• CDPHP offers Medicare Advantage plans to residents of New York.
  • CDPHP offers both Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) plans.
  • Most CDPHP plans include Part D coverage.
  • CDPHP offers plans with no premium.

The Capital District Physicians’ Health Plan Inc. (CDPHP) is a health insurance company based in Albany, New York. CDPHP was founded in 1984 and is dedicated to providing affordable health plans to New York residents.

CDPHP’s Medicare Advantage plans include both Health Maintenance Organizations (HMOs) and Preferred Provider Organizations (PPOs).

Plus, plans include options with no monthly premium payment. This makes CDPHP an affordable option for New York Medicare beneficiaries shopping for Medicare Advantage plans.

CDPHP Medicare Advantage (Part C) plans are offered across several counties in New York. As of 2020, this includes:

  • Albany
  • Broome
  • Chenango
  • Clinton
  • Columbia
  • Delaware
  • Essex
  • Franklin
  • Fulton
  • Greene
  • Hamilton
  • Herkimer
  • Madison
  • Montgomery
  • Oneida
  • Otsego
  • Rensselaer
  • Saratoga
  • Schenectady
  • Schoharie
  • Tioga
  • Warren
  • Washington

CHPHP offers two different types of Medicare Advantage plans in 2020. You can select an HMO or a PPO. Both plan types are offered in all counties that CDPHP covers.

An HMO is a very common type of health insurance plan. With an HMO, like the ones offered by CDPHP, your care is covered when you use your plan’s provider network, and you may have a primary care provider (PCP).

The network will include anywhere you might receive healthcare services, such as:

  • doctors’ offices
  • pharmacies
  • hospitals
  • urgent care centers
  • skilled nursing facilities

You’ll need to stay inside your plan’s network for your services to be covered. If you see a provider out of network, it won’t be covered.

Exceptions are made for emergency care. This is always covered, even if you use an out-of-network provider.

A PPO is very similar to an HMO. You’ll still have a network of providers, but you’ll be able to go outside your network for most services if you pay a higher out-of-pocket cost.

For example, you might have a $15 copayment to see an in-network PCP, but a $40 copayment if you choose to see an out-of-network doctor instead.

Most HMO and PPO Medicare Advantage plans from CDPHP also include Medicare Part D (prescription drug) coverage.

Medicare Advantage plans that combine the coverage of an Advantage plan with Medicare Part D are known as MAPD plans. For many people, MAPD plans are a convenient way to have all their healthcare costs covered by a single plan.

CDPHP doesn’t have separate Medicare Part D plans. The Advantage plans from CDPHP include Part D coverage, but you can’t buy a separate Part D plan from CDPHP.

You can use the Medicare plan finder tool to search for separate Part D plans in New York.

CDPHP Medicare Advantage plans cover a broad range of healthcare services for members.

Like all Medicare Advantage plans, CDPHP plans cover all services covered by Medicare Part A (hospital insurance) and Medicare Part B (medical insurance) combined. Together, parts A and B are often referred to as original Medicare.

In addition to all the services that would be covered by original Medicare, CDPHP covers many extra services. As of 2020, this includes:

  • Part D coverage
  • routine dental coverage
  • routine vision coverage
  • hearing services
  • a hearing aid allowance
  • preventive care, including vaccines and screenings
  • SilverSneakers membership
  • access to local YMCAs and select other gyms
  • access to health support programs
  • access to Zipongo, a nutrition and meal planning app
  • up to $75 reimbursed when you participate in a qualifying weight management program

All CDPHP members also have access to the CafeWell program. Through CafeWell, members can set personal health goals and receive rewards for meeting them.

Actions like sticking to your exercise routine, getting preventive screenings, and losing weight can earn you points. The points can be turned into gift cards of up to $175 per calendar year.

What is the CDPHP Enhanced Primary Care program?

CDPHP plans offer members the chance to receive care from providers who participate in its Enhanced Primary Care (EPC) program. To participate in the EPC, providers need to offer:

  • same-day appointments
  • longer business hours
  • electronic communication and scheduling
  • personalized care

Seeing an EPC program doctor means you’ll have a lower copayment when using most CDPHP plans.

CDPHP Medicare offers six different Medicare Advantage Plans. The prices for each plan are the same no matter what county you live in. You can check out some prices for each plan in the table below.

Sample cost of CDPHP Advantage plans in New York

PlanPremiumPCP visitSpecialist visitER visit
CDPHP $0 Medicare Rx HMO$0$15, or $10 if your provider participates in the EPC program $50$90
CDPHP Basic RX HMO$29.50$12, or $8 if your provider participates in the EPC program$45$90
CDPHP Value RX HMO$59$10, or $5 if your provider participates in the EPC program$35$90
CDPHP Choice RX HMO
(This plan is also available without Part D coverage.)
$128.50 (with Part D)

$39.90 (without Part D)
$10, or $0 if your provider participates in the EPC program $30$90
CDPHP Vital RX PPO$0$15, or $50 out-of-network $50, or $60 out of network $90
CDPHP Flex Rx PPO
(This plan is also available without Part D coverage.)
$40
(with Part D)

$0 (without Part D)
$12, or $8 if your provider participates in the EPC program; $40 out of network$40, or 30% coinsurance out of network$90

Medicare Advantage is also known as Medicare Part C. Medicare Advantage plans are insurance plans from private insurance companies like CDPHP that contract with Medicare to provide coverage.

In order to offer coverage to Medicare beneficiaries, Advantage plans are required to cover all services covered by original Medicare. This includes:

  • PCP visits
  • specialist visits
  • preventive care
  • speech, occupational, and physical therapy visits
  • emergency room visits
  • urgent care visits
  • hospital stays
  • ambulance ride
  • skilled nursing facility stays (limited coverage)
  • home health care (limited coverage)
  • medical equipment

Many plans also offer coverage for things original Medicare doesn’t cover, like dental and vision care. Plans are available from local companies like CDPHP, as well as large national ones.

No matter what company you choose, the Medicare Advantage plans available to you will depend on where you live. Plans are generally only offered in select states, counties, or even cities.

It’s important to note that the price of your Medicare Advantage plan premium is in addition to the price of the Part B premium.

In 2020, the standard Part B premium is $144.60. That means that if you select a plan like the CDPHP $0 Medicare Rx HMO with no premium, you’d still have to pay $144.60. If you chose the CDPHP Value RX HMO, however, you’d pay its $59 premium on top of the Part B premium — a total of $203.60.

Original Medicare doesn’t include coverage for prescription medications unless you receive them in the hospital or other inpatient care settings.

Medicare Part D is prescription drug coverage that can be added to original Medicare and to Medicare Advantage if your plan doesn’t cover prescriptions. If your Medicare Advantage plan already has prescription drug coverage, you don’t need Part D.

Like Advantage plans, Part D plans are offered by private companies and have additional premiums on top of the costs of original Medicare.

Medicare Part D plans have a list of medications they’ll cover. This list is called a formulary and it includes generics, name brands, and specialty medications. Make sure any prescriptions you’re currently taking are covered by a plan’s formulary before purchasing the plan.

Some Part D plans also use a network. Your pharmacy will need to be in your plan’s network as well.

  • CDPHP Medicare Advantage plans offer affordable coverage for New York residents.
  • You can choose between HMOs or PPOs with CDPHP.
  • There are plans available without a premium and with low copayments for many services.
  • CDPHP plans include additional coverage for dental, vision, and hearing care, as well as extras like SilverSneakers membership and fitness rewards.

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