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Capital District Physicians Health Plan Medicare Review

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UPDATED: Nov 30, 2018

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Capital District Physicians Health Plan
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Capital Physician’s Health is a small, local health insurance company providing coverage to residents of a portion of New York. Their products include individual and family HMO and PPO plans and Medicare options.

About Capital Physician’s Health

Named for the district of New York where it was founded, Capital District Physician’s Health Plan (CDPHP) was founded in 1984 by a group of doctors looking to create a better approach to patient care. Highly locally focused, the company serves more than 300,000 members in specific counties.

Capital offers group plans for employers as well as individual and family plans. They also write several government sponsored plans including Medicare and Medicaid coverage. They promise quick access to customer service and local representatives. About half of the company’s board members are practicing physicians.

CDPHP offers both HMO and PPO plans for individuals, but their Medicare Advantage plans are all HMO. Plans can be purchased online, over the phone, or through local agents. The company’s headquarters is in Albany, NY.

CDPHP Medicare Plans

CDPHP offers four Medicare Advantage plans, all of which include prescription drug coverage, and one which can be purchased without the Part D coverage.

The $0 Plan is, as the name implies, a $0-premium plan that will cost you nothing more per month beyond the regular Original Medicare premiums. This plan has a $15 copay for office visits as well as a $50 specialist copay. Inpatient hospital visits have a copay of $450 a day for the first four days.

Dental, hearing, and vision are included, as is prescription coverage. There is a $300 deductible for prescriptions that applies to Tiers 3 and up. Tier 1 drugs start at $3.

Basic Rx has copays of $10 for primary care and $45 for specialist visits. Inpatient hospital visits have a copay of $360 a day for the first five days. Dental, vision, and hearing are included, and there is no prescription drug deductible. Tier 1 drugs again start at $3.

The Value Rx plan has a $15 copay for primary care office visits as well as a $35 copay for specialist visits. The inpatient hospital copay is $295 for the first six days. There is no deductible for prescriptions, which start at $2 for Tier 1, and dental, vision, and hearing are included.

The Choice plan is available either with or without prescription coverage. Primary care visits have a copay of $10 and specialists a copay of $30. Inpatient hospital stays have a copay of $260 a day for the first six days. The plan includes dental, vision, and hearing, and if you choose the Rx option, there is no deductible and prescriptions start at $0 for Tier 1.


CDPHP has reasonable rates, starting with the $0 premium plan and going up to the Choice Rx, which is the most expensive plan at $128.80. Their other plans offer rates in between those two, with every other plan under $100 a month.

These rates are not really comparable outside the small area where CDPHP provides their services but based on what we have seen around the country for Medicare Advantage plans, they are on the low side.

Since these are all HMO plans, we do expect the rates to be lower than a PPO due to the more limited provider network and lack of out of network coverage.


As is common to health insurance companies, CDPHP handles claims directly with the provider. It is rare that an insured would be involved with the process of filing a claim, although in the event that a claim is denied they would be involved in the appeal process.

Though there really is not much in the way of claims information on the copmany’s website, this is standard for Medicare.

Ratings and Consumer Reviews

CDPHP has an A+ rating with the Better Business Bureau (BBB), and has only six complaints on file in the past three years. The BBB page does not currently have any reviews for CDPHP.

The National Committee for Quality Assurance rates CDPHP’s Medicare plans at a 4.5 out of 5 overall, with good marks in most areas of consumer satisfaction.

The company also has a 4.5 out of 5 for their official Medicare star rating for 2019. That ranks them among the best in the state and nationwide as well.

There are 13 reviews of CDPHP on Yelp for an overall two-star rating. There are some positive reviews mixed with the negative, which mainly cite poor customer service and difficulty with coverage.

We were unable to find much else in the way of reviews, which leaves us with the impression of a company that has a solid reputation.

The Bottom Line

If you live in the service area and do not mind the limitations of an HMO, CDPHP plans may be a good choice for you. The rates are reasonable even with low copays, and the plans come with plenty of benefits. CDPHP seem to have a great reputation and little in the way of complaints, which adds up to a good value.

For a list of companies that we recommend, visit our Best Insurance Companies page.

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Capital District Physicians Health Plan Medicare
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About Eric Stauffer

Author: Eric StaufferI am a former insurance agent and banker turned consumer advocate. My priority is to help educate individuals and families about the different types of insurance they need, and assist them in finding the best place to get it.

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