language Interpreter and TTY Availability · C32 | 3 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 4 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD1: Drug Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · D01 | 3 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | 3 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability |
| DD2: Member Complaints and Changes in the Drug Plan’s Performance | ||
| Complaints about the Drug Plan · D02 | 2 out of 5 stars for Complaints about the Drug Plan | not enough data |
| Members Choosing to Leave the Plan · D03 | 3 out of 5 stars for Members Choosing to Leave the Plan | not enough data |
| Drug Plan Quality Improvement · D04 | 3 out of 5 stars for Drug Plan Quality Improvement | 1 out of 5 stars for Drug Plan Quality Improvement |
| DD3: Member Experience with the Drug Plan | ||
| Rating of Drug Plan · D05 | 2 out of 5 stars for Rating of Drug Plan | Plan too small to be measured |
| Getting Needed Prescription Drugs · D06 | 3 out of 5 stars for Getting Needed Prescription Drugs | Plan too small to be measured |
| DD4: Drug Safety and Accuracy of Drug Pricing | ||
| MPF Price Accuracy · D07 | 4 out of 5 stars for MPF Price Accuracy | 5 out of 5 stars for MPF Price Accuracy |
| Medication Adherence for Diabetes Medications · D08 | 2 out of 5 stars for Medication Adherence for Diabetes Medications | 4 out of 5 stars for Medication Adherence for Diabetes Medications |
| Medication Adherence for Hypertension (RAS antagonists) · D09 | 3 out of 5 stars for Medication Adherence for Hypertension (RAS antagonists) | 4 out of 5 stars for Medication Adherence for Hypertension (RAS antagonists) |
| Medication Adherence for Cholesterol (Statins) · D10 | 2 out of 5 stars for Medication Adherence for Cholesterol (Statins) | 2 out of 5 stars for Medication Adherence for Cholesterol (Statins) |
| Statin Use in Persons with Diabetes (SUPD) · D11 | 4 out of 5 stars for Statin Use in Persons with Diabetes (SUPD) | 4 out of 5 stars for Statin Use in Persons with Diabetes (SUPD) |
| Concurrent Use of Opioids and Benzodiazepines (COB) · D12 | 2 out of 5 stars for Concurrent Use of Opioids and Benzodiazepines (COB) | new measure |
| Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) · D13 | 4 out of 5 stars for Polypharmacy: Use of Multiple Anticholinergic Medications in Older Adults (Poly-ACH) | new measure |
Measures are paired between the two years by name, not by the C/D number: CMS reuses those numbers, and in 2027 nineteen of them refer to a different measure than they did in 2026. A measure introduced for 2027 has no 2026 score to show. Published per contract — every plan under H9827 shares it.
Also available in 7 other NY counties
Benefits in plain text
Trinity Health Plan New York Cash Back (HMO) (H9827-004-0) is a 2027 HMO Medicare Advantage plan offered by Trinity Health Plan New York, available to residents of Lewis County, NY.
The monthly premium is $0.00.
The plan reduces the member's Medicare Part B premium by $70.00 a month (a "giveback"); the Part B premium itself must still be paid.
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
The in-network deductible for health services is $550.00.
Its in-network out-of-pocket maximum is $9,250.00.
The drug deductible is $450.00. Tier 1 and 2 exempt.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1 (Preferred Generic): $0.00; tier 2 (Generic): $5.00; tier 3 (Preferred Brand): 25%; tier 4 (Non-Preferred Drug): 35%; tier 5 (Specialty Tier): 28%.
CMS gives the plan's contract (H9827) an overall rating of 3 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS plan Landscape file and the CMS plan benefit package (PBP) files.