2023 EP Sales Presentation Binder by MJHS

Sales Presentation Binder

Elderplan is an HMO plan with Medicare and Medicaid contracts and has a coordination of benefits agreement with the New York State Department of Health. Enrollment in Elderplan depends on contract renewal. Anyone entitled to Medicare Part A and B may apply. Enrolled members must continue to pay their Medicare Part B premium if not otherwise paid by Medicaid or a third party.

Elderplan renews its contract with the Centers for Medicare & Medicaid Services (CMS) annually. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Benefits, premiums and/or co-payments /co-insurance may change on January 1st of each year. This information is not a complete description of benefits. Please contact Elderplan for details.

H3347_EP17326_M 2023 Sales Binder 2023

Are You Eligible For One Of Elderplan’s Products?

4 Do you have Medicare Parts A and B?

4 Do you live in NYC, Dutchess, Nassau, Orange, Putnam, Rockland or Westchester counties for more than six months during the year?

4 Do you also have Medicaid coverage from the State of New York?

About Elderplan

4 Elderplan is a not-for-profit health plan founded right here in New York more than 35 years ago. Our primary objective is ensuring that members of our community receive the care and support they deserve.

4 Elderplan offers a variety of Medicare Advantage plans tailored to fit the changing needs of Medicare and dual Medicare and Medicaid beneficiaries at every level of health.

4 Elderplan is proud to care for people of every race, ethnicity, faith, national origin, gender identity or expression, sexual orientation, or military status.

4 Elderplan/HomeFirst is part of MJHS, a not-for-profit health system founded in 1907, which has a rich history of caring for at-risk New Yorkers with compassion, dignity, and respect. MJHS includes: MJHS Home Care, MJHS Hospice and Palliative Care, as well as Isabella and Menorah Centers for Rehabilitation and Nursing Care. So, should you require access to additional support over time, and choose to receive services from MJHS, the Elderplan team can work together with their colleagues from across the system to better coordinate your care and make it easier for you.

4 Includes more than 193,035 provider locations in our network.

Elderplan has a range of Medicare Advantage Plans designed to meet the needs of our members.

Let’s discuss your current coverage and needs! 4

Finding the right plan for you:

The following questions will help us determine which plan will best fit your needs:

4 Do you have Medicaid?

4 Do you qualify for Low Income Subsidy?

4 Are low co-payments to see your doctors important to you?

4 Are low co-payments for prescription drugs important to you?

4 Is supplemental comprehensive dental important to you?

4 Is assistance with Long-Term Care services at home important to you?

4 Is transportation to and from your doctor’s appointment important to you?

4 Is having the flexibility to choose between supplemental benefits important to you?

4 What other things are important to you in a health plan?

Based on what you have told me today, I believe <plan name> would be the best fit for you. It offers you the benefits you want in a health plan and even more.

Our Plans - Highlights

4 Elderplan for Medicaid Beneficiaries (HMO D-SNP):

A plan designed for people with Medicare who are also receiving financial help from the state (Medicaid, Medicare Savings Program) to help pay for the cost of health care coverage. This plan helps manage medical, hospital and prescription drug benefits under one umbrella. Your medical expenses will be covered at little to no cost to you, there are no referrals for doctor visits, and you have minimal cost-sharing for prescriptions. Plus, you will enjoy an over-the-counter (OTC) benefit, which includes health-related and select grocery items that you can purchase at a store or order online, as well as home delivered meals. New for 2023, you can also use your OTC benefit to pay your home internet bill.* The plan also includes comprehensive dental, transportation to and from medical appointments, vision, worldwide emergency coverage, and Brain Games with BrainHQ®.

4 Elderplan Plus Long-term Care (HMO D-SNP):

A plan was designed for Medicare and Medicaid beneficiaries who need valuable assistance with LongTerm Care at home. You’ll be happy to know that there is no plan premium, no co-payments or for doctor and hospital visits, no referrals for doctor visits, and low co-payments for prescription drugs. Plus, you will enjoy an over-the-counter (OTC) benefit, which includes health-related and select grocery items that you can purchase at a store or order online, as well as home delivered meals. New for 2023, you can also use your OTC benefit to pay certain utility providers like home internet.* The plan also provides transportation to and from medical appointments, worldwide emergency coverage, acupuncture and Brain Games with BrainHQ®.

* The Special Supplemental Benefit for the Chronically Ill (SSBCI) combines the OTC benefit to cover certain grocery items, home delivered meals, and internet bill payments as a part of the monthly OTC allowance. Eligible members will be notified and provided instructions on how to access the benefit.

Our Plans - Highlights

4 Elderplan Extra Help (HMO):

A plan designed for Medicare beneficiaries that offers a little extra help in paying for your health coverage. You get the health care you need with a low premium, and low co-pays, and no referrals to see your doctors. In addition to medical and hospital coverage, our members with Low Income Subsidy (LIS) will also experience additional savings on prescription drug coverage. Plus, you will enjoy an over-the-counter (OTC) benefit, which includes health-related and select grocery items you can purchase at a store or order online, as well as home delivered meals.* The plan also provides comprehensive dental, transportation to and from medical appointments, worldwide emergency coverage, and Brain Games with BrainHQ®.

4 Elderplan Flex (HMO):

A new plan designed for Medicare beneficiaries that gives you the care you need and the choices you want. Elderplan Flex offers a $0 premium, low co-pays, and no referrals to see your doctors. In addition to medical and hospital coverage, you will have the flexibility to choose between supplementary benefits that are most important to you through Elderplan’s Flex Extras. Elderplan’s Flex Extras gives you the option of selecting OTC coverage, which includes health-related and select grocery items and homedelivered meals* or transportation to and from medical appointments. The plan also provides preventive and comprehensive dental and worldwide emergency coverage, acupuncture, gym membership and Brain Games with BrainHQ®.

* The Special Supplemental Benefit for the Chronically Ill (SSBCI) combines the OTC benefit to cover certain grocery items, home delivered meals, and internet bill payments as a part of the quarterly OTC allowance. Eligible members will be notified and provided instructions on how to access the benefit.

Our Plans - Highlights

All of the plans Elderplan offers include: The Award-winning Member-to-Member program, which gives our members the opportunity to connect with each other and participate in exciting activities. Whether it’s a walk in the park, grocery shopping, friendly chat, wellness and relaxation activities, cooking demos, or exercise classes, we want you to have options to feel connected and entertained.

Our respected Wellness Incentive Program that rewards our members with a $25 gift card for every eligible preventive screening and immunization you complete, including the flu shot and Covid-19 vaccine.

Important Information

• Medicare beneficiaries may enroll in Elderplan only during specific times of the year.

• Elderplan/HomeFirst complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

• ATTENTION: If you speak a non-English language or require assistance in ASL, language assistance services, free of charge, are available to you. Call 1-800-353-3765 (TTY 711)

• Elderplan / Homefirst cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

• ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-800-353-3765 (TTY: 711).

• Elderplan / HomeFirst

1-800-353-3765（TTY:711）

• This information is available in different formats. Please call member services at the number listed above if you need plan information in another format or language.

• Esta información esta disponible en diferentes idiomas o formatos, entre ellos en español, en letra grande o en cinta de audio. Si necesita obtener información en otro formato o idioma, comuníquese con el Servicio de Atención al Cliente al número que se menciona anteriormente.

遵守適用的聯邦民權法律規定，不因種族、膚色、民族血統、年齡、殘障或性別而歧視任何人。注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電

Important information about our plans

• Network Lock-in: You must use network providers except in emergency or urgent care situations or for out-of-area dialysis. If you obtain routine care from out-of-network providers neither Medicare nor Elderplan will be responsible for the costs. An exception to this rule is for a member with full Medicaid who may receive other services (not available in Elderplan) through Medicaid Fee for Service (FFS) using your Medicaid card.

— Out-of-network/non-contracted providers are under no obligation to treat Elderplan members, except in emergency situations. For a decision about whether we will cover an out-of-network service, we encourage you or your provider to ask the plan for prior approval before you receive the service. If you don’t receive prior approval, Elderplan may not pay for the service and in some cases the provider will bill you. Please call member services or see your Evidence of Coverage for more information.

• Inpatient Benefit Period: A benefit period begins the day you are admitted as an inpatient (hospital or skilled nursing facility) and ends when you have not received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital co-payment for each benefit period. There is no limit to the number of benefit periods you can have.

Important information about our plans

• Pharmacy Network: Elderplan’s pharmacy network includes standard retail, mail-order, long-term care and home infusion pharmacies. In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances and quantity limitations (restrictions may apply). For mail-order information and additional information about network pharmacies, contact Elderplan’s Member Services Department at 1-800-353-3765 (TTY 711). For Elderplan Plus Long-Term Care Plan call (1-877-891-6447). Hours are 8 am to 8 pm, 7 days week.

— Information may be obtained by visiting Elderplan’s website at www.elderplan.org

• Dual Eligibles: Premiums, co-pays, co-insurance and deductibles may vary based on the level of help you receive from Medicaid. You should contact the plan for further details or call New York State HRA Medicaid Helpline at 1-800-692-6116 between 9 a.m. and 5 pm, Monday through Friday. TTY 711.

• Extra Help: You may be able to get Extra Help to pay for prescription drug premiums and costs. To see if you qualify for Extra Help, call:

— 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day / 7 days a week.

— The Social Security Office 1-800-772-1213 from 8 am to 7 pm, Monday through Friday. TTY users should call 1-800-325-0778.

— New York State HRA Medicaid Helpline at 1-800-692-6116 between 9 am and 5 pm, Monday through Friday. TTY 711.

What are my Medicare Choices? Prescription Drug Coverage Stand-alone Drug Plan D Original Medicare Hospital A Medical B + Part A: Hospital Part B: Medical Part D: Prescription Drugs • Inpatient hospital • Skilled Nursing • Home health • Hospice care • Doctor visits • Outpatient rehab • Urgent care • Durable medical equipment • Outpatient hospital • Lab tests & X-rays Helps cover the cost of prescription drugs Medicare Advantage Hospital A Medical B Additional Benefits ++ + Prescription Drugs D+ + 12

Prescription Drug Payment Stages

Up to $505 $4,660 $7,400

STAGE 1:

DEDUCTIBLE STAGE

If you select a plan with a deductible, you pay the full cost of your drugs until you have paid your deductible. No Medicare drug plan may have a deductible more than $505 in 2023.

Some plans work best with Low Income Subsidy which will reduce the cost sharing (co-payments or co-insurance).

STAGE 2:

INITIAL COVERAGE STAGE

You pay co-pays or coinsurance for your drugs after you have met your deductible.

Your plan pays its share for covered drug costs and you pay your share.

You stay in this stage until the total cost of drugs paid by both you and the plan reaches $4,660.

STAGE 3:

COVERAGE GAP STAGE

You pay 25% coinsurance for generic drugs and 25% for brand name drugs during this stage.

Not everyone will reach the coverage gap.

You stay in this stage until you (or others on your behalf) have spent a total of $7,400 on your drug costs.

Low-cost

STAGE 4: CATASTROPHIC STAGE

Once you and others on your behalf have spent $7,400 in drug costs, you pay $4.15 co-pay for generic drugs and $10.35 co-pay for brand name drugs or 5% coinsurance of retail costs, whichever is higher for the duration of the year.

NY State Pharmaceutical Assistance Program

The Elderly Pharmaceutical Insurance Coverage (EPIC) program supplements Medicare Part D drug coverage for greater annual benefits and savings. When purchasing prescription drugs, show both the EPIC and Medicare Part D drug plan cards at the pharmacy. After the Medicare Part D deductible is met, drug costs not covered by Part D (including co-payments/co-insurance) can be submitted to EPIC for payment. You will pay an EPIC co-payment ranging from $3 to $20 based on the cost of the drug.

EPIC can provide:

• A Medicare Special Enrollment Period (SEP) so that a new member may enroll in a Part D drug plan at any time during the year;

• A Medicare one-time plan change per calendar year for existing members;

• Medicare Part D drug plan premium assistance;

• Co-payment assistance after the Medicare Part D deductible is met, if the member has one. EPIC also covers approved Part D-excluded drugs once a member is enrolled in a Part D drug plan.

Please note that EPIC deductible members must first meet their EPIC deductible before they will pay EPIC co-payments. This is in addition to meeting their Medicare Part D drug plan deductible should their Part D plan have one. For more information, please visit https://www.health.ny.gov/health_care/epic/

NY State Pharmaceutical Assistance Program

To join EPIC, you must:

• Be a New York State resident age 65 or older

• Have an annual income below $75,000 if single or $100,000 if married

– Fee plan eligibility $0-$20,000 single $0-$26,000 married

– Deductible plan eligibility $20,001-$75,000 single $26,001-$100,000 married

• Be enrolled or eligible to be enrolled in a Medicare Part D plan (no exceptions), and

• Not be receiving full Medicaid benefits.

Note:

You can join EPIC at any time during the year. Once enrolled, you will receive a ‘Special Enrollment Period’ to join a Medicare Part D drug plan. You are not eligible to receive EPIC benefits until you are enrolled in a Part D drug plan.

NY State Pharmaceutical Assistance Program

Fee Plan Members

• EPIC annual fees range from $8 – $300 based on your previous year’s income.

• EPIC pays the Part D monthly drug plan premiums up to the average cost of a basic Medicare drug plan in NY, $38.90 per month in 2023.

• EPIC co-payments range from $3 to $20 based on the cost of the drug.

• Members will only pay EPIC co–payments for Part D and EPIC covered drugs after the Part D deductible, if any, is met. Members will pay EPIC co–payments for Part D excluded drugs.

• Bills are mailed quarterly for EPIC fee plan members.

• Members with full “Extra Help” from Medicare will continue to have their EPIC fees waived.

NY State Pharmaceutical Assistance Program

Deductible Plan Members

• EPIC deductibles range from $530 – $3,215 based on the previous year’s income.

• EPIC pays the Part D monthly drug plan premiums up to the average cost of a basic Medicare drug plan in NY, $38.90 per month in 2023, for members with income up to $23,000 single and $29,000 married.

• Members with higher incomes must pay their Medicare Part D premiums each month. Their EPIC deductible will be lowered by the annual cost of a basic Part D plan (approximately $505 per year) to help them pay.

• After you meet your EPIC deductible, you will only pay the EPIC co-payments ranging from $3 to $20 based on the cost of your drug.

• After you meet any Part D deductible, if you have one, out-of-pocket drug costs for covered Part D and EPIC medications will be applied to your EPIC deductible.

EPIC Co-payments

At the pharmacy, seniors present both their EPIC and Medicare Part D drug identification to their pharmacist. The EPIC co-payment is based on the cost of the prescription remaining after billing the Medicare Part D drug plan.

Co-payments for approved drugs purchased after any Medicare Part D deductible is met or for approved Part D – excluded drugs PRESCRIPTION COSTS (AFTER SUBMITTED TO MEDICARE) EPIC CO-PAYMENT Up to $15 $3 $15.01 to $35 $7 $35.01 to $55 $15 Over $55 $20 NY State Pharmaceutical Assistance Program 18

Income

For purposes of your EPIC enrollment, household gross income is the previous year’s total annual income for the member or married spouses. It includes, but is not limited to: • Federal adjusted gross household income as reported on your income tax return • Social Security payments (less Medicare premiums) • Railroad retirement benefits • The taxable amount of IRA distributions and retirement annuities • Support money, including foster care support payments • Supplemental Security income • Tax-exempt interest • Worker’s compensation • Gross amount of loss-of-time insurance • Cash public assistance and relief, other than medical assistance for the needy • Non-taxable strike benefits • Veterans’ disability pensions • Lottery winnings NY State Pharmaceutical Assistance Program 19

NY State Pharmaceutical Assistance

•

made to veterans under the federal Veterans’ Dioxin and Radiation Exposure

Standards Act (Agent

• Payments made to individuals because of their status as victims of Nazi persecution

Program Income not included: • Food stamps • Medicare premiums • Medicaid • Scholarships • Grants • Surplus food

Payments

Compensations

Orange)

Part D Late Enrollment Penalty (LEP)

The late enrollment penalty is an amount added to your Medicare Part D monthly premium. You may owe a late enrollment penalty if you go without Part D or creditable prescription drug coverage for any continuous period of 63 days or more after your Initial Enrollment Period for Medicare Part D coverage is over.

How much is the Part D penalty?

• The cost of the late enrollment penalty depends on how long you went without Part D or creditable prescription drug coverage.

• Medicare calculates the penalty by multiplying 1% of the “national base beneficiary premium“ ($32.74 in 2023) times the number of full, uncovered months you didn’t have Part D or creditable coverage. The monthly premium is rounded to the nearest $.10 and added to your monthly Part D premium amount.

• The national base beneficiary premium may increase each year, so your penalty amount may also increase each year.

If you get Extra Help, you don’t pay the late enrollment penalty.

Calculating the Part D Late Enrollment Penalty

Example:

Mrs. Martinez has Medicare, and her first chance to get Medicare drug coverage (during her Initial Enrollment Period) ended on July 31, 2018. She doesn’t have prescription drug coverage from any other source. She didn’t join a Medicare drug plan by July 31, 2018, and instead joined during the Open Enrollment Period that ended December 7, 2020. Her Medicare drug coverage started January 1, 2021.

Since Mrs. Martinez was without creditable prescription drug coverage from August 2018 –December 2020, her penalty in 2022 is 29% (1% for each of the 29 months) of $33.37 (the national base beneficiary premium for 2022) or $9.68 each month. Since the monthly penalty is always rounded to the nearest $0.10, she will pay $9.70 each month in addition to her plan’s monthly premium.

Here’s the math: • .29 (29% penalty) × $33.37 (2022 base beneficiary premium) = $9.68 • $9.68 rounded to the nearest $0.10 = $9.70 • $9.70 = Mrs. Martinez’s monthly late enrollment penalty for 2022 If you get Extra Help, you don’t pay the late enrollment penalty. 22

When Can You Enroll?

Initial Coverage Enrollment Period (ICEP):

Varies by your birthday

7 month period that starts 3 months before and ends 3 months after the month of your 65th birthday.

Annual Enrollment Period (AEP): Oct 15th – Dec 7th

During this period you can change your Medicare health plans and prescription drug coverage for the following year to better meet your needs. Enrollment will take effect January 1st .

Special Enrollment Period (SEP): All year

You may qualify to change plans based on special circumstances (e.g., you move into a new service area, you qualify for or lose eligibility for Medicaid or Low Income Subsidy).

Medicare Advantage Open Enrollment Period (MA-OEP) Jan 1st – Mar 31st

You can disenroll from your current plan and switch to a different Medicare Advantage plan one time only during this period. You can also return to original Medicare and purchase a Medicare supplement (Medigap) plan.

Let’s Discuss Your Current Coverage • Turning 65 and eligible for Medicare Part A and Part B • Covered through Original Medicare (Medicare Part A and Part B) • Prescription drug (Part D) • Eligible for Medicaid • Financial assistance (e.g., Medicare Savings, LIS, EPIC) • Medicare supplemental insurance (Medigap) • Medicare Advantage plan (Part C) • TRICARE • VA benefits • Employer or union benefits • Current coverage ending soon 24

Elderplan For Medicaid Beneficiaries (HMO D-SNP)

Making sure you receive the care you need is important to us. Making it easy for you to get that care is important too. We understand that coordinating your Medicare and Medicaid benefits can be challenging. That’s why we created a plan that makes your life a little easier by covering your medical, hospital and prescription drug benefits all under one umbrella with no referrals to see doctors.

Your medical expenses will be covered at little-to-no-cost to you and you pay minimal cost-sharing for prescriptions. Plus, you will enjoy an over-the-counter (OTC) benefit, which includes health-related and select grocery items* that you can purchase at a store or order online, as well as meals. New for 2023, you can also use your OTC benefit to pay home internet bill.*

Elderplan For Medicaid Beneficiaries (HMO D-SNP)

The plan also includes comprehensive dental, transportation to and from medical appointments, vision, worldwide emergency coverage, and Brain Games with BrainHQ®. If by now it is not clear that our main goal is keeping you healthy and happy, you should also know that as part of this plan, we offer a Wellness Incentive program, which rewards you for receiving preventive screenings and immunizations.

And because we care about your physical and mental well-being, we provide a fitness benefit (that allows you to join classes from home or work out at the gym) and the BrainHQ® Memory Fitness Program. We also offer the Award-winning Member-to-Member program, which gives our members the opportunity to connect with each other and participate in exciting activities. Whether it’s a walk in the park, grocery shopping, friendly chat, wellness and relaxation activities, cooking demos, or exercise classes, we want you to have options to feel connected.

* Using the OTC benefit for grocery items and meals or to pay your home internet bill are considered Special Supplemental Benefits for the Chronically Ill and are only for eligible members who have certain chronic conditions. Eligible members will be notified and provided instructions on how to access these benefits.

Elderplan For Medicaid Beneficiaries (HMO D-SNP)

Special eligibility requirements

Enrollment in this plan is designed for people who are eligible for both Medicare and New York State Medicaid or who are part of the Medicare Savings Program (MSP). The Medicaid benefit categories and type of assistance served by our plan are listed below:

• Full Benefit Dual Eligible (FBDE): Helps pay Medicare Part A and Part B premiums, and other cost-sharing (like deductibles, coinsurance, and copayments). These individuals are also eligible for full Medicaid benefits.

• Qualified Medicare Beneficiary (QMB): Helps pay Medicare Part A and Part B premiums, and other cost sharing (like deductibles, coinsurance, and copayments).

• Qualified Medicare Beneficiary-Plus (QMB+): Helps pay Medicare Part A and Part B premiums, and other cost sharing (like deductibles, coinsurance, and copayments). These individuals are also eligible for full Medicaid benefits.

• Qualifying Individual (QI): Helps pay Part B premiums

• Qualified Disabled and Working Individuals (QDWI): Helps pay Part A premiums

Elderplan For Medicaid Beneficiaries (HMO D-SNP)

BENEFIT YOU PAY

Part B Deductible

$0 or $226*

PCP Visits $0 or 20% coinsurance*, in-person and telehealth

$0 or 20% coinsurance*, in-person and telehealth

Specialists Visits

No referral needed to see an In-network specialist.

Lab Services/Outpatient Blood Services $0 co-payment

Diagnostic Tests and Procedures

$0 or 20% coinsurance*

Diagnostic Radiological Services

Authorization is required only for PET, MRI, MRA, and CT scan.

Therapeutic Radiology Services $0 or 20% coinsurance*

* If you

Medicaid, you pay $0

are eligible for Medicare cost-sharing assistance under

Elderplan For Medicaid Beneficiaries (HMO D-SNP)

Expanded prescription drug coverage with…UNLIMITED* brand name and generic drugs!

BENEFIT YOU PAY

Part D Premium

Part D Deductible

Initial Coverage Stage (30-day supply)

Generic Drugs (including brand drugs treated as generic)

$0 or $38.90 monthly plan premium**

$0, $99, or $505 per year***

Depending on your “Extra Help” You Pay: $0 co-pay or $1.45 co-pay or $4.15 co-pay or 15% of the cost or 25% of the cost

Initial Coverage Stage (30-day supply)

For all Other Drugs

Depending on your “Extra Help” You Pay: $0 co-pay or $4.30 co-pay or $10.35 co-pay or 15% of the cost or 25% of the cost

*You must still order prescriptions from the Elderplan formulary through a plan-affiliated pharmacy. Utilization rules may apply including Authorization, Step Therapy and/or Quantity Limits

**If you are eligible for Medicare cost-sharing assistance under Medicaid, you pay $0

***Depending on your level of “Extra Help” (LIS).

Elderplan For Medicaid Beneficiaries (HMO D-SNP)

BENEFIT YOU PAY

$0* cost-sharing for each benefit period, OR

$1,600 deductible

Days 1-60: $0 co-payment per day

Hospital Stays

Emergency Care

Urgent Care

Worldwide Emergency/Urgent

Transportation

Up to $50,000

Days 61-90: $400 co-payment per day

Days 91 and beyond: $800 co-payment per lifetime reserve day (up to 60 days over your lifetime).

Beyond lifetime reserve days: you pay all costs.

Authorization is required.

$0 or 20% co-insurance* (up to $90) per visit. (waived if admitted within 24 hours for the same condition)

$0 or 20% co-insurance* (up to $60) per visit.

$0 cost-sharing

*If you are eligible for Medicare cost-sharing assistance under Medicaid, you pay $0.

Care/Emergency

Elderplan For Medicaid Beneficiaries (HMO D-SNP)

BENEFIT YOU RECEIVE

Over-the-Counter (OTC)

OTC + Grocery* + Meals* + Internet Pay*

$155 Every Month (The OTC card balance cannot be carried over to the next month)

Fitness Benefit (Gym Access) + on-demand

workout classes and one-on-one Healthy Aging Coaching sessions by phone, video, or chat.

$155 Every Month

The Special Supplemental Benefit for the Chronically Ill (SSBCI) combines the OTC benefit to cover certain grocery items, home delivered meals, and internet bill payments as a part of the monthly OTC allowance. Eligible members will be notified and provided instructions

*For eligible members with certain chronic condition.

$0 cost-sharing

Elderplan For Medicaid Beneficiaries (HMO D-SNP)

BENEFIT YOU PAY

Diagnostic Hearing Exams (Medicare covered)

Routine Hearing Exam

$0% or 20% coinsurance*

$0 co-payment once every 3 years

Routine Hearing Aids

Up to $1,300 for both ears combined, every three years. $0 co-payment for fitting and evaluation every three years (Authorization is required by a Provider or Specialist)

Diagnostic Vision Exams (Medicare covered)

Routine Eye Exam

Routine Eyewear

Medicare-Covered Eyewear

$0% or 20% coinsurance*

$0 co-payment (one routine eye exam for eyewear every year

$0 co-payment for non-Medicare covered eyewear including contact lenses or eyeglasses (lenses and frames) up to $100 annual maximum per calendar year.

$0 co-payment for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery

*If you are eligible for Medicare cost-sharing assistance under Medicaid, you pay $0.

Elderplan For Medicaid Beneficiaries (HMO D-SNP)

BENEFIT YOU PAY

Preventive Care

Comprehensive Dental (Medicare-covered only)

$0 cost-sharing

Supplemental Comprehensive Dental

0% or 20% coinsurance*

Diabetic Supplies (Medicare-covered only)

$1500 annual allowance. Limited to selected service codes.

$0 cost-sharing

Transportation Services

$0 cost-sharing for up to 24 one-way trips annually

You may take up to 24 one-way trips to a plan approved health-related location per year by Taxi, Bus, Subway, or Van

*If you are eligible for Medicare cost-sharing assistance under Medicaid, you pay $0.

Why Choose Elderplan For Medicaid Beneficiaries

(HMO D-SNP)?

Recap of a few plan highlights:

4 You can choose quality Board-Certified Private Practice Network Providers

4 Low co-pays for prescription drugs

4 You will receive up to $1,860 a year for over the counter (OTC) health-related, select healthy grocery items, meals and internet bill pay*

4 Transportation to an Elderplan provider 24 one-way trips per year as well as Worldwide Emergency Transportation at no copayment or coinsurance

4 Between Elderplan, Medicare Advantage and State Medicaid, you may not pay for your medical services provided by in-network providers!**

4 Health Club Membership with a participating Silver and Fit Health Club, plus online workouts and training

4 Wellness Incentive program, which rewards you for receiving preventive screenings and immunizations

4 Access to award-winning Member-to-Member program

4 Elderplan is a not-for-profit organization that reinvests our earnings to bring you improved benefits and services.

* Unused OTC card balance cannot be carried over to the next month. Grocery items, meals and utility bill pay for eligible members (with certain chronic conditions)

** Your cost-sharing will depend on your level of Medicaid.

Q&A / Final Summary of Benefits Review

We just need to complete your enrollment application and you’re all set! 4 Choose your PCP 4 Remember you must use network providers for routine services with the exception of emergency, urgently needed services and out of network dialysis 4 You must also use Elderplan’s pharmacy network which includes standard retail, mail-order, long-term care and home infusion pharmacies. Ready to Join the Elderplan Family? 35

4 The Centers for Medicare and Medicaid Services (CMS) at 1-800-Medicare (1-800-633-4227). TTY/TTD users should call 1-877-486-2048, 24 hours a day/7 days a week;

4 The Social Security Administration at 1-800-772-1213 between 8 am and 7 pm, Monday through Friday. TTY/TTD users should call 1-800-325-0778; or the

4 The New York State HRA Medicaid Helpline 1-888-692-6116 (TTY 711) from 9 am to 5 pm Monday through Friday.

You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call:

Elderplan Cares 36

Elderplan Plus Long-Term Care (HMO D-SNP)

Receiving the care and support you need in the safety and comfort of your own home is important. This plan was designed for Medicare and Medicaid beneficiaries who need valuable assistance with Long-Term Care at home.

You’ll be happy to know that Elderplan Plus Long-Term Care has no plan premium, no co-payments for doctor and hospital visits, no referrals for doctor visits, and low co-payments for prescription drugs. Plus, you will enjoy an over-the-counter (OTC) benefit, which includes health-related and select grocery items that you can purchase at a store or order online, as well as home delivered meals. New for 2023, you can also use your OTC benefit to pay your home internet bill.*

Elderplan Plus Long-Term Care (HMO D-SNP)

The plan also provides transportation to and from medical appointments, worldwide emergency coverage, acupuncture, and Brain Games with BrainHQ®. We also offer the Award-winning Member-to-Member program, which gives our members the opportunity to connect with each other and participate in exciting activities. Whether it’s a walk in the park, grocery shopping, friendly chat, wellness and relaxation activities, cooking demos, or exercise classes, we want you to have options to feel connected.

Perhaps one of the biggest perks of being enrolled in this plan is that you are assigned a dedicated Care Manager who leads a team of caring clinical professionals who are all committed to helping you stay healthy. Your Care Manager will stay in touch with your doctors, as well as help arrange your medical visits and transportation to get you there.They will be your go-to person and will work to help ensure you get the care you need to remain safely at home. In addition, a registered nurse will visit you from time to time to check on you and assess your needs. And, when it comes to who provides your care at home, you have choices. We are happy to provide a Home Health Aide who will assist you with activities such as bathing, dressing and meals. If, however, you prefer someone you already know provide your care, you can pick a friend, neighbor, or in some cases a family member through the Consumer-Directed Personal Assistance Services (CDPAS) program, and they will be paid for their time.

Elderplan Plus Long-Term Care (HMO D-SNP)

Special eligibility requirements

Enrollment in this plan is only for people who are eligible for both Medicare and full New York State Medicaid, need long-term care services, require care management, and are eligible for a nursing home level of care, but prefer and are able to live at home

Are expected to need one of the following Community Based Long Term Care Services for more than 120 days: nursing services at home; therapies in the home, home health aide services, personal care services in the home, adult day health care, private duty nursing, or Consumer-Directed Personal Assistance Services.

You are determined eligible for Long-Term care services by Elderplan or an entity designated by the New York State Department of Health using the current NYS eligibility tool.

Please note: If you lose your Medicaid eligibility but can reasonably be expected to regain eligibility within three (3) months, then you are still eligible for membership in our plan. The Evidence of Coverage (EOC) tells you about coverage and cost sharing during a period of deemed continued eligibility. If you do not regain Medicaid eligibility you will be disenrolled after the 3 months. See the EOC for more information.

Elderplan Plus Long-Term Care (HMO D-SNP)

BENEFIT YOU PAY

$0 monthly plan premium

Part D Premium

Primary Care Provider (PCP) Visits

(Because you are a dual-eligible member with full Medicaid benefits and Low-Income Subsidy benefits, your plan premium is covered on your behalf)

$0 cost-sharing for each visit, in-person and telehealth

Specialist Visits

Lab Services, Outpatient Blood Services, Diagnostic Tests and Procedures

$0 cost-sharing for each visit, in-person and telehealth

No referral needed to see an in-network specialist.

$0 cost-sharing

Diagnostic Radiological Services

Authorization is required only for PET, MRI, MRA, and CT scan.

Therapeutic Radiological Services $0 cost-sharing

Elderplan Plus Long-Term Care (HMO D-SNP)

Expanded prescription drug coverage with…UNLIMITED* brand name and generic drugs!

BENEFIT YOU PAY

Part D Deductible

Initial Coverage Stage (30-day supply)

Generic Drugs (including brand drugs treated as generic)

$0, $104, or $505 per year**

Depending on your level of “Extra Help” you pay: $0 co-pay or $1.45 co-pay or $4.15 co-pay or 15% of the cost or 25% of the cost

Initial Coverage Stage (30-day supply)

For all Other Drugs

Depending on your level of “Extra Help” you pay: $0 co-pay or $4.30 co-pay or $10.35 co-pay or 15% of the cost or 25% of the cost

*You must still order prescriptions from the Elderplan formulary through a plan-affiliated pharmacy. Utilization rules may apply including Prior Authorization, Step therapy and/or Quantity Limits.

**Depending on your Extra Help (“LIS”)

Elderplan Plus Long-Term Care (HMO D-SNP)

BENEFIT YOU PAY

$0 cost-sharing for each benefit period.

Hospital Stays

Emergency Care

Our plan covers 90 days for an Inpatient Hospital Stay. Our plan also covers 60 “lifetime reserve days.”

These are “extra” days that we cover.

Authorization is required

$0 cost-sharing for each visit

Urgent Care $0 cost-sharing for each visit

Worldwide Emergency/Urgent Care/Emergency Transportation Up to $50,000

$0 cost-sharing

Over-the-Counter (OTC)

OTC + Grocery + Meals* + Internet Pay*

$215 Every Month

(this monthly limited benefit does not carry over from one month to another)

$215 Every Month

*For eligible members with certain chronic condition.

Elderplan Plus Long-Term Care (HMO D-SNP)

BENEFIT YOU PAY

Hearing Services – Medicare Covered

$0 cost-sharing for Medicare-covered diagnostic hearing exams

$0 cost-sharing for Medicaid-covered services

Hearing Services – Medicaid Covered*

Hearing Aid(s) up to $600 per ear with a $1200 maximum every 3 years. Authorization is required for hearing aid(s) by a Provider or Specialist. 1-year supply of batteries included with the purchase and will be shipped with the hearing aid.

Vision Care – Medicare Covered

Medicare-Covered Eyewear

$0 cost-sharing for Medicare-covered services

$0 cost-sharing for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery

Vision Care/Eyewear – Medicaid Covered* $0 cost-sharing for Medicaid covered services

Personal Care Services* (Medically necessary ADL and IADL)

$0 cost-sharing

*These benefits are available for members who qualify for full Medicaid benefits.

Elderplan Plus Long-Term Care (HMO D-SNP)

BENEFIT YOU PAY

Social and Environmental Support*

$0 cost-sharing

Personal Emergency Response Services* $0 cost-sharing

Diabetes Monitoring (Diabetic Supplies) –Medicare Covered

$0 cost-sharing for Medicare-covered services and supplies.

Testing strips limited to certain manufacturers

Diabetes Monitoring (Diabetic Supplies) –Medicaid Covered * $0 cost-sharing

Home Health Care – Medicaid Covered * $0 cost-sharing Authorization is required

Acupuncture services (supplemental) $0 cost-sharing for up to 28 visits per year

*These benefits are available for members who qualify for full Medicaid benefits.

Recap of a few plan highlights:

4 Your Medicare and Medicaid benefits will be coordinated through a dedicated Care manager 4 You will receive up to $2,580 a year for over-the-counter health- related, select healthy grocery items, meals and internet bill pay * 4 Non-emergency/medically necessary transportation to and from doctor appointments 4 No copayment for Worldwide Emergency, emergency transportation and urgent coverage with a maximum benefit amount of $50,000 4 Between Elderplan, Medicare Advantage and State Medicaid, you do not pay for your medical services provided by in- network providers! 4 Wellness Incentive program, which rewards you for receiving preventive screenings and immunizations 4 Access to award-winning Member-to-Member program 4 Elderplan is a not-for-profit organization that reinvests our earnings to bring you improved benefits and services * Unused OTC card balance cannot be carried over from month to month. Grocery items, meals and internet bill pay for eligible members (with certain chronic conditions) ** Your cost-sharing will depend on your level of Medicaid. Q&A / Final Summary of Benefits Review Why Choose Elderplan Plus Long-Term Care (HMO D-SNP)? 45

Ready to

the Elderplan Family?

Join

We just need to complete your enrollment application and you’re all set! 4 Choose your PCP 4 Remember you must use in-network providers for routine services with the exception of emergency, urgently needed services and out of network dialysis 4 You must also use Elderplan’s pharmacy network which includes standard retail, mail-order, long-term care and home infusion pharmacies 46

Elderplan Cares

4 The Centers for Medicare and Medicaid Services (CMS) at 1-800-Medicare (1-800-633-4227). TTY/TTD users should call 1-877-486-2048, 24 hours a day/7 days a week;

4 The Social Security Administration at 1-800-772-1213 between 8 am and 7 pm, Monday through Friday. TTY/TTD users should call 1-800-325-0778; or the

4 The New York State HRA Medicaid Helpline 1-888-692-6116 (TTY 711) from 9 am to 5 pm Monday through Friday.

You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call:

Elderplan Flex (HMO)

A new plan designed for Medicare beneficiaries that gives you the care you need and the choices you want. Elderplan Flex offers a $0 premium, low co-pays, and no referrals to see your doctor. In addition to medical and hospital coverage, you will have the flexibility to choose between supplementary benefits that are most important to you through Elderplan’s Flex extras. Elderplan’s Flex Select Extras give you the option of selecting OTC coverage, which you can use to pay for health-related, select grocery items at a store or order online, as well as home-delivered meals*, or transportation to and from medical appointments. The plan also provides comprehensive dental, worldwide emergency coverage, acupuncture, gym membership, and Brain Games with BrainHQ®.

* For eligible members (with certain chronic conditions) the Special Supplemental Benefits for the Chronically Ill (grocery benefit) combines with the OTC benefit to cover certain grocery items and meals as a part of the quarterly OTC allowance. Eligible members will be notified and provided instructions on how to access the benefit.

Elderplan Flex (HMO)

Making sure you receive the care you need is important to us. Making sure it’s affordable is important too. That’s why we designed a plan for Medicare beneficiaries, which offers a little extra help in paying for your health coverage. You get the health care you need with a low premium and low co-pays.

Plus, you will enjoy an over-the-counter (OTC) benefit, which includes health-related and select grocery items you can purchase at a store or order online, as well as meals. The plan also provides comprehensive dental, transportation to medical appointments and Brain Games with BrainHQ®.

Elderplan

BENEFIT YOU

co-payment for each office

co-payment for telehealth

for Endocrinologist Visits

referral needed to see an in-network specialist.

Flex (HMO) 50

PAY Part D Premium $0 monthly plan premium Primary Care Provider (PCP) Visits $0 cost-sharing for each visit, in-person and telehealth Specialist Visits $35

visit $10

Lab Services, Outpatient Blood Services $0 cost-sharing Diagnostic Tests and Procedures $35 co-payment for each service Diagnostic Colonoscopies in Office Settings: $0

BENEFIT YOU PAY

Outpatient

Diagnostic Radiological

is required for PET, MRI, MRA, and CT scan.

Therapeutic

Benefit (Gym Access) + on-demand workout classes and one-on-one Healthy Aging Coaching sessions by phone, video, or chat.

Elderplan Flex (HMO) 51

X-Rays $20 co-payment for each service

Services 20% coinsurance for each service Authorization

Radiology Services 20% coinsurance Fitness

$0 cost-sharing Acupuncture $0 cost sharing for up to 20 visits per year.

Elderplan Flex (HMO)

BENEFIT YOU PAY

Choose one of two Select Extras benefits:

Select Extras*

Over the Counter (OTC)

Select Extra*

OTC + Grocery + Meals*

• Over-the-Counter (OTC) or

• Non-emergency transportation.

Members who select OTC as their Select Extras benefit will receive: $120 every quarter for eligible OTC items (this quarterly limited benefit does not carry over from one quarter to another)

Members who select OTC as their Select Extras benefit may also be eligible for the Special Supplemental Benefit for the Chronically Ill (SSBCI) which combines with the OTC benefit to cover certain grocery items and meals as a part of the quarterly OTC allowance.**

Members who select Transportation as their Select Extras benefit will receive:

Transportation Select Extra*

$0 cost-sharing for up to 48 one-way trips per year You may take up to 48 one-way trips to a plan approved health-related location per year by Taxi, Bus, Subway, or Van

* Flex members will be allowed a choice of one of two Select Extras benefits upon enrollment: OTC benefit or Non-emergency transportation.

** For eligible members (with certain chronic conditions) the Special Supplemental Benefits for the Chronically Ill (grocery benefit) combines with the OTC benefit to cover certain grocery items and meals as a part of the quarterly OTC allowance. Eligible members will be notified and provided instructions on how to access the benefit.

Elderplan Flex (HMO) 53 * The deductible only applies to drugs in Tiers 4 & 5. Members pay the full cost of their drugs until their $375 deductible is met, then the cost-shares are applied in the initial coverage stage. ^ One-month supply for Standard retail (in-network), Long-term care (31-day), and Out-of-network cost-share. † NDS – Non-Extended Days Supply. Certain Specialty drugs will be limited up to a 30-day supply per fill. ** 60-day supply is also available for Standard retail (in-network). *** Utilization rules may apply including Prior Authorization, Step therapy and/or Quantity Limits PART D PREMIUM $0 per month PART D DEDUCTIBLE & INITIAL COVERAGE STAGE TIERS (TIER NAME) DEDUCTIBLE* RETAIL PHARMACY COST (30-day supply)^ RETAIL PHARMACY COST (90-day supply)**† MAIL ORDER PHARMACY COST (90-day supply)† Tier 1 (Preferred Generic) $0 $4 co-payment $12 co-payment $8 co-payment Tier 2 (Generic) $10 co-payment $30 co-payment $20 co-payment Tier 3 (Preferred Brand) $47 co-payment $141 co-payment $94 co-payment *Tier 4 (Non-Preferred Drug) $375 $100 co-payment $300 co-payment $200 co-payment *Tier 5 (Specialty Tier) 25% coinsurance 25% coinsurance 25% coinsurance Expanded Prescription drug coverage with…UNLIMITED*** Brand and Generic drugs! If you qualify for “Extra Help,” you may not pay the amounts listed in the table below for your Part D prescription drugs. The exact amount you pay may vary depending on the amount of “Extra Help” you receive, as well as the Part D phase you are in.

Elderplan Flex (HMO)

BENEFIT YOU PAY

Deductible: $0 Days 1-5: $390 co-payment per day

Inpatient Hospital Stays

Days 6 and beyond: $0 co-payment per day.

Unlimited inpatient days are based on medical necessity. Authorization is required.

$90 co-payment per Medciare-covered visit

Emergency Care

Urgent Care

If admitted to the hospital within 24 hours for the same condition, there is no cost-share.

$35 co-payment for office visits $10 co-payment for telehealth

co-payment

Ambulance $215 co-payment for each one-way trip

Worldwide Emergency/Urgent Care/Emergency Transportation Up to $50,000 $0

Elderplan Flex (HMO)

BENEFIT YOU PAY

Supplemental Preventive Dental

Coverage is limited to certain dental codes covering oral exams, cleanings, and dental x-rays.

(Please refer to Evidence of Coverage for details or call member services).

$0 copayment

Supplemental Comprehensive Dental

Coverage is limited to certain dental codes covering restorative, endodontic, prosthodontic, periodontics and maxillofacial, and adjunctive general services, and oral and maxillofacial surgery.

(Please refer to Evidence of Coverage for details or call member services).

$100 deductible

$0 copayment for covered comprehensive dental services up to the $1,500 annual maximum benefit once deductible is met.

Benefit frequency may be limited per American Dental Association guidelines.

Comprehensive Dental (Medicare-covered)

20% coinsurance for Medicare-covered comprehensive dental services.

Elderplan Flex (HMO)

BENEFIT YOU PAY

Diagnostic Hearing Exams – Medicare-covered

$35 co-payment for each Medicare-covered diagnostic hearing exam.

Supplemental Routine Hearing Exams

$0 co-payment for one Routine (non-Medicarecovered) hearing exam every year.

Hearing aids

Up to $1,000 annually for both ears combined ($500 will be available per ear)

$0 copayment for Fitting/Evaluation for Hearing Aid every year.

Authorization required for hearing aid(s) by a physician or specialist

Elderplan Flex (HMO)

BENEFIT YOU PAY

Diagnostic Vision Exams – Medicare-covered $25 co-payment for Medicare-covered eye exams

Routine Vision Exam (one every year)

$0 co-payment for one routine eye exam for eyewear

Vision Eyewear – Medicare-covered

$0 copayment for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery.

Supplemental Routine Eyewear

$0 co-payment for Routine (non-Medicare-covered) eyewear up to $200 annual maximum per year including contact lenses and eyeglasses (lenses and frames).

Elderplan Flex (HMO)

BENEFIT YOU PAY

Preventive Services $0 co-payment

Diabetic Supplies

$0 co-payment for Medicare-covered Diabetes Supplies Testing strips limited to certain manufacturers.

59 Recap of a few plan highlights: 4 $0 Monthly Part D Premium 4 Low cost sharing on prescription drugs 4 $0 copayment for your in-network PCP, including telehealth 4 There are no referrals necessary for in network specialists 4 You can choose from quality board-certified private practice providers 4 Freedom to choose benefits that are important to you with Elderplan Flex Select Extras 4 If you select over-the-counter (OTC) as your Elderplan Flex Select Extras, you will receive up to $480 a year for OTC health related items, as well as select grocery items and meals if eligible** 4 If transportation is selected as your supplemental benefit, you will receive up to 48 one-way trips per year to plan approved medical related locations by Taxi, Bus, Subway, or Van. Why Choose Elderplan Flex (HMO)?

60 Why Choose Elderplan Flex (HMO)? Recap of a few plan highlights: 4 Fitness Benefits (Gym) at participating Silver&Fit® fitness centers and YMCAs + on-demand workout classes and one-on-one Healthy Aging Coaching sessions by phone, video, or chat. 4 Supplemental Preventive and Comprehensive Dental coverage 4 Wellness Incentive program, which rewards you for receiving preventive screenings and immunizations 4 Access to award-winning Member-to-Member program 4 Elderplan is a not-for-profit organization, reinvesting our earnings to bring you improved benefits and services ** Unused OTC card balance cannot be carried over from quarter to quarter. Grocery items and meals are for eligible members with certain chronic conditions. Q&A / Final Summary of Benefits Review

61 Ready to join the Elderplan Family? We just need to complete your enrollment application and you’re all set! 4 Choose your PCP 4 Remember you must use in-network providers for routine services with the exception of emergency, urgently needed services and out-of-network dialysis 4 You must also use Elderplan’s pharmacy network which includes standard retail, mail-order, long-term care and home infusion pharmacies

Elderplan Cares

You may be able to get extra help to pay for your prescription drug premiums and costs. To see if you qualify for getting extra help, call: 4 The Centers for Medicare and Medicaid Services (CMS) at 1-800-Medicare (1-800-633-4227). TTY/TTD users should call 1-877-486-2048, 24 hours a day/7 days a week; 4 The Social Security Administration at 1-800-772-1213 between 8 am and 7 pm, Monday through Friday. TTY/TTD users should call 1-800-325-0778; or the 4 The New York State HRA Medicaid Helpline 1-888-692-6116 (TTY 711) from 9 am to 5 pm Monday through Friday.

Elderplan Extra Help (HMO)

You get the health care you need with a low premium and low co-pays. In addition to medical and hospital coverage, our members with Low Income Subsidy (LIS) will also experience additional savings on prescription drug coverage.*

Plus, you will enjoy an over-the-counter (OTC) benefit, which includes health-related and select grocery items you can purchase at a store or order online, as well as homedelivered meals.** The plan also provides comprehensive dental, transportation to medical appointments, worldwide emergency coverage, acupuncture, gym membership and Brain Games with BrainHQ®. We also offer the Award-winning Member-to-Member program, which gives our members the opportunity to connect with each other and participate in exciting activities. Whether it’s a walk in the park, grocery shopping, friendly chat, wellness and relaxation activities, cooking demos, or exercise classes, we want you to have options to feel connected.

* Beneficiaries enrolling in Elderplan Extra Help Medicare Advantage Prescription Drug Plan who do not have Low Income Subsidy will not be eligible for the reduced LIS cost sharing for Part D prescription costs.

Elderplan Extra Help (HMO)

BENEFIT YOU PAY

Part D Premium

Primary Care Provider (PCP) Visits

$38.90* monthly plan premium

$0 cost sharing for in-person and telehealth visits

Specialist Visits

$35 co-payment for each office visit $10 co-payment for telehealth

No referral needed to see an in-network specialist

Lab Services/Outpatient Blood Services $0 cost-sharing

Diagnostic Tests and Procedures $35 co-payment per service

Outpatient X-Rays $20 co-payment for each X-ray service

Diagnostic Radiological Services

Therapeutic Radiological Services

Fitness Benefit (Gym Access) + on-demand workout classes and one-on-one Healthy Aging Coaching sessions by phone, video, or chat.

20% coinsurance per service

Authorization is required for PET, MRI, MRA, and CT scan.

20% coinsurance per service

$0 cost-sharing

*Your plan premium may be lower based on your Extra Help (“LIS”).

Elderplan Extra Help (HMO)

BENEFIT YOU RECEIVE

$80 every quarter

Over-the-Counter (OTC)

OTC + Grocery + Meals*

Acupuncture

Transportation

(this quarterly limited benefit does not carry over from one quarter to another)

$80 every quarter

The Special Supplemental Benefit for the Chronically Ill (SSBCI) which combines with the OTC benefit to cover certain grocery items and meals as a part of the quarterly OTC allowance.

$0 co-payment per visit.

You may receive up to 20 visits per year.

$0 cost-sharing for up to 32 one-way trips per year

You may take up to 32 one-way trips to a plan approved health-related location per year by Taxi, Bus, Subway, or Van

Elderplan Extra Help (HMO) PART D PREMIUM $38.90 per month PART D DEDUCTIBLE & INITIAL COVERAGE STAGE TIERS (TIER NAME) DEDUCTIBLE* RETAIL PHARMACY COST (30-day supply)^ RETAIL PHARMACY COST (90-day supply)**† MAIL ORDER PHARMACY COST (90-day supply)† Tier 1 (Preferred Generic) $0 $4 co-payment $12 co-payment $8 co-payment Tier 2 (Generic) $10 co-payment $30 co-payment $20 co-payment Tier 3 (Preferred Brand) $47 co-payment $141 co-payment $94 co-payment *Tier 4 (Non-Preferred Drug) $505 $100 co-payment $300 co-payment $200 co-payment *Tier 5 (Specialty Tier) 25% coinsurance 25% coinsurance 25% coinsurance *The deductible only applies to drugs in Tiers 4 & 5. Members pay the full cost of their drugs until their $505 deductible is met, then the cost-shares are applied in the initial coverage stage. ^One-month supply for Standard retail (in-network), Long-term care (31-day), and Out-of-network cost-share. †NDS – Non-Extended Days Supply. Certain Specialty drugs will be limited up to a 30-day supply per fill. Expanded Prescription drug coverage with…UNLIMITED*** Brand and Generic drugs! If you qualify for “Extra Help,” you may not pay the amounts listed in the table below for your Part D prescription drugs. The exact amount you pay may vary depending on the amount of “Extra Help” you receive, as well as the Part D phase you are in. 66

Elderplan Extra Help (HMO)

BENEFIT YOU PAY

Deductible: $0

Days 1-5: $390 co-payment

Inpatient Hospital Stays

Emergency Care

Urgent Care

Ambulance

Days 6 and beyond: $0 co-payment per day

Unlimited inpatient days are based on medical necessity

Authorization is required

$90 co-payment per visit

If admitted to the hospital within 24 hours for the same condition, there is no cost-sharing.

$35 co-payment per office visit $10 co-payment for telehealth visits

co-payment

$215 co-payment for each one-way trip

Authorization is required for non-emergency services

Worldwide Emergency/Urgent Care/Emergency Transportation Up to $50,000 $0

Elderplan Extra Help (HMO)

BENEFIT YOU PAY

Supplemental Preventive Dental

Coverage is limited to certain dental codes covering oral exams, cleanings, and dental x-rays. (Please refer to Evidence of Coverage for details or call member services).

$0 copayment

Supplemental Comprehensive Dental

Coverage is limited to certain dental codes covering restorative, endodontic, prosthodontic, periodontic and maxillofacial, and adjunctive general services, and oral and maxillofacial surgery. (Please refer to Evidence of Coverage for details or call member services).

For dental copayment schedule please refer to Evidence of Coverage or Summary of Benefits for details or Call Member Services

Benefit frequency may be limited per American Dental Association guidelines.

Comprehensive Dental (Medicare-covered)

20% coinsurance for Medicare-covered comprehensive dental services.

Elderplan Extra Help (HMO)

BENEFIT YOU PAY

Diagnostic Hearing Exams – Medicare-covered

$35 co-payment for each Medicare-covered diagnostic hearing exam.

Supplemental Routine Hearing Exams

$0 co-payment for one Routine (non-Medicarecovered) hearing exam every year.

Up to $500 maximum benefit every 3 years for one ear.

Hearing Aids

$0 copayment for Fitting/Evaluation for Hearing Aid every 3 years for one ear.

Authorization required for hearing aid(s) by a physician or specialist

Diagnostic Vision Exams – Medicare-covered $25 co-payment for Medicare-covered eye exams

Routine Vision Exam (one every year) $0 co-payment for one routine eye exam for eyewear

Vision Eyewear - Medicare-covered

$0 copayment for one pair of Medicare-covered eyeglasses or contact lenses after cataract surgery.

Supplemental Routine Eyewear

$0 co-payment for Routine (non-Medicare-covered) eyewear up to $150 annual maximum per year including contact lenses and eyeglasses (lenses and frames).

Elderplan Extra Help (HMO)

BENEFIT YOU PAY

Preventive Services $0 co-payment

Diabetic Supplies

$0 co-payment for Medicare-covered Diabetes Supplies

Testing strips limited to certain manufacturers.

Recap of a few plan highlights: 4 Low-cost sharing on prescription drugs (depending on LIS level) 4 $0 copayment for your in-network PCP, including telehealth 4 There are no referrals necessary for in network specialists 4 You can choose from quality board-certified private practice providers 4 You will receive up to $320 a year for over the counter *(OTC) health related, select healthy grocery items and meals** 4 Fitness Benefits (Gym) at participating Silver&Fit® fitness centers and YMCAs + on-demand workout classes and one-on-one Healthy Aging Coaching sessions by phone, video, or chat. 4 Supplemental Preventive and Comprehensive Dental coverage 4 Wellness Incentive program, which rewards you for receiving preventive screenings and immunizations 4 Access to award-winning Member-to-Member program 4 Elderplan is a not-for-profit organization that reinvests our earnings to bring you improved benefits and services * Unused OTC card balance cannot be carried over from quarter to quarter. ** Grocery items and meals for eligible members (with certain chronic conditions) Why choose Elderplan Extra Help (HMO)? 71

We just need to complete your enrollment application and you’re all set! 4 Choose your PCP 4 Remember you must use in-network providers for routine services with the exception of emergency, urgently needed services and out-of-network dialysis 4 You must also use Elderplan’s pharmacy network which includes standard retail, mail-order, long-term care and home infusion pharmacies. Ready to Join the Elderplan Family? 72

You

help

and costs. To see if

drug

qualify for getting extra help, call:

4 The Centers for Medicare and Medicaid Services (CMS) at 1-800-Medicare (1-800-633-4227). TTY/TTD users should call 1-877-486-2048, 24 hours a day/7 days a week;

4 The Social Security Administration at 1-800-772-1213 between 8 am and 7 pm, Monday through Friday. TTY/TTD users should call 1-800-325-0778; or the

4 The New York State HRA Medicaid Helpline 1-888-692-6116 (TTY 711) from 9 am to 5 pm Monday through Friday.

may be able to get extra

to pay for your prescription

premiums

you

Elderplan Cares 73

74 PRODUCT(S) ELDERPLAN EXTRA HELP- NO LIS ELDERPLAN PLAN FLEX (PPO)- NO LIS ELDERPLAN WITH LIS LEVEL 1 ELDERPLAN WITH LIS LEVEL 2 ELDERPLAN WITH LIS LEVEL 3 ELDERPLAN WITH LIS LEVEL 4 Premium $38.90 $0 $0 $0 $0 25%, 50%, 75%, or 100% of plan premium Deductible $505 $505 (Tiers 4 & 5 only) $375 (Tiers 4 & 5 only) $0 $0 $0 $104 (Tiers 4 & 5 only) Initial Coverage Limit $506-$4660 Tier 1 – $4 Tier 2 – $10 Tier 3 – $47 Tier 4 – $100 Tier 5 – 25% Tier 1 – $4 Tier 2 – $10 Tier 3 – $47 Tier 4 – $100 Tier 5 – 25% $4.15 Generic $10.35 Brand $1.45 Generic $4.30 Brand $0 15% or plan Tier copayment (whichever is less) Coverage Gap $4661-$7400 25% 25% $4.15 Generic $10.35 Brand $1.45 Generic $4.30 Brand $0 15% Catastrophic (7401+) Greater of: 5% or $1.45 Generic $4.30 Brand Greater of: 5% or $1.45 Generic $4.30 Brand $0 $0 $0 $1.45 Generic $4.30 Brand What are the beneficiary’s Part D financial responsibilities with Elderplan for 2023?